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IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


// 


4is 


V  C^x 


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1.0 


111 


I.I 


1^ 


■  50 

Hr  1^  12.0 


1.8 


1-25      1.4      1.6 

■* 6"     

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Photographic 

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Corporation 


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Collection  de 
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Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The( 
toth 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


□ 

D 
D 
□ 

□ 
n 


0 


n 


D 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagee 

Covers  restored  and/or  laminated/ 
Couverture  restaur^e  et/ou  peliiculde 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  gdographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire} 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Relie  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  reliure  serree  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  intdrieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajout^es 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  6tait  possible,  ces  pages  n'ont 
pas  6t6  film6es. 

Additional  comments:/ 
Commentaires  suppldmentaires; 


L'institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  iui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-dtre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  m^thode  normale  de  filmage 
sont  indiqu6s  ci-dessous. 


□    Coloured  pages/ 
Pages  de  couleur 

□    Pages  damaged/ 
Pages  endommag^es 

I      I    Pages  restored  and/or  laminated/ 


D 
D 


Pages  restaurdes  et/ou  pelliculees 

Pages  discoloured,  stained  or  foxei 
Pages  ddcolordes,  tachet^es  ou  piquees 

Pages  detached/ 
Pages  ddtach^es 

Showthrough/ 
Transparence 

Quality  of  prir 

Qualit^  in6gale  de  I'impression 

Includes  supplementary  materia 
Comprend  du  materiel  supplementaire 


Thei 
poss 
of  th 
filmi 


Origi 
begii 
the  I 
sion, 
othe 
first 
sion, 
or  ill 


r~l  Pages  discoloured,  stained  or  foxed/ 

I      I  Pages  detached/ 

r~7l  Showthrough/ 

I      I  Quality  of  print  varies/ 

I      I  Includes  supplementary  material/ 


The 
shall 
TINl 
whic 

Map 
diffe 
entir 
begi 
right 
requ 
metl 


Only  edition  available/ 
Seule  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  film^es  d  nouveau  de  fapon  i 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  filmd  au  taux  de  reduction  indiqu6  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

y 

12X 


16X 


20X 


24X 


28X 


32X 


The  copy  filmed  here  has  been  reproduced  thanks 

L'exemplaire  film6  fut  reproduit  grice  A  la 

to  the  generosity  of: 

g6n«rosit6  de: 

3ils 

University  of  British  Columbia  Library 

University  of  British  Columbia  Library 

du 
difier 

The  images  appearing  here  are  the  best  quality 

Les  images  suivantes  ont  6X6  reproduites  avec  le 

jne 

possible  considering  the  condition  and  legibility 

plus  grand  soin,  compte  tenu  de  la  condition  et 

lage 

of  the  original  copy  and  in  iteeping  with  the 

de  la  nettetiS  de  ■>Aemplaire  fi!m6,  et  en 

filming  contract  specifications. 

conformity  avec  les  conditions  du  contrat  de 
filmage. 

Original  copies  in  printed  paper  covers  are  filmed 

Les  exemplaires  originaux  dont  la  couverture  en 

beginning  with  the  front  cover  and  ending  on 

papier  est  imprimde  soot  filmds  en  commengant 

the  last  page  with  a  printed  or  illustrated  impres- 

par  le  premier  plat  et  en  terminant  soit  par  la 

sion.  or  the  bank  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmds  en  commengant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernidre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —^'  (meaning  'CON- 
TINUED "),  or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Un  des  symboles  suivants  apparaitra  sur  la 
dernidre  image  de  cheque  micrufiche,  selon  le 
cas:  le  symbole  --»-  signifie  "A  SUIVRE",  le 
symbole  V  signifie  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  dtre 
film6s  A  des  taux  de  reduction  diffirents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  clich6,  il  est  filmd  d  partir 
de  I'angle  sup^rieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  an  prenant  le  nombre 
d'images  nicessaire.  Les  diagrammes  suivants 
illustrent  la  methods. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

THE  PRINCIPLES  AND 


PEAGTICE  OF  MEDICINE 


T^KSIGXEl)   FOU   THE   USE   OF 
rRACTITIUNKH.-;   AND   STUDENTS   OF  MEDICINK 


BY 


WILLIAM  OSLER,  M.  D. 


FKI.I.OW    (IP    TIIK    ItOVAI-    (•nl,l,K(iB    OF    IMIYSICIANS,    I.ONnON 

I'ltOFKSSDIl   OF    MKDIITNK    IN    TIIK    JOHNS    HOPKINS    I  NIVKliSITY    ANt) 

I'HYSICIAN-IN-CillKF    TO    TIIK     JOHNS     HOPKINS     HOSPITAL,    HALTIMOKK 

FORMKItl.Y    PItOFKSSOU   OF    THE    INSTITITKS   OF    MKDICINK,    MOOIM,    UN1VKU8ITY,    MONTKKAL 

AND  PKoFKssoi:  OF  »:i.i>::;Al.  MKDKMNK 

IN    TIIK    I  NIVKUHITY    OF    PENNSYLVANIA,    PHILAIIKLPHIA 


J     t 

•I     -t 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1893 


»-«^<-         ^V«  /^ 


COPYRIOHT,    )8!)8, 

By  D.  APPLKTON   AND  COMPANY. 


TO 

THE    MEMORY  OP   MY   TEACHERS: 

WILLIAM  ARTHUR  JOHNSON, 

PRIEST   OF   THE   PARISH    OK    WESTON,    ONTARIO. 

-TAMES  BOVELL, 

OK   THE   TORONTO   SCHOOL   OK   MEDICINK, 

AND  OK   THE 

UNIVERSITY   OK    TRINITY    COM,EGE,   TORONTO. 

ROBERT  PALMER  HOWARD 

DEAN   OF    THE    MEDICAL    KACnr.TY   AND   PROFESSOR   O."    MEDICINE 
M^OILL    UNI\  ERSITY,   MONTREAL. 


><  O  T  E  . 


Xfy  thanks  are  due  to  my  former  first  assistant,  II.  A,  TiSftPTn", 
f.)r  imich  help,  direct  and  indirect;  to  his  sneeessor,  W.  S.  Tliayer. 
for  assistance  in  tlie  section  on  Hhxxl  Diseases  and  tor  tlie 
preparation  of  the  illustrative  charts;  to  I).  McM'editli  lleiise,  for 
the  statistics  on  tuberculosis ;  to  II.  M.  Thotnas,  for  luany  su<^- 
ii^estions  in  the  section  on  Nervous  Diseases,  and  j)articularly  in 
the  section  on  Topical  Diagnosis;  to  L.  P.  Powell,  of  the  John.-' 
Hopkins  University  Library,  for  a  carefid  revision  of  the  manu- 
script; and  to  Miss  B.  O.  Ilumpton,  for  valuable  aid,  especially  in 
the  ])reparation  of  the  index.  , 


Johns  Hopkins  FTospital, 

Baltimore,  January  1,  1892. 


^p 


"  Experience  is  fjiliaeious  and  jiulgmcnt  dilTieult." 
IIii'i'ocBATEs:  Aphorisms,  I. 

"And  I  siiid  of  medicine,  that  this  is  an  nrt  which 
considers  the  constitution  of  the  patient,  and  has 
principles  of  action  and  reasons  in  each  case." 

Plato:  Oorgias. 


CONTENTS. 


1. 

11. 

III. 

IV. 


V. 

VI. 

VII. 

VIII. 

IX. 

X, 

XI. 

xir. 

XIII. 

XIV. 

XV. 

XVI. 

XVll. 


XVIII. 

XIX. 

XX, 

XXI. 


XXII, 
XXIII. 
XXIV. 

XXV. 


SECTION   I. 
SPECIFIC  INFECTIOUS  DISEASES. 

PAOK 

Tyi)hoid  Fever t 

Typhus  Fever ;{9 

Keliipsins  Fever 48 

SmivU-pox 4<l 

Variola  Vera 49 

Ilu-niorrluigie  Small-pox 58 

Varioloid 54 

Vaccinia  (Cow-pox) — Vaccination 60 

Varicella  (Chicken-pox) fiS 

Scarlet  Fever 67 

Measles 77 

Kubclla  (ROtheln) 81 

E[)idemic  Parotitis  (3Iuini)s) 82 

Whooping-cough 84 

Influenza 87 

Dengue 90 

Cerebro-spinal  Meningitis 93 

Diphtheria 99 

Erysipelas 110 

Septicicinia  and  Pvirinia 114 

Sopticfcmia 114 

Pyromia 116 

Cholera  Asiatica 118 

Yellow  Fever 125 

Dysentery V,iO 

Malari.il  Fever 140 

Intermittent  Fever 147 

Continued  and  Remittent  Malarial  Fever 151 

Pernicious  Malarial  Fever 152 

Malarial  Cachexia 153 

Anthrax 156 

Rabies 159 

Tetanus 162 

Syphilis 165 

Acquired .        .  167 

Congenital 169 

Visceral 172 


•  •  • 

Vlll 


CONTENTS. 


XXVI.  TubernuloMM 

1.  (Juiionil  Klioloijy  nnil  Morbid  Aimtomy     . 

2.  Acute  TubtTciilosis 

y.  Tul)i'r('iil().siH  of  thu  Lyiiiph-Kliui'ls  (Scrofula) 

4.  PuliiionHry  'riibi'rciil()><is  (I'litlii^is,  ("oiisimiiit.ioii) 

5.  'I'liberoulosis  of  the  Serous  Mcnibriiucx 
(I.  Tuberculosis  of  Ihii  AliiueriUiry  Canal 
7.  Tuberculosis  of  the  Liver   .... 
H.  Tuberculosis  of  the  IJraiii  a  id  Spinal  Cord 
1).  Tulierculosis  of  the  Geiiiti-urinary  System 

10.  Tui)ercuh)sis  of  the  Arteries 

11.  Projjnosis  in  Tuberculosis  . 
18.  l'ro|)hyluxis  in  'i'ubercMilosis 
l;i.  Treat  nienl  of  Tul)erculosi'<. 

XXVII.  Leprosy 

XXVHI.  (Jlanders 

XXIX.  Actinomycosis 

XXX.  Infectious  Diseases  of  Doubtful  Nature     . 

1.  Febriculi  (Ephemeral  Kever)     . 

2.  Weil's  Disease 

3.  Milk-sickness 

4.  Jlalta  Fever 

5.  Mountain  Fever  .... 
C.  Miliary  Fever  (Sweating  Sickness)     . 


PAOR 

1H4 

1H4 

1U7 

204 

208 

2;]5 

2.'}» 

243 

242 

24;j 

24« 

24fl 

247 

249 

25« 

2r)!» 

2(!l 

204' 

204 

2()5 

2«« 

2G« 

208 

268 


SECTION  II. 
CONSTITUTIONAL  DISEASES. 

I.  Rheumatic  Fever 270 

II.  Chronic  liheumatism 278 

III.  Pseudo-rheumatic  AfTectlons 279 

IV.  Muscular  liheumatism 281 

V.  Arthritis  Defornuins  (Rheumatoid  Arthritis) 282 

VI.  Gout 287 

VIL  Diabetes  Mellitus 295 

VIlI.  Diabetes  Insipidus 305 

IX.  Ricketo 307 

X.  Scurvy  (Scorbutus) 312 

XL  Purpura 316 

XII.  Ilajmophilia 320 


SECTION  III. 
DISEASES  OF  THE  DtGESTIVE  SYSTEM. 


■  t 


I.  Diseases  of  the  Moutli 

Stomatitis .... 
Aphthous  Stomatitis 
Ulcerative  Stomatitis 
Parasitic  Stomatitis  (Thrush) 
Gangrenous  Stomatitis 
Mercurial  Stomatitis 


323 
323 
323 
324 
325 
326 
327 


11 


CONTENTS. 


IX 


II.  DispasoH  of  the  Siiliviiry  Olmuls 

Ilypoi  c!crctioii       .... 

Xi^nisloniiii 

Iiiniinimiitinii  of  t\w.  Siiliviiry  (iliiiids 
III.   Discasos  of  tlic  I'litiryiix    . 
Circiiliitory  DisUirliiiiu'cs 
Acute  I'lmryii^'ilis .... 
C'lironic  l'lmryiif;itis 
Ulccralioii  of  tlio  I'liaryiix     . 
Aculo  Iiifi'cUous  IMilc;,'iii()n  of  the  IMiaryiix 
lic'tro-pliaryiij^oal  Abscess 
Anjjina  liudovici    .... 
IV'.  Diseases  of  1  ho  Tonsils 

Follicular  or  liucuiiar  T(Jiisillilis 
Siippurativ'  Tonsillitis  . 
t'liroiiic  'I'urisillitis 
V.  Diseases  of  t  lie  (Ksophagtis 
Acute  (Hsopliap;itis 
Spasm  of  the  (Ksojihagus 
Stricture  of  the  (Ksopliaifus  . 
Cancer  of  the  (Esophaj^tis 
liupturo  of  the  (Esoplui^'us   . 
Dilatations  and  Diverticula  . 
VI.  Diseases  of  Iho  Stonuich     . 

Jlethods  of  Clinical  Examination  . 
Acute  Gastritis       .... 

Phlegmonous  Oiistritis 

Toxic  Gastritis    .... 

Diphtheritic  Gastritis 

Mycotic  Gastritis 
Chronic  Gastritis  (Chronic  Dys])epsia) 
Neuroses  of  Stomach 

Gastralgia 

Nervous  Dyspepsia     . 

Nervous  Von  iting 

Peristaltic  Unrest 

Rumination        .... 
Dilatation  of  Stomadi    . 
Peptic  Ulcer  (Gastric  and  Duodenal) 
Cancer  of  Stomach. 
IliPinorrhage  from  the  Stomach     . 
VII.  Diseases  of  the  Intestines . 

1.  Diseases  of  the  Intestines  associated  with  Diar 

Catarrhal  Enteritis 
Diarrhnea       .... 
Enteritis  in  C'h".drcn     . 
Diphtheritic  or  ('roupous  Enteritis 
Phlegmonous  Enteritis 
Mucous  Colitis 
Ulcerative  Enteritis 

2.  Miscellaneous  AfTections  of  the  Bowels 

3.  Appendicitis  (Typhlitis  and  Perityphlitis) 


rhoea 


PAOB 

H'iH 
82H 
n2H 

!i2N 

im 
mm 

iCIl 

ii.'ii 
aaa 
im 
»8a 

Bi)2 

'.v,m 

•Ml 
343 
348 
344 
344 
344 
348 
350 
3r)0 
351 
351 
351 
350 
35!) 
3(i0 
3«1 
3(ia 
3()2 
3(14 
30S 
37« 
385 
388 
388 
388 
388 
391 
305 
BOG 
306 
307 
403 
405 


CONTENTS. 


ducts 


Typhlitis      . 
Appemlioitis . 

4.  Intestinftl  Obstruction    . 

5.  OonstJi'.itiou  (Costiveness) 
VIII,  Diseases  of  the  Liver 

1.  Jaumlieo  (luteriis)   . 

2.  Affections  of  the  Hlootl-vessels  of  the  Liver 

3.  Diseases  of  the  Bile-passages 

Catarrhal  Jaiiiulico 
1  Cholelithiasis  ((Jall-stoncs) 

Other  Affections  of  the  IJile 

4.  Cirrhosis  .... 
••j.  Abscess  of  the  Liver 

6.  New  (irowths  in  the  Liver 

7.  Patty  Liver     . 

8.  Amyloid  Liver 
IX.  Diseases  of  the  Pancreas . 

L  Ilannorrhafje   . 

2.  Acute  Pancreatitis  . 

;5.  ("hronic  Pancreatitis 

4.  Pancreatic  Cysts 

5.  Cancer     .... 
X.  Diseases  of  tlio  Poritonieuin    , 

1.  Acute  General  Peritonitis 

2.  Peritonitis  in  Infants 
a.  Localized  Peritonitis 

4.  Chronic  Peritonitis. 

5.  New  Growths  in  the  Peritonieuni 

6.  Ascites  (IIydro-peritona;uni) 


PAflR 

405 
40« 

4i;j 

420 
423 
423 

427 
430 
430 
431 
437 
440 
44(1 
451 
4r)5 
450 
457 
457 
458 
4(11) 
4(iO 
4(51 
4(52 
4(52 
4G0 
460 
407 
408 
469 


SECTION  IV. 
DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

I.  Diseases  of  the  Nose ,        .  474 

Acute  Coryza 474 

Chronic  Nasal  Catarrh ,  475 

Autumnal  Catarrh  (Hay  Fever) 477 

Epistaxis 478 

II.  Diseases  of  the  Larynx 480 

1.  Acute  Catarrhal  Laryngitis 480 

2.  Chronic  Laryngitis 481 

3.  (Edematous  Laryngitis 481 

4.  Membranous  Laryngitis  (Croup) 482 

5.  Spasmodic  Laryngitis  (Laryngismus  Stridulus) 486 

(5.  Tuberculous  Laryngitis 487 

7.  Syphilitic  Laryngitis 489 

in.  Diseases  of  the  Bronchi 490 

1.  Acute  Bronchitis 490 

2.  Chronic  Bronchitis 492 

3.  Bronchiectasis 495 

4.  Bronchial  Asthma  .        . ♦        .        .  497 

5.  Fibrinous  Bronchitis 501 


CONTENTS. 


XI 


IV.  Diseases  of  the  Lungs        .... 
1.  Circulatory  Disturbances  in  the  Lungs 
3.  Pneumonia 

3.  Chronic  Interstitial  Pneumonia  (Cirrhosis  of  L 

4.  Broncho-i)iieumonia  (Capillnry  Bronchitis 

5.  Emphysema        .... 

Comjiensatory  Emphysema     . 
Hypertrophic  p]mpliysenui 
Atrophic  Emphysema 
C.  Gangrene  of  the  Lung 

7.  Abscess  of  the  Lung  . 

8.  Pneumonokoniosis 

9.  New  Growths  in  the  Lungs 
V.  Diseases  of  the  Pleura 

1.  Acute  Pleurisy    .... 

Fibrinous  or  Plastic  Pleurisy  . 
Sero-fibrinous  Pleurisy    . 
Purulent  Pleurisy  (Empyema) 
Tuberculous  Pleurisy 
Other  Varieties  of  Pleurisy 

2.  Chronic  Pleurisy 

3.  Ilydrothorax       .... 

4.  Pneumothorax  (Ilydro-pneumothorax  and  Pyo 
Affioitions  of  the  Mediastinum  . 


ung) 


pneumo'liorax) 


PAOB 

503 
503 
611 
582 
53(5 
544 
544 
545 
549 
550 
553 
553 
556 
558 
558 
558 
558 
503 
5(5(5 
506 
571 
574 
574 
577 


SECTION  V. 
DISEASES  OF  THE   CIRCULATORY  SYSTEM. 


I.  Diseases  of  the  Pericardium 

1.  Pericarditis         .... 

2.  Other  Affections  of  the  Pericardium 
II.  Diseases  of  the  Heart . 

1.  Endocarditis       .... 
Acute  P^ndocarditis 
Chronic  Endocarditis 

3.  Chronic  Valvular  Disease  . 

Aortic  Incompetency 
Aortic  Stenosis 
Mitral  Incompetency 
Mitral  Stenosis 
Tricuspid  Valve  Disease . 
Pulmonary  Valve  Disease 
Combined  Valvular  Lesions   . 

3.  Hypertrophy  and  Dilatation 

Hypertrophy  of  the  Heart 
Dilatation  of  the  Heart  . 

4.  Affections  of  the  Jlyocardium    . 

Aneurism  of  the  Heart   . 
Rupture  of  the  Heart 
New  Growths  and  Parasites   . 
Wounds  and  Foreign  Bodies  . 


581 
581 
591 
592 
593 
593 
599 
002 
002 
008 
010 
014 
618 
030 
020 
028 
028 
035 
040 
646 
647 
647 
648 


xn 


CONTENTS. 


S.  Neuroses  of  the  Heart 

Pulpitiitioti    .... 

AnhythiiiiH   .... 

Rapid  Uofirt  (Tachycardia)   . 

Slow  liwirl  (Iinidy<;ardia) 

Angina  Pectoris    , 
fl.  Conf^enital  AfToctionis  of  the  Heart 
HI.  Diseases  of  the  Arteries     ... 

1.  Degenerations   .... 

2.  Arterio-seierosis  (Arterio-caiiiliary  F: 
'.i.  Aneurism 

Aneurism  of  the  Thoracic  Aorta 

Aneurism  of  the  Abdominal  Aorta 

Aneurism  of  the  Hranches  of  the  Abdominal  Aorta 

A rterio- venous  Aneurism 

Congenital  Aneurism 


''ibrosis) 


PAGE 
040 

G4» 
650 

052 
«5;j 
055 
059 

ma 

068 

004 
670 
671 
680 
681 
082 
682 


SECTION  VI. 
DISEASES  OF  THE  BLOOD  AND   DUCTLESS   GLANDS. 


I.  AnaJinia 

Secondary  Anaemia 
Primary  or  Essential  AnaMuia 
II.  Leuka>mia 

III.  Ilodgkin's  Disease 

IV.  Addison's  Di.-^ase 

V.  Diseases  of  the  Thyroid  Gland  . 

(ioitre 

Tumors  of  th(!  Thyroid  . 
Exojththalmic  (ioitre 
Myxu-'dema     .... 


084 
084 
080 
OiiO 
,704 
708 
711 
711 
712 
712 
714 


SECTION  VII. 

DISEASES  OF  THE  KIDNEYS. 

I.  Anomalies  in  Form  and  Position 

Movable  Kidney    . 
II.  Circulatory  Disturbances  . 
III.  Anomalies  of  the  Urinary  Secretion 
1.  IlaMuaturia 

3.  HiL'moglobinuria 
!!.    Mbuminuria     . 

4.  Pyuria  (Pus  in  the  Urine) 
Si.  Chyluria  (Non-parasitic) . 

6.  Lithuria  .... 

7.  Oxaluria  .... 

8.  Cystiiniria 

9.  Phosphaturia    . 

10.  Indicanuria 

11.  Melanuria 

12.  Other  Substances     . 


717 
717 
721 
722 
^22 
723 
725 
729 
730 
730 
733 
734 
734 
735 
736 
736 


CONTENTS. 


xiii 


IV. 
V. 

VI. 


VII. 

VIII. 

IX. 

X, 

XI, 

XII. 

XI 11. 


(Jraimia 

Acute  lirijfht's  Disease 

(.Jhronie  Brij^ht's  Disease  . 

Chronic  Piireuchyiiiatous  Nephritis 
Chronic  I;;tcrstitial  Nejjhritis 

Amyloid  Disease       .... 

Pyelitis 

Hydronephrosis        .... 

Nepiirolithiasis  (Renal  Calculus) 

Tumors  of  the  Kidney 

Cystic  Disease  of  the  Kidney    . 

I'erineplirie  Abscess 


VAOV, 

787 
741 

74« 
747 
74!» 
7r)7 
7.'58 
702 
705 
770 

77a 


SECTION  VIII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


51 
J2 


I.  Diseases  of  the  Nerves 

1.  Neuritis  (Inflammation  of  the  Nerve-fibres) 

2.  Neuronuita 

5J.  Diseases  of  the  Cranial  Nerves 

Olfactory  Nerve 

Optic  Nerve  and  Tract 
Lesions  of  the  Uetina 
Lesions  of  the  Optic  Nervo 
Affections  of  the  Chiasma  and  Tract 
Affections  of  the  Tract  and  Centres 

Motor  Nerves  of  the  Eyeball 

Fifth  Nerve 

Facial  Nerve 

Auditory  Nerve 

Glosso-iiharyngeal  Xervo 

Piieuinogastric  Nerve   .... 

Spinal  Accessory  Nervo 

Hypoglossal  Nerve       .... 
4.  Diseases  of  the  Spinal  Nerves 

Cervical  Plexus 

liraehial  Plexus 

Lumbar  and  Sacral  Plexuses 

Sciatica 

II.  Diseases  of  (iie  .Spimil  Cord      .... 

1.  Affections  of  the  Jleninges 

Diseases  of  the  Dura  Mater  . 
Diseases  of  the  Pia  Slater  . 
llaMnorrhage  into  the  Siiinal  IMcmbranes 

2.  Affections  of  the  Blood-ves.sels 
a.  Acute  Affections  of  the  Spinal  Cord 

Acute  Diffuse  Jlyelitis 
Myelitis  of  the  Anterior  Horns    . 
Acute  and  Subacute  Polio-myelitis  in  Adults 
Acute  Ascending  (Landry's)  Paralysis 
4.  Chronic  Affections  of  the  Spinal  Cord    . 
Spastic  Paraplegia        .... 


775 
775 
781 
782 
782 
783 
783 
78« 
787 
788 
790 
795 
797 
801 
805 
806 
809 
812 
813 
813 
814 
817 
818 
820 
820 
820 
822 
824 
826 
828 
828 
881 
836 
886 
836 
83« 


^  CONTENTS. 

PAOH 

Locomotor  Ataxia 840 

Hereditary  Ataxia  (Friedreich's  Ataxia) MS 

Syringo-inyelia 849 

Compression  of  the  Spinal  Cord 851 

Lesions  of  the  Cauda  Kquina  and  Conus  Medulhiris    ....  854 

Tumors  of  Spinal  Cord  and  its  Membranes 855 

Progressive  (Spinal)  Muscular  Atrophy 857 

Hidbar  Paralysis         .        . 860 

III.  Diseases  of  the  Brain 863 

1.  Affections  of  the  Meninges 862 

Diseases  of  the  Dura  Mater  (Pachymeningitis) 863 

Diseases  of  the  Pia  Mater 863 

2.  Affections  of  the  Blood-vessels 867 

Ilypenemia 867 

Anaemia 868 

CEdeina  of  the  Brain 86!) 

Cerebral  Hii'inori'liago 870 

Emlwlism  and  Thrombosis  (Cerebral  Softening) 878 

Aneurism  of  the  Cerebral  Arteries 883 

Endarteritis 884 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins 885 

8.  Affections  of  the  Substance 887 

Topical  Diagnosis 887 

Aphasia 808 

Inflammation  of  the  Brain 903 

4.  Hemiplegia  and  Diplegia  in  Children 906 

Hemiplegia 906 

Spastic  Diplegia  (Birth  Palsies) 909 

Spastic  Paraplegia 910 

5.  Sclerosis  of  the  Brain 911 

Miliary  Sclerosis 912 

Diffuse  Sclerosis • 912 

Tuberous  Sclerosis ,  913 

Insular  Sclerosis  (Sclerose  en  Plaques) 913 

6.  Chronic  Diffuse  Meniugo-encephalitis 914 

7.  Tumors  of  the  Brain 918 

8.  Chronic  Hydrocephalus 923 

IV.  General  aiul  Functional  Diseases 924 

1.  Acute  Delirium  (Bell's  Mania) 924 

2.  Paralysis  Agitans 926 

Other  Forms  of  Tremor 929 

3.  Acute  Chorea  (Sydenham's  Chorea ;  St.  Vitus's  Dance)  ....  929 

4.  Other  Affections  described  as  Chorea 943 

Chorea  Major;  Pandemic  Chorea 942 

Habit  Spasm  ;  Convilsive  Tic 942 

Saltatoric  Spasm 943 

Chronic  Chorea 944 

Rhythmic  Chorea 945 

J"    Infantile  Convulsions  (Eclampsia) 945 

v..  Epilepsy 948 

Grand  Mai 950 

Petit  Mai 953 


CONTENTS. 


XV 


PAOB 

•'acksonian  Epil^sy 053 

7.  Migraine 957 

8.  Neuralgia 959 

9.  Professional  Spasms ;  Occupation  Neuroses 963 

10.  Tetany 966 

11.  Hysteria 967 

Convulsive  Form 968 

Non-convulsive  Form 969 

12.  Neurasthenia 978 

13.  The  Traumatic  Neuroses 981 

14.  Other  Forms  ot  Functional  Paralysis 985 

Periodical  Paralysis 985 

Astasia — Abasia 98G 

V.  Vaso-motor  and  Trophic  Disorders 987 

1.  Raynaud's  Disease 987 

2.  Angio-neurotic  ffidema 989 

3.  Facial  Ilemi-atrophy 990 

4.  Acromegalia 991 

5.  Scleroderma 993 

Ainhum 994 

SECTION  IX. 
DISEASES  OF  THE   MUSCLES. 

I.  Myositis 995 

II.  Idiopathic  Muscular  Atrophy 996 

1.  Pseudo-hypertrophic  Muscular  Atrophy 996 

2.  Primary  Atrophic  Muscular  Paralysis 997 

III.  Thomsen's  Disease  ;  Myotonia  Congenita 998 

IV.  Paramyoclonus  Multiplex 999 


24 


19 


SECTION  X. 
THE   INTOXICATIONS;  SUN-STROKE;  OBESITY, 

I.  Alcoholism 1001 

1.  Acute  Alcoholism 1001 

2.  Chronic  Alcoholism 1001 

3.  Delirium  Tremens 1003 

II.  Morphia  Habit 1005 

III.  Lead  Poisonir.g .  1007 

IV.  Arsenical  Poisoning 1011 

V.  Ptomaine  Poisoning 1012 

1.  Meat  Poisoning 1013 

2.  Poisoning  by  Milk  Products 1014 

3.  Poisoning  by  Shell-fish  and  Fish 1014 

VI.  Grain  Poisoning 1015 

1.  Ergotism 1015 

2.  Lathyrism 1016 

3.  Pellagra 1016 

VII.  Sun-stroke 1017 

VIII.  Obesity 1019 

'    B 


xvi 


CONTENTa 


SECTION  XI.  • 

DISEASES    DUE  TO  ANIMAL  PARASITES 


I.  Psorospcrniinsis 

1.  Inteniul  Psorospcrmiasis  . 

2,  Cutaneous  Psorosperiniasis 
II.  Distorniasis        .... 

III.  Diseases  causetl  by  Nematodes  . 

1.  Ascariasis  . 

2.  Trichiniasis 

3.  Ankyloslnmiasis 

4.  Filiariasis . 

5.  Drucontiasis 

6.  Other  Nematodes 

IV.  Diseases  caused  by  Cestodes 


V. 
VI. 


Intestinal  Cestodes ;  Tape-worms 
2.  Visceral  Cestodes 

Cysticercus  CellulosiB    . 
Eehinococeus  Disease    . 
Multilocular  Eehinococeus 
Parasitic  Arachnida 
Parasitic  Insects 


VII.  Pseudo-parasites  (Myiasis) 


PAOE 

.  1022 
.  1022 
.  1023 
.  1024 
.  1025 
.  1025 
.  1020 
.  1031 
.  1033 
.  1034 
.  1035 
.  1036 
.  1036 
.  1039 
.  1039 
.  1041 
.  1046 
.  1047 
.  1048 
.  1050 


Hrf 


CHxYETS  AND  ILLUSTRATIONS. 


CHART  PAOB 

].  Typlioid  Fever  with  Relapse 13 

II.  Typhoid  Fever — Hyperpyrexia — Death 14 

III.  Illustrating  the  Blooil  Changes  in  Typhoid  Fever 18 

IV.  Typhoid  Fever — Ilu'inorrhago  from  the  Bowels*         .        .        .        .        ,21 
V.  Illustrating  Influence  of  Baths  in  Typhoid  Fever 85 

VI.  Relapsing  Fever  (after  Murchison) 45 

VII.  Small-pox  (after  Strilmpell) 50 

VIII.  IIa>morrhagic  Small-pox 03 

IX.  Scarlet  Fever  (after  Striiinpell) 70 

X.  Measles  (after  StrUmpell) 78 

XI.  Malaria— Tertian  Ague 148  and  149 

XII.  Illustrating  Heredity  in  Tuberculosis 188 

XIII.  Chronic  Tuberculosis,  Two-hourly  Chart  for  Three  Days  ....  224 

XIV.  Blood   Chart,  illustrating  Rapid   Production  of  Anicmia  in   Purpura 

Ilicmorrhagica 31f) 

XV.  Temperature,  Pulse,  and  Respiration  Chart  in  Pneumonia        .        .        .518 

XVI.  Blood  Chart,  illustrating  Auirmia  in  Purpura  Ilicmorrhagica  .        .        .  685 

XVII.  Blood  Chart,  illustrating  Chlorosis 088 

XVIII.  Blood  Chart,  illustrating  Pernicious  AnaMiiiii 093 

XIX.  Blood  Chart,  illustrating  Lcukicmia 701 

FiaURB 

I.  Optic  and  Visual  Tracts  (after  Starr) 788 

II.  Motor  Area  of  the  Cerebral  Cortex  (after  Mills) 890 

III.  Motor  Tract  (after  Starr) 892 

IV.  Degeneration  of  Pyramidal  Tract  in  Hemisphere,  Crus,  Pons,  and  Me- 

dulla (after  Gowers) 893 

V.  Lichthcim's  Schema  in  Aphasia 899 


*  The  red  shows  the  two-hourly,  the  black  the  morning  and  evening  temperature. 


ii< 


A  TEXT-BOOK  ON 
THE  PRACTICE  OF  MEDICINE. 


SECTION  I. 


SPECIFIC  mFECTIOUS  DISEASES. 


1.  TYPHOID  FEVER. 

Definition. — An  infectious  disease,  characterized  anatomically  by 
hyperplasia  and  ulceration  of  the  lymph-follicles  of  the  intestines,  swell- 
ing of  the  mesenteric  glands  and  spleen,  and  parenchymatous  changes 
in  the  other  organs.  Tlie  bacillus  of  Eberth  is  constantly  present  in  the 
lesions.  Clinically  the  disease  is  marked  by  fever,  a  rose-colored  eruption, 
diarrhoea,  abdominal  tenderness,  tympanites,  and  enlargement  of  the 
spleen ;  but  these  symptoms  are  extremely  inconstant,  and  even  the  fever 
varies  in  its  characters. 

Historical  Note. — The  dates  1813  and  1850  include  the  modern 
discussion  of  the  subject.  Prior  to  the  former  year  many  observers  had 
noted  clinical  differences  in  the  continued  fevers.  Iluxham  in  particular, 
in  his  remarkable  essay,  had  recognized  varieties.  In  1813  Pierre  Breton- 
neau,  of  Tours, distinguished  "dothienenterite  "  as  a  separate  disease;  and 
Petit  and  Serres  described  entero-mesenteric  fever.  Trousseau  and  Vel- 
jjcau,  students  of  Brctonneau,  Avere,  in  1820,  instrumental  in  making  his 
views  known  to  Andral  and  others  in  Paris.  In  1829  Louis'  great  work 
appeared,  in  which  the  name  "  typhoid  "  was  given  to  the  fever.  At  this 
period  typhoid  fever  alone  prevailed  in  Paris,  and  it  was  universally  be- 
lieved to  be  identical  with  the  continued  fever  of  Great  Britain,  where 
in  reality  typhoid  and  typhus  coexisted,  and  the  intestinal  lesion  was 
regarded  as  an  accidental  occurrence  in  the  course  of  ordinary  typhus. 
Louis'  students  returning  to  their  homes  in  different  countries  had 
opportunities  of  studying  the  prevalent  fevers  in  the  thorough  and  sys- 
tematic manner  of  their  master.  Among  these  were  certain  young 
American  physicians,  to  one  of  whom,  Gerhard,  of  Philadelphia,  is  due 
the  great  honor  of  having  first  clearly  laid  down  the  differences  between 
the  two  diseases.  His  papers  in  the  American  Journal  of  the  Medical 
Sciences  are  undoubtedly  the  first  in  any  language  which  give  a  full  and 
2 


SPRriFIC   INFECTIOUS   DISEASES. 


'    I 


if 


it: 


satisfactory  account  of  the  clinical  and  anatomical  di.stinctions  we  now 
recognize.  No  student  rliould  fail  to  read  these  articles,  among  the  most 
classical  in  Anu'rican  medical  literature. 

Louis'  iniluemic  was  early  felt  in  Hoston,  to  which,  in  18IJ3,  James 
Jackson,  Jr.,  had  returned  from  Paris.  In  this  year  he  demonstrated,  in 
his  father's  wards  at  the  Massachusetts  General  Hospital,  the  identity  of 
the  typhus  of  this  country  with  the  typhoid  of  Louis.  He  had  already, 
in  1830,  noticed  the  intestitud  lesions  in  the  common  fever  of  New  Eng- 
land. Though  cut  oir  at  the  very  outset  of  his  career,  we  may  reason- 
ably attribute  to  his  inspiration  the  two  elaborate  memoirs  on  t^'phoid 
fever  which,  in  1838  and  1839,  were  issued  from  the  ^lassachusetts  Gen- 
eral IIos])ital,  by  James  Jackson,  Sr.,  and  Enoch  Hale.  These,  with  Ger- 
hard's articles,  contributed  to  make  typhoid  fever,  as  distinguished  from 
typhus,  widely  recognized  in  the  profession  here  long  before  the  distinc- 
tions were  recognized  generally  in  Euro})e.  Thus,  the  diseases  were  de- 
scribed under  dillercnt  headings  in  the  first  edition  of  IJartlett's  admirable 
work  on  Fevers  published  in  1843. 

The  recognition  in  Paris  of  a  fever  distinct  from  typhoid,  without  in- 
testinal lesions,  was  due  largely  to  the  influence  of  the  able  papers  of 
George  C.  Shattuck,  of  Boston,  and  Alfred  Stille,  of  Philadelphia,  which 
were  read  before  the  Societe  medicale  d'Observatiou  in  1838.  At  Louis' 
request,  Shattuck  went  to  the  London  Fever  Hospital  to  study  the  disease 
in  England,  where  he  saw  the  two  distinct  affections,  and  brought  back  a 
report  which  was  very  convincing  to  the  members  of  the  society. 

Stille  had  the  advantage  of  going  to  Paris  knowing  thoroughly  the 
clinical  features  of  typhus  fever,  for  he  had  been  Gerhard's  house-physician 
at  the  Philadelphia  Hospital,  where  he  had  studied  during  the  epidemic 
of  1836.  At  La  Pitic,  with  Louis,  he  saw  quite  a  different  affection,  while 
in  London,  Dublin,  and  Naples  he  recognized  typhus  as  he  had  seen  it  in 
Philadelphia.  The  results  of  his  observation  were  given  in  an  exhaust- 
ive paper  which  presented  in  tabular  form  the  contrasts  and  distinctions, 
clinical  and  anatomical,  which  we  now  recognize. 

In  Great  Britain  the  non-identity  of  typhus  and  typhoid  was  clearly 
established  at  Glasgow,  where  from  1836  to  1838  A.  P.  Stewart  studied 
the  continued  fevers,  and  in  1840  published  the  results  of  his  observations. 
In  the  decade  which  followed  many  important  works  were  issued  and 
more  correct  views  gradually  prevailed ;  but  it  was  not  until  the  publica- 
tion of  Jenner's  observations  between  1849  and  1851  that  the  question 
was  finally  settled  in  England. 

Etiology. — Typhoid  fever  prevails  especially  in  temperate  climates,  in 
which  it  constitutes  the  most  common  continued  fever.  Widely  distrib- 
uted throughout  all  parts  of  the  United  States  and  Canada,  it  probably 
presents  everywhere  the  same  essential  character. 

It  prevails  most  in  the  autumn  months.  Of  1,889  cases  admitted  to 
the  Montreal  General  Hospital  in  twenty  years,  more  than  fifty  per  cent 


TYPHOID  FKVEU. 


8 


irly 
lied 
ms. 
md 
ica- 
lion 

in 
J-ib- 
|bly 

to 
snt 


were  in  the  months  of  August,  Scptembor,  and  October.  Of  1,381  coses 
treated  during  twelve  years  at  tlio  Toronto  General  Hospital,  7(il  occurred 
iu  these  months  (Graham).     It  has  been  well  called  the  autumnal  fever. 

It  lias  been  observed  to  prevail  most  in  hot  and  dry  seasons.  Accord- 
in"  to  Pettonkofer,  epideniics  are  most  common  when  the  ground-water  ia 
low,  under  which  circumstances  the  springs  and  water-sources  drain  more 
thoroughly  contaminated  foci  and  are  more  likely  to  bo  highly  charged 
with  poison.  It  may  be  also,  as  Baumgarten  suggests,  that  in  dry  seasons 
tlie  poison  is  more  disseminated  by  the  dust. 

Males  and  females  are  about  equally  liable  to  the  disease,  but  males 
with  typhoid  are  much  more  frequently  admitted  into  hospitals. 

Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  The  greatest 
susceptibility  is  between  the  ages  of  fifteen  and  twenty-five.  Of  (JGO  of 
the  Montreal  cases  there  were  under  fifteen  years  of  age,  51 ;  between 
fifteen  and  twenty-five  years,  308 ;  between  twenty-five  and  thirty-five  years, 
153 ;  between  thirty-five  and  forty-fivo  years,  43 ;  between  forty-five 
and  fifty-five  years,  G ;  and  over  fifty-five  years,  9.  Cases  arc  rare  over  sixty. 
It  is  not  very  infrequent  in  childhood,  but  infants  are  rarely  attacked. 
Murchison  has  seen  a  case  at  the  sixth  month.  It  is  stated  that  the  disease 
may  be  congenital  in  cases  in  which  the  mother  has  had  the  disease  late  in 
pregnancy. 

As  in  other  fevers,  not  all  exposed  to  the  infection  take  the  disease, 
and  there  are  grades  of  susceptibility.  Some  families  seem  more  disposed 
to  infection  than  others. 

The  Specific  Germ. — The  researches  of  Eberth,  Koch,  Gaffky,  and 
others  have  shown  that  there  is  a  special  micro-organism  constantly  asso- 
ciated with  typhoid  fever.  It  is  a  rather  short,  thick,  motile  bacillus,  with 
rounded  ends,  in  one  of  which,  sometimes  in  both  (particularly  in  cultures), 
there  can  be  seen  a  glistening  round  body,  believed  to  be  a  spore;  but 
these  polar  structures  are  probably  only  areas  of  dense  protoplasm.  It 
grows  readily  on  various  nutritive  media,  and  on  potato  in  a  characteris- 
tic manner,  as  the  growth  is  invisible.  This  feature  is  not  peculiar  how- 
ever to  the  typhoid  bacillus.  It  is  ditficult  to  differentiate  from  the  bac- 
terium coli  coniimme,  except  by  certain  chemical  tests.  This  organism 
fulfils  two  of  the  requirements  of  Koch's  law — it  is  constantly  present, 
and  it  grows  outside  the  body  in  a  specific  manner.  The  third  require- 
ment, the  production  of  the  disease  experimentally  by  the  cultures,  has  not 
yet  been  met.  Probably  the  animals  used  for  experimentation  are  not  sus- 
cptible  to  typhoid  fever.  The  bacilli  inoculated  in  large  quantities  into 
the  blood  of  rabbits  are  pathogenic,  and  in  some  instances  ulcerative  and 
necrotic  lesions  in  the  intestine  may  be  produced.  But  similar  intestinal 
lesions  may  be  caused  by  other  bacteria,  including  the  huctcrium  coli  com- 
mune. 

The  bacilli  produce  various  poisons,  of  which  Brieger  has  described  a 
ptomaine — typhotoxin,  and  Brieger  and  Frankel  a  toxalbumin;  but  our 


H 


I- 


;u 


I  1 


V'- 


»l 


4  si'kcifk;  infpxtious  diseases. 

inforniution  on  tlieso  substances  is  still  very  (Infective,  (-iilturcs  arc  killod 
at  a  toniiHTatiiro  of  f50°  C.  It  is  not  probable  that  the  typhoid  bacillus  pro- 
duces spores,  but  it  resists  dryin;?  for  days,  liouillon  cultures  are  destroyed 
by  cnrl'oli*;  acid,  1  to  5i()(),  and  by  corrosive  sublimatcf,  I  to  ^,500. 

In  recent  cases  of  typhoid  fever  the  bacillus  is  found  in  the  lymphoid 
tissues  of  the  intestines,  in  the  mesenteric  glands,  in  the  siileen,and  iji  the 
liver.  It  occurs  also  in  irregular  clumps  in  the  contents  of  the  intestines 
and  in  the  stools.  'J'ho  bacillus  is  said  to  have  been  found  rarely  in  the 
blood,  in  tlie  rose-colored  spots  (?),  and  in  the  urine. 

Outside  the  body  the  bacilli  retain  their  vitality  for  weeks  in  water. 
VVhetlier  an  increase  can  occur  is  not  yet  finally  settled.  Holton  denies  it, 
but  the  general  oi)inion  seems  to  be  that  such  increase  may  take  place  to 
some  extent.  They  disappear  from  ordiiuiry  water  in  competition  with 
saprophytes  in  a  few  days.  In  milk  they  undergo  rapid  development  with- 
out changing  the  appearance  of  the  ndlk.  They  may  increase  in  the  soil 
and  retain  their  vitality  for  months.  They  are  not  killed  by  freezing,  but, 
as  Prudden  has  shown,  may  live  in  ice  for  months.  In  many  epidemics 
the  bacilli  have  been  detected  in  the  infected  water.  The  detection  how- 
ever of  the  typhoid  bacillus  in  drinking-water  is  by  no  means  easy,  and 
the  question  in  individual  cases  must  be  settled  by  exports  wlio  have  had 
special  experience  with  this  germ.  IJoth  Prudden  aiul  Ernst  have  found 
it  in  water-filters. 

Modes  of  Conveyance. — («)  Contngion. — Typhoid  fever  is  certainly 
not  a  very  contagious  disease,  but  the  possibility  of  direct  transmission 
must  be  acknowledged.  The  poison  is  not  given  off  from  the  skin  or  in 
the  breath,  but  in  the  freces.  I'ractically  only  those  persons  are  liable  to 
contract  the  disease  in  this  way  who  have  to  do  with  the  stools  or  with  ihe 
body-linen  of  patients.  I  have  known  several  instances  in  which  nurses 
appear  to  have  been  infected  under  these  conditions. 

{b)  Infection  of  water  is  unquestionably  the  most  common  mode  of 
conveyance.  Many  epidemics  have  been  shown  to  originate  in  the  con- 
tamination of  a  well  or  a  spring.  A  very  striking  one  occurred  at  Ply- 
mouth, Pa.,  in  1885,  which  was  investigated  by  Shakespeare.  The  town, 
with  a  population  of  eight  thousand,  was  in  part  supplied  with  drink- 
ing-water from  a  reservoir  fed  by  a  mountain  stream.  During  January, 
February,  and  March,  in  a  cottage  by  the  s'de  of  and  at  a  distance  of  from 
sixty  to  eighty  feet  from  this  stream,  a  man  was  ill  with  typhoid  fever. 
The  attendants  were  in  the  habit  at  night  of  throwing  out  the  evacua- 
tions on  the  ground  toward  the  stream.  During  these  months  the  ground 
was  frozen  and  covered  with  snow.  In  the  latter  part  of  March  and  early 
in  April  there  Avas  considerable  rainf  11  and  a  thaw,  in  which  a  large  part 
of  the  three  months'  accumulation  of  discharges  was  washed  into  the  brook, 
not  sixty  feet  distant.  At  the  very  time  of  this  thaw  the  patient  had  nu- 
merous and  copious  discharges.  About  the  10th  of  April  cases  of  typhoid 
fever  broke  out  in  the  town,  appearing  for  a  time  at  the  rate  of  fifty  a 


TYPHOID   FKVKR.  5 

(lav.  In  all  about  twelve  hundred  people  were  affected.  An  immonso  ma- 
jority of  all  the  cases  wore  in  the  part  of  the  town  which  received  water 
I'loiii  tlie  infected  reservoir. 

Milh  also  may  he  the  source  of  infection.  One  of  the  most  thoronj^hly 
studied  epitlemics  due  to  thia  cause  was  that  investigated  hy  IJallard  in 
I.sliugton.  The  milk  may  ho  contaminated  by  infected  water  used  in 
I'h'iiusiiijj  the  cans.  In  fresh  milk  it  has  been  shown  that  the  genus  grow 
riii)i(lly. 

Kilth,  bad  sewers,  or  cessj)ools  can  not  in  themselves  cause  typhoid 
fever,  but  they  furnish  the  coiulitions  suitable  for  the  preservation  of  the 
bacillus  and  possibly  for  its  propagation. 

[(')  Contann'nad'on  of  the  Soil. — I'ottcnkofer  holds  that  the  poison  is 
not  eliminated  in  a  comlition  ca])ablo  of  communicating  the  disease 
directly,  but  that  it  must  first  undergo  changes  in  the  soil,  which  changes 
are  favored  by  the  grouiul-water. 

It  does  not  seem  probable  that  typhoid  fever  is  communicated  by  tho 
air  alone,  as  by  tho  nu-dium  of  sewer-gas. 

Once  in  the  intestinal  canal  the  typhoid  germs  probably  do  not  like 
the  cholera  bacilli  increase  in  the  secretions,  but  penetrate  tho  epithelial 
lining  and  reach  the  lymphoid  tissue,  u})ou  which  they  exert  their  spe- 
ciiic  action,  causing  a  cell  i)roliferation  greatly  in  excess  of  tho  physiologi- 
cal process.  The  necrosis  may  be  regarded  as  the  result  of  the  maximum 
intensity  of  the  action  of  the  bacilli — an  action  not  confined  to  the  lym- 
phatic api)aratus  of  the  intestinal  wall,  but  also  met  with  in  a  typical  man- 
ner in  the  enlarged  mesenteric  glands  and  in  the  liver  and  s})leen. 

It  has  not  yet  been  definitely  determined  whether  the  c()!\stitutional 
disturbances  in  typhoid  fever  depend  upon  the  toxalbumins  jiroduced  in 
the  growth  of  the  bacilli,  though  this  is  in  tho  highest  degree  i)robable. 

Morbid  Anatomy. — The  statistical  details  uiuler  this  heading  are 
based  ujjon  sixty-four  autopsies,  a  majority  of  which  were  performed  at  tho 
Montreal  Ueneral  Hospital,  and  upon  the  records  of  two  thousand  post- 
luortenis  at  tho  Munich  Pathological  Institute.* 

Intestines. — A  catarrhal  condition  exists  throughout  the  small  and 
large  bowel,  and  to  this  is  due,  in  all  probability,  tiie  diarrluea  with  the 
tliiu  pea-soup-liko  stools.  Associated  with  this  catarrh  there  is  during 
life  some  epithelial  desquamation. 

Specific  changes  occur  in  the  lymphoid  elements  of  the  bowel,  chiefly 
at  tho  lower  end  of  the  ileum.  Tho  alterations  wliieh  occur  are  most  con- 
veniently described  in  four  stages  : 

1.  IFi/perj)Iasin,  which  involves  the  glands  of  Peyer  in  tho  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  tho  large  intestine.  The  follicles 
are  swollen,  grayish-white  in  color,  and  the  patches  may  project  to  a  dis- 
tance of  from  three  to  five  mm.    In  exceptional  cases  they  may  be  still  more 


*  Mlinchener  luedicinische  Wochenschrift,  Xos.  3  and  4, 1891. 


6 


SPECIFIC  INFECTIOUS  DISEASES. 


:! 


1 


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^     I 


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^1 


prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's  head  to 
a  large  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but  project 
to  a  variable  extent.  Occasionally  they  are  very  prominent  and  may  be 
almost  pedunculated.  Microscopical  examination  shows  at  the  outset  a 
condition  of  hyperaemia  of  the  follicles.  Later  there  is  a  groat  increase 
and  accumulation  of  colls  of  the  lymph-tissue  ^vhich  n^ay  even  infdtrato 
the  adjacent  mucosa  and  the  muscularis ;  and  tlio  blood-vessels  are. more  or 
less  compressed,  which  gives  the  whitish  aniT^mic  appearance  to  the  follicles. 
The  colls  have  all  the  characters  of  ordiiuiry  lymph-corpuscles.  Some 
of  them  however  arc  larger,  epithelioid,  and  contain  several  nuclei.  Oc- 
casionally colls  containing  red  blood-corpuscles  are  seen.  This  so-called 
medullary  iniiltration,  Avhich  is  always  more  intense  toward  the  lower  end 
of  the  ileum,  reaches  its  height  from  the  eighth  to  the  tenth  day  and  then 
undergoes  one  of  two  changes,  resolution  or  necrosis.  Death  very  rarely 
takes  place  at  tliis  stage.  I  have  seen  but  one  instance  in  my  series — a 
girl,  aged  twenty-four,  who  died  at  the  end  of  the  first  week  with  severe 
nervous  symptoms  and  in  whoso  ileum  the  lym})h-f()lli('les  were  greatly 
swollen,  pitted  and  cribriform,  but  without  necrosis.  Resolution  is  accom- 
plisliod  by  a  fatty  and  granular  change  in  the  colls,  wliich  are  destroyed 
and  absorbed.  A  curious  condition  of  the  patches  is  produced  at  this 
stage,  in  which  they  have  a  reticulated  appearance,  tlie  2}i('Q'i<'s  «;  surface 
rHic}(Ue.  The  swollen  follicles  in  the  patch  undergo  resolution  and 
shriuk  more  rapidly  than  the  surrounding  framework,  or  what  is  more 
probable  the  follicles  alone  owing  to  the  intense  hyperplasia  become  ne- 
crotic and  disintegrate  leaving  the  little  pits.  In  this  process  superficial 
hamiorrhages  may  result  and  small  ulcers  may  originate  by  the  fusion  of 
these  superficial  losses  of  substance. 

There  is  nothing  distinctive  in  the  hyperplasia  of  tlie  lymph-follicles 
in  typhoid  fever.  Apart  from  this  disease  we  rarely  see  in  adults  a 
marked  affection  of  these  glands  with  fever.  In  children  however  it  is 
not  uncommon  when  death  has  occurred  from  intestinal  affections.  It  ir, 
also  met  with  in  measles,  diphtheria,  and  scarlet  fever. 

2.  Xcrrosis  and  S/onr/In'iif/. — When  the  hvperiilasia  of  the  lymph-fol- 
licles reaches  a  certain  grade  resolution  is  no  longer  possible.  The  blood- 
vessels become  choked,  there  is  a  condition  of  anaemic  necrosis,  and 
slouglis  form  which  must  be  separated  and  thrown  oti.  The  necrosis  is 
probably  due  in  great  part  to  the  direct  action  of  the  bacilli.  The  process 
may  be  superficial,  affecting  only  the  upper  part  of  the  mucous  coat,  or  it 
may  extend  to  and  involve  the  submucosa.  It  is  always  more  intense 
toward  the  ileo-ca^cal  valve,  and  in  very  severe  cases  the  greater  part  of 
the  mucosa  of  the  last  foot  of  the  ileum  may  be  converted  into  a  brownish- 
black  eschar.  The  necrosis  in  the  solitary  glands  forms  a  yellowish  cap 
which  often  involves  only  the  most  prominent  point  of  a  follicle.  The 
extent  to  which  the  necrosis  reaches  is  very  variable.  It  may  pass  deep 
into  the  muscular  coat  reaching  to  or  even  perforating  the  peritonajum. 


TYPHOID  FEVER. 


of 


'>: 


3,  Ulceration. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the 
mucosa  may  not  be  involved  and  the  loss  of  substance  may  be  small  and 
shallow.  More  commonly  the  slough  in  separating  exposes  the  submucosa 
and  muscularis,  particularly  the  latter,  which  forms  the  floor  of  a  majority 
of  all  typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  patch  to 
slough  away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is 
rarely  seen.  Irregularly  oval  and  rounded  forms  are  most  common.  A 
large  patch  may  present  three  or  four  nlcers  divided  by  septa  of  mucous 
membrane.  The  terminal  six  or  eight  inches  of  the  mucous  membrane 
of  the  ileum  may  form  a  large  ulcer,  in  which  are  here  and  there  islands 
of  mucosa.  The  edges  of  the  ulcer  are  usually  swollen,  soft,  sometimes 
congested,  and  often  undermined.  At  a  late  period  the  ulcers  near  the 
valve  may  have  very  irregular  sinuous  borders.  The  base  of  a  typhoid 
ulcer  is  smooth  and  clean,  usually  formed  of  the  submucosa  or  of  the 
muscularis. 

There  may  be  large  ulcers  near  the  valve  and  swollen  hypersemic 
patches  of  Peyer  in  the  upper  part  of  the  ileum. 

4.  Healing. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base  and  gives  to  it  a  soft,  shining  appearance. 
The  mucosa  gradually  extends  from  the  edge,  and  a  new  growth  of  epi- 
thelium is  formed,  The  glandular  elements  are  reformed;  the  healed 
ulcer  is  somewhat  depressed  and  is  usually  pigmented.  Occasionally  an 
appearance  is  seen  as  if  an  ulcer  had  healed  i/i  one  place  and  was  extend- 
ing in  another.  In  death  during  relapse  healing  ulcers  may  be  seen  in 
some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
slouglis,  as,  when  resolution  is  impossible,  the  removal  of  the  necrosed 
part  is  the  first  step  in  the  process  of  repair.  Practically,  in  fatal  cases, 
we  seldom  meet  with  evidences  of  cicatrization,  as  the  majority  of  deaths 
occur  before  this  stage  is  reached. 

Large  Intestine. — 1'he  ciBcum  and  colon  are  affocted  in  about  one 
third  oi  the  cases  (in  nineteen  of  the  sixty-four).  Sometimes  the  solitary 
glands  are  great!}'  enlarged.  The  ulcers  are  usually  larger  in  the  cajcum 
tlian  in  the  colon.  Perforation  of  the  ca;cum  is  rare.  'J'he  app*  ndix  may 
be  involved.  In  my  cases  there  was  ulceration  in  two  and  perforation  in 
one  case.  I  dissected  a  case  in  Montreal  in  which  the  patient  died  three 
months  after  an  attack  of  typhoid  fever,  and  a  localized  abscess  was  found, 
due  to  perforation  of  tiic  appendix.     Death  resulted  from  pylephlebitis. 

Perforation  of  the  Bowel. — In  one  hundred  and  fourteen  cases  of  the 
two  tliousand  Munich  autopsies  (f)-?  per  cent)  and  in  fourteen  instances 
in  my  series,  the  intestine  was  perforated  and  death  caused  by  peritonitis. 
The  perforation  may  occur  iu  ulcers  from  which  the  sloughs  have  already 


.•1 


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8 


SPECIFIC  INFECTIOUS  DISEASES. 


;  I 

J: 


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I 


separated,  or  it  may  be  directly  due  to  the  extension  of  a  necrosis  through 
all  the  coats.  In  only  a  few  cases  is  the  perforation  at  the  bottom  of  a 
clean  thin-walled  ulcer.  In  one  instance  the  perforation  occurred  two 
weeks  after  the  temperature  had  become  normal.  The  sloughs  were,  as  a 
rule,  adherent  about  the  site  of  perforation.  A  majority  of  the  cases  were 
in  small  deep  ulcers.  There  may  be  two  or  even  three  perforations.  The 
orifice  is  usually  within  the  last  foot  of  the  ileum.  In  only  one  of  my 
cases  was  it  distant  eighteen  inches.  Peritonitis  was  present  in  every  in- 
stance. 

Hiemorrhayc  from  the  bowels  occurred  in  ninety-nine  of  the  Munich 
cases,  and  in  nine  of  my  series.  The  bleeding  seems  to  result  directly 
from  the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find 
the  bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a 
firm  clot  was  adherent  to  it.  The  bleeding  may  also  come  from  the  soft 
swollen  edges  of  the  patch. 

The  mesenteric  glands  at  first  show  intense  hyperaemia  and  subse- 
quently become  greatly  swollen.  Spots  of  necrosis  are  common.  In  sev- 
eral of  my  cases  8uj)puration  had  occurred.  The  bunch  of  glands  in  the 
mesentery,  at  the  lower  end  of  the  ileum,  is  especially  involved.  The  re- 
troperitoneal glands  are  .also  swollen. 

The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease. 
In  only  one  of  my  cases  did  it  exceed  (GOO  grammes)  20  ounces  in  weight. 
The  tissue  is  soft,  even  diffluent.  Infarction  is  not  infrequent.  Kupture 
may  occur  spontaneously  or  as  a  result  of  injury.  In  the  Munich  autop- 
sies there  were  five  instances  of  rupture  of  the  spleen,  one  of  which  re- 
sulted from  a  gangrenous  abscess. 

The  liver  sliows  signs  of  parenchymatous  degeneration.  Early  in  the 
disease  it  is  hyper.x'mio,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granu- 
lar and  loaded  with  fat.  Necrotic  areas  occur  in  many  cases,  as  described 
by  Ilandford.  They  have  been  studied  recently  by  Reed  in  Welch's  lab- 
oratory. No  definite  association  could  be  determined  between  the  groups 
of  bacilli  and  the  necrotic  areas.  In  twelve  of  the  Munich  autopsies  liver 
abscess  was  found,  and  in  three,  acute  yellow  atrophy.  Diphtheritic  in- 
flammation of  the  gall-bladder  is  occasionally  met  with.  This  may  lead 
to  perforation  and  fatal  peritonitis. 

The  ki(hiei/s  show  cloudy  swelling,  with  granular  degeneration  of  the 
cells  of  the  convoluted  tubules;  less  commoi.ly  an  acute  nephritis.  A  rare 
condition  dcstiribed  by  Rayer,  Wagner,  and  others  is  the  occurrence  of 
numerous  small  areas  infiltrated  with  round  cells,  which  may  have  the 
appearance  of  Iyrni)homata  (Wagner),  or  may  pass  on  to  softening  and 
suppuration,  producing  the  so-called  miliary  abscesses.  It  is  usually 
a  late  change.  The  bacilli  have  been  found  by  some  observers  in  these 
areas.  The  bacilli  can  be  obtained  by  culture  from  the  kidneys,  and  have 
been  found  in  many  instances  in  sections.    They  have  also  been  found  in 


TYPHOID  FEVER.  0 

the  urine  in  a  few  cases.  Diphtheritic  inflammation  of  the  pelvis  of  the 
kidney  may  occur.  It  was  present  in  three  of  my  cases,  in  one  of  which 
the  tips  of  the  papulae  were  also  affected.  Catarrh  of  the  bladder  is  not 
uijcommon.  Diphtheritic  inflammation  of  it  may  also  occur  Orchitis  is 
occasionally  met  with. 

The  anatomical  changes  in  the  respiratory  organs  are  not  very  numer- 
ous. Ulceration  of  the  larynx  occurs  in  a  certain  number  of  cases ;  in  the 
Munich  series  it  was  noted  one  hundred  and  seven  times.  It  may  come  on 
at  the  same  time  as  the  ulceration  in  the  ileum,  but  the  bacilli  have  not 
yet,  I  believo,  been  found  in  the  ulcers.  They  occur  in  the  posterioi  wall, 
at  the  insertion  of  the  cords,  at  the  base  of  the  epiglottis,  and  on  the  ary- 
epiglottidean  folds.  In  the  later  periods  catarrhal  and  diphtheritic  ulcers 
may  be  present. 

(Edema  of  the  glottis  was  present  in  twenty  of  the  ilunich  cases,  in 
eight  of  which  tracheotomy  was  performed.  Diphtheritic  laryngitis  is  not 
very  uncommon.  It  occurred  in  a  most  extensive  form  in  two  of  my  cases. 
In  one  the  membrane  was  chiefly  in  the  pharynx,  and  extended  only  upon 
the  epiglottis;  in  the  other  there  was  a  uniform  membrane  which  extended 
into  the  trachea  and  in  the  tubes  of  the  second  dimension.  In  eiglit  cases 
in  my  series  there  was  lobar  pneumonia.  Hypostatic  congestion  and  the 
condition  of  the  lung  spoken  of  as  splenization  are  very  common.  Gan- 
grene of  the  lung  occurred  in  forty  cases  in  the  Munich  series ;  abscess  of 
tlie  lung  in  fourteen ;  haemorrhagic  infarction  in  one  hundred  and  tv-'cnty- 
nine.  Pleurisy  is  not  a  very  common  event.  Fibrinous  pleurisy  occurred 
in  about  six  per  cent  of  the  Munich  cases,  and  empyema  in  nearly  two  per 
cent. 

Changes  in  the  Circulatory  System. — Endocarditis  is  rare.  It  was  not 
present  in  any  of  my  cases,  and  existed  in  eleven  only  of  tlie  Munich 
autopsies,  in  which  also  there  were  fourteen  cases  of  pericarditis.  Myo- 
carditis is  not  very  infrequent.  Dewevrc,*  in  a  scries  of  forty-eight 
cases,  found  in  sixteen  granular  or  fatty  degeneration,  and  in  three  a  pro- 
liferating endarteritis  in  the  small  vessels.  It  is  remarkable  tliat  even  in 
cases  of  death  from  heart-failure,  Avith  intense  fever,  the  cell-fibres  may 
present  little  or  no  observable  chuiige.  The  arteries  are  not  infrequently 
involved  in  typhoid  fever.  Barie  distinguislies  an  acute  obliti'rating  arteri- 
tis and  a  partial  arteritis,  and  states  that  they  both  occur  most  commonly 
in  the  arteries  of  the  lower  extremities.  Tliey  are  responsible,  no  doubt, 
for  certain  of  the  cases  of  blocking  of  the  arterial  trunks.  This  arteritis? 
may  affect  the  smaller  vessels,  particularly  those  of  the  heart.  In  tlie 
veins,  thrombi  are  not  infrequently  found,  particularly  in  the  femoral 
veins,  and  more  rarely  in  the  cerebral  sinuses. 

Nervous  System. — There  are  very  few  coarse  changes  met  with.  Men- 
ingitis is  extremely  rare.     It  was  not  present  in  any  one  of  my  autop- 


*  Archives  g^n^ralcs  de  Medecine,  1887,  8. 


J 


10 


SPECIFIC  INFECTIOUS  DISEASES. 


nf 


sies,  and  occurred  in  only  eleven  of  the  two  thousand  Munich  cases.  The 
anatomical  lesion  upon  which  the  aphasia — seen  not  infrequently  in  chil- 
dren— depends,  is  not  known.  Possibly,  as  Leyden  states,  it  may  be  due 
to  slight  encephalitis.  Parenchymatous  changes  have  been  met  with  in 
the  peripheral  nerves,  and  appear  to  be  not  very  uncommon,  even  when 
there  have  been  no  symptoms  of  neuritis. 

The  voluntary  muscles  show,  in  certain  instances,  the  peculiar  changes 
described  by  Zenker  which  occur  in  all  long-standing  febrile  affections 
and  are  not  peculiar  to  typhoid  fever.  The  muscle  substance  within  the 
sarcolemma  undergoes  either  a  granular  degeneration  or  a  hyaline  trans- 
formation. The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the 
pectorals  are  most  commonly  involved. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be 
well  first  to  give  a  general  description  and  then  to  study  more  fully  the 
sypmtoms,  complications,  and  sequelae  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  a  week  to 
ten  days,  during  wliich  there  are  feelings  of  lassitude  and  inaptitude  for 
work.  The  onset  is  rarely  abrupt.  There  may  be  prodromal  symptoms, 
either  a  rigor,  which  is  rare,  or  chilly  feelings,  headache,  nausea,  loss  of 
appetite,  pains  in  the  back  and  legs,  and  nose-bleeding.  These  symptoms 
increase  in  severity  and  the  patient  at  last  takes  to  his  bed.  From  this 
event,  in  a  majority  of  eases,  the  definite  onset  of  the  disease  may  be  dated. 
Dui'ing  the  first  week  there  is,  in  some  cases  (but  by  no  means  in  all,  as 
has  long  been  taught),  a  steady  rise  in  the  fever,  the  evening  record  rising 
a  degree  or  a  degree  and  a  half  higher  each  day,  reaching  103°  or  104°. 
The  pulse  is  rapid,  from  100  to  110,  full  in  volume,  but  of  low  tension 
and  often  dicrotic;  the  tongue  is  coated  and  white;  the  abdomen  is 
slightly  distended  and  tender.  Unless  the  fever  is  high  there  is  no  de- 
lirium, but  the  patient  complains  of  headache,  and  there  is  mental  con- 
fusion and  wandering  at  night.  The  bowels  may  be  constipated,  or  there 
may  be  two  or  three  loose  movements  daily.  Toward  the  end  of  the  week 
the  spleen  becomes  enlarged  and  the  rash  appears  in  the  form  of  rose- 
colored  spots,  seen  first  on  the  dkin  of  the  abdomen.  Cough  and  bron- 
chitic  symptoms  are  not  uncommon  at  the  outset. 

In  the  second  wech^  in  cases  of  moderate  severity,  the  symptoms  be- 
come aggravated ;  the  fever  remains  high  and  the  morning  reinission  is 
slight.  The  pulse  is  rapid  and  has  lost  its  dicrotic  character.  There  is 
no  longer  headache,  but  there  is  mental  torpor  and  dulness.  The  face 
looks  heavy ;  the  lips  are  dry ;  the  tongue,  in  severe  cases,  becomes  dry 
also.  The  abdominal  symptoms  are  more  marked — diarrha-a,  tympanites, 
and  tenderness.  Death  may  occur  during  this  week,  with  pronounced 
nervous  symptoms,  or,  toward  the  end  of  it,  from  haemorrhage  or  perfora- 
tion. In  mild  cases  the  fever  declines,  and  by  the  fourteenth  day  may  bo 
normal. 

In  the  third  week,  in  cases  of  moderate  severity,  the  pulse  ranges  from 


TYPHOID  FEVER. 


11 


110  to  130 ;  the  temperature  now  sliows  marked  morning  remissions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  flesh  is  now  more 
noticeable,  and  the  weakness  is  pronounced.  The  diarrhoea  and  meteor- 
ism  may  persist.  Unfavorable  symptoms  at  this  stage  are  the  pulmo- 
nary complications,  increasing  feebleness  of  the  heart,  and  pronounced 
delirium  with  muscular  tremor.  Special  dangers  are  perforation  and 
haemorrhage. 

With  the  fourth  week,  in  a  majority  of  instances,  convalescence  be- 
gins. The  temperature  gradually  reaches  the  normal  point,  the  diarrhoea 
stops,  the  tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases 
the  fourth  week  may  present  an  aggravated  picture  of  the  third ;  the 
patient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the  tongue  dry, 
and  the  abdomen  distended.  He  lies  in  a  condition  of  profound  stupor, 
with  low  muttering  delirium  and  subsultus  tendinum,  and  passes  the 
faeces  and  urine  involuntarily.  Heart-failure  and  secondary  complications 
are  the  chief  dangers  of  this  period. 

In  the  fifth  and  sixth  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In 
this  period  we  meet  with  relapses  in  the  milder  forms  or  slight  recru- 
descence of  the  fever.  At  this  time,  too,  occur  many  of  the  complications 
and  sequelae. 

Special  Features  and  Symptoms. — Mode  of  Onset. — As  a  rule,  the 
symptoms  develoj)  insidiously,  and  the  patient  is  unable  to  fix  definitely 
the  time  at  which  he  began  to  feel  ill.  The  following  are  the  most  im- 
portant deviations  from  this  common  course  : 

{a)  Onset  with  Pronounced  Nervous  Manifestations. — Headache,  of  a 
severe  and  intractable  nature,  is  by  no  means  an  infrequent  initial  symp- 
tom. Again,  a  severe  facial  neuralgia  may  for  a  few  days  ])\\i  the  practi- 
tioner off  his  guard.  In  cases  in  which  the  patients  have  kept  about  and, 
as  they  say,  fought  the  disease,  the  very  first  manifestations  may  be  pro- 
nounced delirium.  Such  patients  may  even  leave  home  and  wander  about 
for  days.  In  rare  cases  the  disease  sets  in  witli  the  most  intense  cerebro- 
spinal symptoms,  simulatijig  meningitis — severe  headache,  photophobia, 
retraction  of  the  head,  twitching  of  the  muscles,  and  even  convulsions. 
Occasionally  drowsiness,  stupor,  and  signs  of  basilar  meningitis  may  exist 
for  ten  days  or  more  before  the  characteristic  syin2)tonis  develop ;  occasion- 
ally the  onset  is  with  mania. 

{b)  With  Pronounced  Pulmonary  Symptoms. — The  initial  bronchial 
catarrh  may  be  of  great  severity  and  disguise  the  otlicr  features  of  the 
disease.  More  striking  still  are  those  cases  in  which  the  disease  sets  in 
with  a  single  chill,  with  pain  in  the  side  and  all  the  characteristic  features 
of  lobar  pneumonia. 

(c)  With  Intense  Gastro-intest innl  Symptoms. — The  vomiting  may  be 
incessant  and  uncontrollable.  Occasionally  there  are  cases  with  such  in- 
tense vomiting  and  diarrhcoa  that  a  suspicion  of  poisoning  may  be  aroused. 


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{(I)  With  Symptoma  of  an  Acute  Nephritis. — Smoky  or  bloody  urine, 
witli  much  albumen  and  tube-easts. 

(c)  Ambulatory  Form. — Deserving  of  especial  mention  arc  those  cases 
of  typhoid  fever  in  which  tlie  patient  keeps  about  and  attempts  to  do 
work,  or  perhaps  takes  a  long  journey  to  his  home.  lie  may  come  under 
observation  for  the  first  time  with  a  temperature  of  104°  or  105°,  and  tlio 
rash  well  ont.  Such  cases  seem  always  to  run  a  more  severe  course  than 
others,  and  in  general  hospitals  they  contribute  largely  to  the  total  mor- 
tality. Finally,  there  are  rare  instances  in  which  the  first  symptoms  are 
perforation,  or  a  profuse  haemorrhage  from  the  bowels. 

Facial  Aspect. — Early  iu  the  disease  the  cheeks  arc  flushed  and  the 
eyes  bright.  Toward  the  end  of  the  first  week  the  expression  becomes 
more  listless,  and  when  the  disease  is  well  established  the  expression  is  dull 
and  heavy. 

Fever. — {a)  Regular  Couri".  (Chart  I.) — In  the  stage  of  invasion 
the  temperature  may  rise  steadily  during  the  first  five  or  six  days.  The 
evening  temperature  is  about  a  degree  or  a  degree  and  a  half  higher  than 
the  morning  remission,  so  that  a  temperature  of  104°  or  105°  is  not  un- 
common by  the  end  of  the  first  week.  Having  reached  the  fastigium  or 
height,  the  fever  then  persists  with  slight  morning  remissions.  The  tem- 
perature curve  follows  the  normal  diurnal  variations,  the  maximum  oc- 
curring between  four  and  eight  o'clock  in  the  evening  and  the  minimum 
between  four  and  eight  in  the  morning.  At  the  end  of  the  second  and 
throughout  the  third  week  the  temperature  becomes  more  distinctly  re- 
mittent. The  difference  between  the  morning  and  evening  may  be  three 
or  four  degrees,  and  the  morning  temperature  may  even  be  normal.  It 
falls  by  gradual  lysis,  and  the  temperature  is  not  considered  normal  until 
the  evening  record  is  at  98-3°. 

(b)  Variations  in  the  normal  temperature  curve  are  common.  We  do 
not  always  see  the  gradual  step-like  ascent  in  the  early  stage ;  the  cases 
do  not  often  come  under  observation  at  this  time.  When  the  disease  sets 
in  with  a  chill,  the  temperature  may  rise  at  once  to  103°  or  104°.  In 
many  cases  defervescence  occurs  at  the  end  of  the  second  week  and  the 
temperature  may  fall  rapidly,  reaching  the  normal  within  twelve  or  twenty 
hours.  An  inverse  type  of  temperature,  high  in  the  morning  and  low  in 
the  evening,  is  occasionally  seen  but  has  no  especial  significance. 

Sudden  falls  in  the  temperature  may  occur ;  thus,  as  shown  in  Chart 
IV',  a  drop  of  10°  may  follow  an  intestinal  haemorrhage,  and  the  fall  may 
bo  very  apparent  even  before  the  blood  has  appeared  in  the  stools.  Hy- 
perpyrexia, temperature  above  10G°,  is  not  very  common  in  typhoid  fovcr 
except  just  before  death,  when  I  have  known  the  thermometer  to  register 
10a'5°.    (Chart  II.) 

(c)  Post-Typhoid  Elevations — Fever  of  Convalescence. — During  con- 
valescence, after  the  temperature  has  been  normal,  perhaps  for  five  or 
six  days,  the  fever  may  rise  suddenly  to  102°  or  103°,  and,  after  per- 


V 

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V 


14 


SPECIFIC   INFECTIOUS  DISEASES. 


sisting  for  from  one  to  three  days  or  even  longer,  falls  to  normal.  With 
this  there  is  no  constitutional  tlistiirbance,  no  furring  of  the  tongue,  no  dis- 
tention of  the  abdomen.  These  so-called  recrudescences  are  by  no  means 
uncommon,  and  are  of  especial  importance,  as  they  cause  great  anxiety  to 
the  practitioner.  They  are  attributed  most  frequently  to  errors  in  diet, 
constipation,  emotions,  and  excitement  of  any  sort,  such  as  seeing  friends. 
There  are  cases  in  which  the  temperature  declines  almost  to  the  nor- 
mal at  the  end  of  the  third  week,  the  tongue  cleans,  and  the  patient  enters 


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CuART  II. — Hyperpyrexia — death. 

apparently  upon  a  satisfactory  convalescence.  The  evening  temperature, 
however,  does  not  reach  98-5°,  but  constantly  keeps  about  99-5°  or  100°, 
and  occasionally  rises  to  100-5°.  This,  in  the  late  stages  of  convalescence, 
I  have  seen  due  to  the  post-typhoid  anaemia.  Complications  should  be 
carefully  looked  for,  particularly  insidious  pleurisy  or  bone  lesions. 

In  certain  of  these  cases  the  persistence  of  the  fever  seems  to  be  really 
a  nervous  phenomenon,  and  there  is  nothing  in  the  condition  of  the 
patient  to  cause  uneasiness  except  the  evening  elevation  of  temperature. 
If  the  tongue  is  clean,  the  appetite  good,  and  there  are  no  intestinal 
symptoms,  it  may  be  disregarded.  1  have  frequently  found  this  condition 
best  met  by  allowing  the  patient  to  get  up  and  by  stopping  the  use  of  the 
thermometer.    This  prolonged  slight  elevation  of  the  fever  after  the  dis- 


I 


TYPHOID  FEVER. 


15 


appearance  of  all  the  symptoms  is  most  common  in  children  and  in 
patients  of  nuirkod  nervous  temperament. 

((/)  The  Fever  of  the  Relapse. — This  is  a  repetition  in  many  instances 
of  tlie  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at 
a  certain  height  and  then  a  gradual  leeline.  It  is  shorter  than  the  original 
jiyrexia,  and  rarely  continues  more  than  two  or  three  weeks.     (Chart  I.) 

(e)  Afebrile  7'i/phouL — There  are  cases  described  in  whicli  the  chief 
features  of  the  disease  have  been  present  without  tlie  existence  of  fever. 
They  are  extremely  rare  in  this  country.  No  instance  of  the  kind  has 
come  under  my  observation. 

Skin. — The  rash  of  typhoid  fever  is  very  characteristic.  It  consists 
of  a  number  of  rose-colored  spots,  which  appear  from  the  seventh  to  the 
tenth  day,  usually  first  upon  the  abdomen.  The  spots  are  flattened 
papules,  slightly  raised,  of  a  rose-red  color,  disappearing  on  pressure,  and 
ranging  in  diameter  from  two  to  four  millimetres.  They  can  be  felt  as 
distinct  elevations  on  the  skin.  Sometimes  each  spot  is  capped  by  a  small 
vesicle.  The  spots  may  be  dark  in  color  and  occasionally  become  pete- 
ahial.  After  persisting  for  two  or  three  days  they  gradually  disappear, 
leaving  a  brownish  stain.  They  come  out  in  successive  crops,  but  rarely 
appear  after  the  middle  of  the  third  week.  They  are  present  in  the  typ- 
ical relapse.  The  rash  is  most  abundant  upon  the  abdomen  and  lower 
thoracic  zone  and  often  abounds  upon  the  back.  It  is  extremely  variable 
in  degree.  There  are  cases  in  which  it  spreads  to  the  extremities  and  often 
to  the  face.  I  can  not  say  that  in  my  experience  these  cases  with  the 
more  abundant  eruption  have  been  of  specially  severe  type.  The  rash  is 
not  always  present.  Murchison  states  that  it  is  frequently  absent  in 
children. 

A  branny  desquamation  is  not  rare  in  cases  in  which  the  sudaminal 
vesicles  have  been  abundant;  occasionally  the  skin  may  peel  in  large 
flakes. 

The  following  accidental  rashes  are  met  with  in  typhoid  fever : 

1.  Erythema. — It  is  not  very  uncommon  in  the  first  week  of  typhoid 
fever  to  find  the  skin  of  a  vivid  red  color,  almost  like  a  scarlatinal  rash. 
This  is  particularly  noticeable  on  the  abdomen  and  chest,  but  the  rash 
may  spread  to  the  extremities.  It  may  possibly  in  some  instances,  but 
certainly  not  always,  be  due  to  quinine.  I  have  seen  it  much  more  fre- 
quently in  the  past  five  years  (during  which  time  I  have  rarely  ordered 
a  dose  of  quinine  in  this  disease)  than  I  did  in  Montreal,  where  we  used 
quinine  largely  as  an  antipyretic. 

3.  The  tache  hleudtre — Feliomata. — These  are  pale-blue  sj)ots,  subcu- 
ticular, from  4  to  10  mm.  in  diameter,  of  irregular  outline  and  most 
abundant  about  the  chest,  abdomen,  and  thighs.  They  sometimes  give  a 
very  striking  appearance  to  the  skin.  It  can  be  readily  seen  that  the  in- 
jection is  in  the  deeper  tissues  and  not  superficial.  This  rash  is  quite 
without  significance.    Since  my  attention  was  called  to  its  association  with 


16 


SPECIFIC   INFECTIOUS  DISEASES. 


I 


I 


is 


body  licp,  I  have  met  with  no  instance  in  which  these  were  not  present. 
Several  Frencih  observers  maintain  that  they  are  duo  to  the  irritating 
effects  of  the  fluid  secreted  by  pediculi. 

3.  Sudaminal  and  miliary  eruptions  are  common  in  all  cases  in  whicli 
there  is  profuse  sweatin;;. 

4.  Urticaria  is  occasionally  met  with,  and  lastly  herpes,  but  this  is  un- 
common in  comparison  witli  its  frequency  in  malaria  and  pneumonia. 

The  iarhe  rcirfuuilc,  a  red  line  with  white  borders,  can  be  produced 
by  drawinjf  the  nail  over  the  skin.  It  is  a  vaso-motor  phenomenon  which, 
as  in  other  fevers,  can  bo  readily  elicited,  ])articularly  in  nervous  sub- 
jects. Jlere  may  be  mentioned  certain  other  cutaneous  jihenomena  also 
of  vaso-motor  nature :  thus  exposure  of  the  abdomen  may  be  sufficient  to 
cause  a  pinkish  injection,  which  may  in  places  change  to  an  ivory  white, 
giving  a  curious  mottled  appearance  to  the  skin.  A  similar  appearance 
may  be  seen  on  the  arms.  The  general  tint  may  be  white,  with  irregu- 
lar patches  or  streaks  of  pink  or  dark  red. 

Sweats. — At  the  height  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  ser  the  abdomen  or  chest 
moist  with  pers})iration,  particularly  in  the  reaction  which  follows  the 
bath.  Sweats  in  some  instances  constitute  a  striking  feature  of  the  dis- 
ease. They  may  occasionally  be  associated  with  chilly  sensations  or  actual 
chills.  Jaccoud  and  others  in  France  have  especially  described  this 
fmdornl  form  of  typhoid  fever.  There  may  be  recurring  paroxysms  of 
chill,  fever,  and  sweats  (even  several  in  twenty-four  hours),  and  the  case 
may  be  mistaken  for  one  of  intermittent  fever.  The  fever  toward  the 
end  of  tlie  second  week  and  during  the  third  week  may  be  intermittent. 
The  characteristic  rash  is  usually  present,  and  if  absent  the  negative  con- 
dition of  the  blood  is  sufficient  to  exclude  malaria.  I  have  seen  cases  of 
this  form  in  Montreal,  where  there  could  have  been  no  suspicion  of  ma- 
larial infection. 

(Edema  of  the  skin  occurs  : 

1.  As  the  result  of  vascular  obstruction,  most  commonly  of  a  vein,  as 
in  thrombosis  of  the  femoral  vein. 

2.  In  connection  with  nephritis. 

3.  In  association  with  the  anaemia  and  cachexia. 

The  hair  is  very  apt  to  fall  out  after  an  attack  of  typhoid  fever.  In- 
stances of  permanent  baldness  are  of  extreme  rarity.  As  in  other  diseases 
associated  with  fever  the  nutrition  of  the  nails  suffers,  and  during  and 
after  convalescence  a  transverse  ridge  is  seen. 

And,  lastly,  it  is  stated  that  a  peculiar  odor  is  exhaled  from  the  skin  in 
typhoid  fever.  Whether  due  to  a  cutaneous  exhalation  or  not,  there  cer- 
tainly is  a  very  distinctive  smell  connected  with  many  patients.  I  have 
repeatedly  had  my  attention  directed  to  it  by  nurses.  Nathan  Smith 
describes  it  as  of  a  "  semi-cadaverous,  musty  character." 

Circulatory  System. — The  blood  presents  important  changes.     The 


W 


TYPHOID   FEVER. 


17 


as 


ith 


followinf:^  atatomonts  aro  hasotl  on  studies  wliicih  W.  S.  Thayer  has  made 
ill  my  ward.  .Uuriujj  the  first  two  weeks  there  may  be  little  or  no  change 
in  the  blood.  Profuse  sweats  or  copious  diarrht«a  may,  as  llaycm  luus 
shown,  cause  the  corpuscles — as  in  the  collapse  stage  of  cholera — to  rise 
above  nornuil.  In  the  third  week  a  fall  usually  takes  place  in  corpuscles 
and  luemoglobin  and  the  number  may  sink  ra])idly  even  to  1,.'{()0,()0()  per 
c.  mm.,  gradually  rising  to  normal  during  convalescence.  Wlusn  the 
patiei\t  first  gets  up,  there  may  be  a  slight  fall  in  the  number  of  the  oor- 
pii.scles. 

The  amount  of  luemoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  number  of  red  corpuscles,  and  during  recov- 
ery the  normal  color  standard  is  reached  at  a  later  period.  'I'lie  number 
of  colorless  corpuscles  varies  little  from  the  normal  standard  ((!,()U0  ±  per 
c.  mm.).  As  a  rule,  perhaps  the  number  is  slightly  subnormal  (Pee). 
This  fact  is  important,  and  may  be  at  times  of  real  diagnostic  value  in 
ilistiiiguishing  typhoid  fever  from  various  septic  fevers  and  acute  inflam- 
matory processes  in  which  there  is  leucocytosis. 

The  accom2)anying  blood-chart  shows  these  changes  well. 

The  post-typhoid  aiuemia  may  reach  an  extreme  grade.  In  one  of  my 
cases  the  blood-cori)uscles  sank  to  1,300,000  per  cubic  mm.  and  the  haemo- 
globin to  about  twenty  i)er  cent.  These  severe  grades  of  anaunia  are  not 
common  in  my  experience.  In  the  Munich  statistics  there  were  fifty- 
four  cases  with  general  and  extreme  aniumia. 

Of  changes  in  the  blood  plasma  very  little  is  known. 

The  jmhc  in  typhoid  fever  presents  no  special  characters.  It  is  in- 
creased in  rapidity  in  proportion  to  the  heiglit  of  the  fever.  As  a  rule,  in 
the  first  week  it  is  above  100,  full  in  volume  and  often  dicrotic.  There  is 
no  acute  disease  with  which,  in  the  early  stage,  a  dicrotic  pulse  is  so  fre- 
quently associated.  Even  with  high  fever  the  jmlso  may  not  be  greatly 
accelerated.  As  the  disease  progresses  the  pulse  becomes  more  rapid, 
feebler,  and  small.  In  the  extreme  prostration  of  severe  cases  it  may 
reach  150  or  more,  and  is  a  mere  undulation — the  so-called  running  pulse. 
The  lowered  arterial  pressure  is  manifest  in  the  dusky  lividity  of  the  skin 
and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 
sionally becomes  very  slow.  After  no  other  acute  fever  do  Ave  so  fre- 
quently meet  with  bradycardia.  I  have  counted  the  pulse  as  low  as 
thirty,  and  instances  are  on  record  of  still  fewer  beats  to  the  minute. 

The  heart-sotmds  are  at  first  clear  and  loud,  and  free  from  murmur, 
but  in  severe  cases,  as  the  prostration  develops,  the  first  sound  becomes 
feeble  and  there  is  often  to  be  heard,  at  the  apex  and  along  the  left  sternal 
margin,  a  soft  .systolic  murmur.  The  first  sound  may  be  gradually  anni- 
hilated, as  pointed  out  by  Stokes.  In  the  extreme  feebleness  of  the  ataxic 
forms,  the  first  and  second  sound  become  very  similar  and  the  long  pause 
is  much  shortened.        . 


1 1 


i|  lii 


'  ']' 


18 


si'kcikk;  inkkotious  diskasks. 


Of  curdiac!  cornpIiiMiUotiH,  pcrimrUitifi  is  ruro  and  has  boon  mot  with 
cluody  in  children  and  in  association  with  jinounionia.  It  was  not  prca- 
cnt  in  any  of  niy  (iascs  and  occuirrcd  in  only  fourteen  of  the  two  thousand 


tOQ% 


BLACK,  RED  CORPUSCLES. 


REO.HAEMOGLOalN. 

Chart  lil. 


MEAN  NORM, 

NUMBEn  Of 

WHITE 

cORPuacLEa 


BLUE,  COLORLESS  CORPUSCLES. 


Munich  post-mortems.  Endocarditis  is  also  uncommon,  I  saw  one  case 
at  the  Philadelphia  Hospital.  It  must  be  very  rare,  as  there  were  only 
eleven  cases  noted  in  the  Munich  records.  Myocarditis  is  more  common. 
The  following  statement  may  be  made  with  reference  to  the  condition  of 
the  licart-muscle  in  this  disease :  In  protracted  cases  the  muscle-fibre  is 
usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color.  The  softening 
may  be  extreme,  though  rarely  of  the  grade  described  by  Stokes,  in  which, 
when  held  apex  up  by  the  vessels,  the  organ  collapsed  over  the  hand. 


TYI'IIOII)   KF.VKU. 


10 


fonniiij?  a  musliroom-liko  raj).  Micro.scopicnlly,  tlio  filn'cs  may  sliow  littlo 
or  no  climi^^c,  evfii  whoii  tlin  inipiilso  of  tin-  licart  liarf  bcfii  ('xtrcriK'ly  fcc- 
l)l('.  A  ^'ramilar  paivncliyniatoiis  (U-gc^iicralioii  is  ('(tjiitnoii.  Fatty  <l<'j,'t'n- 
cralioii  may  bo  prcsont,  particularly  in  l()n<,'-,stan(liiij^  cases  with  ati;cinia. 
'Clio  hyaline  change  is  not  common.  The  st'j^riK^ntin;?  myocarditis,  in 
which  tlio  comcnt  stihstanco  is  softened  ho  that  tiio  miiscle-oella  separate, 
has  also  been  found,  l)ut  it  is  })robably  a  post-mortem  chan<,'e. 

Complications  in  the  Ar/ttrirs. — Obliteration  of  lar<.a!  or  stmill  arterial 
iriinks  is  one  of  the  rare  complications  of  typhoid  fever.  A  considerable 
number  of  cases  are  scattered  through  the  literature.  'J'h((  obliteration 
may  bo  duo  either  to  embolism  or  to  thrombosis.  In  a  nuijority  of  cases 
tiio  femoral  artery  is  involved  and  gangrene  of  the  foot  and  leg  occurs. 
In  several  cases  there  has  been  obliteration  of  both  femorals  with  extension 
of  the  clot  into  the  aorta  and  gangrene  of  both  legs.  In  a  case  which  I 
saw  with  Iloddick,  of  Montreal,  the  ol)literatioii  of  the  left  femoral 
occurred  on  the  sixteenth  day.  On  the  twentieth  day  the  patient  had 
pain  in  the  right  leg  and  there  was  no  i)ulsation  in  the  femoral  urtery. 
Gangrene  gradually  developed  in  both  feet,  and  death  took  ])lace  in  the 
sixth  week.  In  these  cases  the  condition  is  prcjbably  duo  to  thrombosis, 
not  end)olistn,  and  is  associated  with  a  blood  state  Avhich  favors  clotting, 
or  possil)ly  with  a  local  arteritis.  The  condition  is  not  invariably  fatal. 
Of  twenty  cases  collected  by  IJarchoud,*  eight  died. 

Thrombi  in  the  Veina. — This  is  a  much  more  frequent  complication, 
and,  according  to  Murchison,  is  met  with  in  about  one  per  cent  of  the 
cases.  It  occurs  most  frequently  in  a  crural  vein,  and-  more  commonly  in 
the  left  than  in  the  right ;  duo  possibly,  as  suggested  by  Liel)ermeister,  to 
the  fact  that  the  left  common  iliac  vein  is  crossed  by  the  right  iliac 
artery,  and  does  not  permit  of  so  free  a  flow  of  blood  as  in  the  right  vein. 
Thrombosis  is  indicated  by  enlargement  and  anlema  of  the  limb,  but  gan- 
grene never  results  from  obstruction  of  the  vein  alone.  It  is  not  a  very 
xinfavorable  complication.  In  one  case  of  my  series  the  thrombus  had 
suppurated  and  there  was  pyaemia.  Occasionally  the  thrombosis  may 
extend  into  the  pelvic  veins  and  into  the  vena  cava.  In  one  instance  the 
thrombus  was  in  the  right  circumflex  iliac  vein  alone,  and  the  superficial 
veins  on  the  right  side  of  the  abdomen  were  in  conse<iucnce  greatly  en- 
larged.    Sudden  dtnith  has  been  caused  by  dislodgment  of  a  thrombus. 

Infarcts  in  the  kidneys,  spleen,  and  lungs  are  by  no  means  uncommon 
in  typhoid  fever.  They  are  associated  usually  with  thrombosis  in  the 
arteries,  rarely  with  embolism. 

Digestive  System. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  Thirst  is  constant,  and 
should  be  fully  and  freely  gratified.  Even  when  the  mind  becomes  be- 
numbed and  the  patient  no  longer  asks  for  water,  it  should  be  freely  given. 


*  Paris  Thesis,  1881. 


so 


SPECIFIC  INFECTIOUS  DISEASES. 


'i 


l\ 


'H 


■i 


Tlio  tongue  prescnta  the  clianges  inevitable  in  a  prolonged  fever,  but  there 
are  no  distinctive  characters.  Early  in  the  disease  it  i>'  moist,  swollen, 
and  coated  with  a  thin  white  fur,  which,  as  the  disease  progresses,  becomes 
denser.  It  may  remain  moist  throughout.  In  severe  cases,  particularly 
those  with  delirium,  the  tongue  becomes  very  dry,  partly  owing  to  the 
fact  that  such  patients  breathe  with  the  mouth  open.  It  may  be  covered 
with  a  brown  or  brownish-black  fur,  or  with  crusts  between  which  are  cracks 
and  fissures.  In  these  cases  the  teeth  and  lips  may  be  covered  with  a  dark 
brownish  matter  called  tordes — a  mixture  of  food,  epithelial  debris,  Viwdi 
micro-organisms.  By  keeping  the  mouth  and  tongue  clean  from  the  out- 
set the  fissures,  which  are  extremely  painful,  may  be  prevented.  During 
convalescence  the  tongue  gradually  becomes  clean,  and  the  fur  is  thrown 
off,  either  insensibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished  ;  salivation  is  rare. 

ParotitiH  is  not  so  common  as  in  typhus  fever.  It  was  present  in 
forty-five  of  the  two  thousand  Munich  cases.  It  did  not  occur  in  any  of 
my  series  of  fatal  cases.  It  is  usually  unilateral,  and  in  a  majority  of 
cases  goes  on  to  suppuration.  It  is  icgarded  as  a  very  fatal  complication, 
but  recovery  has  followed  in  four  or  five  of  my  cases.  It  undoubtedly 
maj  arise  from  extension  of  inflammation  along  Steno's  duct.  This  is 
probably  not  so  serious  a  form  as  when  it  arises  from  metastatic  inflam- 
mation. 

The  pharynx  may  be  the  seat  of  slight  catarrh.  Sometimes  the  fauces 
are  deei)ly  congested.  ^Membranous  pharyngitis  is  a  serious  and  fatal 
complication,  which  may  come  on  in  the  third  week. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting 
are  not  common.  There  are  instances,  however,  in  which  vomiting,  re- 
sisting all  measures,  is  a  marked  feature  from  the  outset,  and  may  directly 
cause  death  from  exhaustion.  Vomiting  does  not  often  occur  in  the  sec- 
ond and  third  week,  unless  tissociated  with  some  serious  complication.  In 
a  few  of  these  cases  ulcers  have  been  found  in  the  stomach. 

Of  intestinal  symptoms,  diarrliwa  is  the  most  important.  In  some 
epidemics  constipation  exists,  but  in  any  long  series  of  cases  diarrhoea 
will  be  found  to  be  a  prominent  feature  of  the  disease.  Its  absence  must 
not  be  taken  as  an  indication  that  the  intestinal  disease  is  of  slight  ex- 
tent. I  have  seen,  on  several  occasions,  the  most  extensive  infiltration 
and  ulceration  of  the  Peyer's  glands  of  the  small  intestine,  Avith  the  colon 
filled  with  solid  fseces.  The  diarrhoea  is  caused  less  by  the  ulcers  than  by 
the  associated  catarrh,  and,  as  in  tuberculosis,  it  is  probable  that  when  this 
is  in  the  large  intestine  the  discharges  are  more  frequent.  It  is  most 
common  toward  the  end  of  the  first  and  throughout  the  second  week,  but 
it  may  not  occui  until  the  third  or  even  the  fourth  week.  The  number 
of  discharges  ranges  from  three  to  eight  or  ten  in  the  twenty-four  hours. 
They  are  usually  abundant,  thin,  grayish-yellow,  granular,  of  the  con- 
sistency and  a]>pearanco  of  pea-soup,  and  resemble  very  much,  as  Addison 


If 

in 


TYIMIOII)    FKVKR. 


21 


remarked,  tlie  normal  contents  of  the  small  bowel.  The  reaction  is  alka- 
line and  the  odor  olTensive.  On  standing,  the  discharges  separate  into  a 
til  in  serous  layer,  containing  albumen  and  salts,  and  a  lower  stratum,  con- 
sisting of  epithelial  debris,  remnants  of  food,  and  numerous  crystals  of 
triple  phosphates.     Blood  may  be  in  small  amount,  and  only  recognized 


o  °  '  L 
g  £  I  2  ?  i?l 
^    ^    *"     "  •"  S| 


3 


o 
I 
'3, 


1) 

J3 


to 

3 

-a 

U 

o 

a 


v^     ^ 


by  the  microscope.  Sloughs  of  the  Peyer's  glands  occiur  either  as  gray- 
ish-yellow fragments  or  occasionally  as  ovoid  nuisses,  an  inch  or  more  in 
length,  in  which  portions  of  the  bowel  tissue  may  be  found. 

IIcBinorrhage  from  the  bowels  is  a  serious  complication,  occurring  in 
from  3  to  5  per  cent  of  all  cases.     It  occurred  in  ninety-nine  of  the  two 


SPECIFIC  INFECTIOUS  DISEASES. 


n 

■is 


0 


m 


m 


ji 


11 


thousand  Munich  autopsies,  and  it  was  present  in  nine  of  my  cases.  There 
may  be  only  a  slight  trace  of  blood  in  the  stools,  but  too  often  it  is  a  pro- 
fuse, free  haemorrhage,  which  rapidly  proves  fatal.  It  occurs  most  com- 
monly between  the  end  of  the  second  and  the  beginning  of  the  fourth 
week,  the  time  of  the  separation  of  the  sloughs.  Occasionally  it  results 
simply  from  the  intense  hyperaemia.  It  usually  comes  on  without  warn- 
ing. A  sensation  of  sinking  or  collapse  is  experienced  by  the  patient,  the 
temperature  falls,  and  may,  as  in  the  annexed  chart,  drop  eight  or  ten 
degrees  in  a  few  hours.  Fatal  collapse  may  supervene  before  the  blood 
appears  in  the  stool.  Haemorrhage  usually  occurs  in  cases  of  considerable 
severity.  Graves  and  Trousseau  held  that  this  was  not  a  very  dangerous 
symptom,  but  statistics  show  that  death  follows  in  from  thirty  to  fifty  per 
cent  of  the  cases. 

It  must  not  be  forgotten  that  melaena  may  also  be  part  of  a  general 
hoemorrhagic  tendency,  in  which  case  it  is  associated  with  petechiae  and 
haematiiria. 

Meteorism  is  a  frequent  symptom,  and  if  of  moderate  grade  is  not 
serious,  but  when  excessive  it  is  usually  of  ill-omen.  Owing  to  defective 
tone  in  the  walls,  in  severe  cases  owing  to  infiltration  with  serum,  gas  ac 
cumulates  in  the  small  and  large  bowels,  particularly  in  the  latter.  It  is 
rightly  held  to  be  to  some  extent  a  measure  of  the  intensity  of  the  local 
lesions.  When  extreme,  it  pushes  up  the  diaphragm  and  interferes  very 
much  with  the  action  of  the  heart  and  lungs.  It  undoubtedly  also  favors 
perforation. 

Abdominal  tenderness  on  pressure  and  gurgling  in  the  right  iliac 
fossa  exist  in  a  large  proportion  of  all  the  cases.  The  tenderness  may  be 
more  or  less  diffuse  over  the  abdomen,  but  it  is  commonly  limited  to  the 
right  side  It  is  rarely  excessive  and  may  be  elicited  only  on  deep  press- 
ure. Gurgling  indicates  simply  the  presence  of  gas  and  fluid  faeces  in 
the  colon  and  caecum. 

Perforation  of  an  ulcer  into  the  peritonaeum,  the  most  serious  abdom- 
inal complication  of  the  disease,  occurred  in  one  hundred  and  fourteen  of 
the  two  thousand  Munich  cases,  and  in  fifteen  of  the  sixty-four  cases  of  my 
series  It  is  usually  indicated  by  the  onset  of  sudden  acute  pain  in  the 
abdomen,  and  symptoms  of  collapse.  It  is  most  common  at  the  md  cf  the 
second  or  in  the  third  week,  but  in  one  of  my  cases  it  occurred  as  early 
as  the  eighth  day  and  in  another  in  the  sixth  week,  two  weeks  after  the 
dvening  temperature  had  become  normal.  It  is  not  infrequently  associated 
with  haemorrhage.  The  presence  of  indigestible  food,  severe  vomiting, 
excessive  meteorism,  and  ascarides  have  been  assigned  as  causes.  This 
accident  is  much  more  common  in  men  than  in  women.  The  perforation 
is  usually  in  the  ileum,  but  may  occur  in  the  colon.  As  a  rule  it  promptly 
causes  symptoms  of  peritonitis — distentioii  of  the  abdomen,  marked  ten- 
derness, rigidity  of  the  abdominal  walls,  vomiting,  a  collapsed,  pinched 
expression,  and  a  rapid,  small  pulse.     In  very  severe  cases,  with  )narkei^ 


TYPHOID  FEVER. 


28 


Ir> 


mental  disturbance  the  symptoms  may  not  excite  suspicion,  but  the  tem- 
perature usually  falls  and  the  symptoms  of  collapse  are  well  marked.  The 
diagnosis  is  easy,  except  in  cases  in  which  tympanites  and  tenderness 
have  been  prominent  features,  when  it  may  be  very  difficult  to  say  whether 
perforation  has  occurred.  An  indication  of  value  in  such  instances  is  the 
obliteration  of  the  liver  dulness  by  gas  in  the  peritoneal  cavity,  a  symptom 
upon  which  Alonzo  Clark  and  Flint  laid  great  stress,  and  the  value  of 
which  I  havo  on  several  occasions  been  able  to  demonstrate.  It  is  some- 
what lessened  by  the  fact  that  extreme  tympany  may  almost,  if  not  quite, 
obliterate  the  liver  dulness.  Recovery  from  perforation  is  undoubtedly 
possible,  though  rare. 

Peritonitis  without  perforation  may  also  occur  by  extension  from  the 
ulcer  or  occasionally  by  rupture  of  a  softened  mesenteric  gland.  It  was 
present  in  2'2  per  cent  of  the  Munich  autopsies. 

The  spleen  is  invariably  enlarged  in  typhoid  fever,  and  in  a  majority  of 
cases  the  edge  can  be  felt  below  the  costal  margin.  By  the  end  of  the  first 
week  the  enlargement  is  evident,  unless  there  is  great  distention  of  the 
colon,  when  the  spleen  may  be  pushed  far  back  and  difficult  to  feel.  Even 
the  normal  area  of  dulness  may  not  be  obtainable.  I  have  seen  a  very  large 
spleen  post  mortem,  when  during  life  the  increase  in  size  was  not  observ- 
able. Toward  the  fourth  week  it  diminishes  in  size.  In  four  of  my 
autopsies  it  weighed  less  than  normal.  Infarcts  and  abscesses  are  occa- 
sionally found.  Rupture  of  the  spleen  in  typhoid  fever,  due  to  a  slight 
blow,  has  been  seen  by  Bartholow.     Spontaneous  rupture  may  also  occur. 

Liver. — Symptoms  on  the  part  of  this  organ  are  rare.  Enlargement 
is  occasionlly  detected.  Jaundice  is  a  very  rare  complication.  It  may  be 
either  of  a  catarrhal  nature  or  due  to  parenchymatous  changes.  It  was 
present  in  only  I'l  per  cent  of  the  Munich  autopsies.  Abscess  of  the 
liver  is  a  very  rare  sequela. 

Respiratory  System. — Epistaxis  is  an  early  symptom  in  many  cases, 
ail )  i>vecedes  typhoid  fever  more  commonly  than  it  does  any  other  febrile 
•.itVol'on.     It  is  occasionally  profuse  and  serious. 

ir'tyngitis  is  not  very  common.  The  ulcers  and  the  j^erichondritis 
..  0  , '.ready  been  described.  CEdema  apart  from  ulceration  is  rare.  In 
till:  -ov  itry  the  laryngeal  complications  of  typhoid  fever  seem  much  less 
frequent  than  on  the  Continent.  I  have  seen  ulcers  in  only  four  or  five 
instances,  and  twice  only  perichondritis,  both  of  which  cases  recovered, 
one  after  th.  expectoration  of  large  portions  of  the  thyroid  cartilage. 

Brotichitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indi- 
cated by  the  presence  of  numerous  piping  rdles.  It  may  come  on  with  great 
Kevority,  and  in  a  pase  at  the  Philadelphia  Hospital  I  regarded  for  several 
(lays  the  bronchial  catarrh  as  the  primary  affection.  The  smaller  tubes 
may  be  involved,  producing  urgent  cough  and  even  slight  cyanosis.  Col- 
iip  ^e  und  lobular  pneumonia  may  also  occur. 

Lobar  pneumonia  is  met  with  under  two  conditions : 


^! 


m 


SPECIFIC  INFECTIOUS  DISEASES. 


! 


ill 


1.  It  may  be  the  initial  symptom  of  the  disease.  After  an  indisposition 
of  a  day  or  so,  the  patient  is  seized  with  a  chill,  has  high  fever,  pain  in 
the  side,  and  within  forty-eight  hours  there  are  signs  of  consolidation,  and 
the  evidences  of  an  ordinary  lobar  pneumonia.  The  intestinal  symptoms 
may  not  develop  until  toward  the  end  of  the  first  week  or  later ;  the  pul- 
monary symptoms  persist,  crisis  does  not  occur ;  the  aspect  of  the  patient 
changes,  and  by  the  end  of  the  second  week  the  clinical  picture  is  that  of 
typhoid  fever.  Spots  may  then  be  present  and  doubts  as  to  the  nature  of 
the  case  are  solved.  In  other  instances,  in  the  absence  of  a  characteristic 
eruption  the  case  remains  dubious,  and  it  is  impossible  to  say  whether 
the  disease  has  been  pneumonia,  in  which  the  so-called  typhoid  symp- 
toms have  developed,  or  whether  it  was  typhoid  fever  with  early  im- 
plication of  the  lungs.  Whether  tliis  condition  depends  upon  the  pneu- 
mococcus  or  is  the  result  of  an  early  localization  of  the  typhoid  bacillus 
has  not  yet  been  settled.  I  have  twice  performed  autopsies  in  cases  of 
this  pneunio-typht  t*''  it  is  called  by  the  French  and  Germans,  and  can 
speak  positively  of  i-;  with  all  the  symptoms  of  a  frank  pueumoria. 

2.  Lobar  piieumon;,  orms  a  serious  and  by  no  means  infrequent 
complication  of  the  second  or  third  week.  It  was  present  in  over  8  per 
cent  of  the  Munich  cases  and  occurred  in  nine  of  my  cases.  The  symp- 
toms are  usually  not  marked  There  may  be  no  rusty  sputa,  and,  unless 
sought  for,  the  condition  is  frequently  overlooked.  Infarction,  abscess 
and  gangrene  are  occ'asional  pulmonary  complications. 

Hypostatic  congestion  of  the  lungs  and  oedema,  due  to  enfeebled  circu- 
lation in  the  later  periods  of  the  disease,  are  very  common.  The  physical 
signs  are  defective  resonance  at  the  bases,  feeble  breath-sounds,  and,  on 
deep  inspiration,  moist  rales.  Pleurisy  is  by  no  means  an  uncommon 
complication.  It  was  present  in  about  8  per  cent  of  the  Munich  autop- 
sies. It  may  develop  slowly  in  convalescence,  in  which  case  it  is  almost 
always  purulent.  Another  occasional  pulmonary  complication  is  hmmopty- 
xis,  which  I  once  saw  at  the  height  of  the  disease.  After  death,  no  lesions 
of  the  lungs  or  bronchi  were  discovered.  Miliary  tuberculosis  occasionally 
develops,  and  some  writers  hold  that  there  is  a  greater  susceptibility  to 
infection  with  the  tubercle  bacillus  after  this  than  after  other  fevers. 

Nervous  System. — As  already  noted,  the  disease  may  set  in  with  in- 
tense and  persisting  headache  or  an  aggravated  form  of  neuralgia.  There 
are  cases  in  which  the  effect  of  the  poison  is  manifested  on  the  nervous 
system  early  and  with  the  greatest  intensity.  There  are  headaclie,  photo- 
}ihobia,  retraction  of  the  neck,  marked  twitching  of  the  muscles,  rigidity, 
and  even  convulsions.  In  such  cases  the  diagnosis  of  meningitis  is  in- 
variably made.  I  have  examined  post  mortem  three  such  cases,  in  two  of 
which  the  diagnosis  of  (!erebro-spinal  fever  had  been  made.  In  not  one  of 
them  was  there  any  trace  of  meningeal  inflammation,  only  the  niost  in- 
tense congestion  of  the  cerebral  and  spinal  pia.  Meningitis,  however,  may 
occur,  but  is  extremely  rare,  as  shown  by  the  Munich  record,  in  which 


TYPHOID  FEVER. 


25 


there  were  only  eleven  among  the  two  thousand  cases.  Stokes's  dictum 
that  "  there  is  no  single  nervous  symptom  which  may  not  and  does  not 
occur  independently  of  any  appreciable  lesion  of  the  brain,  nerves,  or 
.s])inal  cord,''  is  too  often  forgotten. 

Delirium  is  present  in  all  severe  cases.  It  is  certainly  less  frequent 
luider  a  rigid  plan  of  hydrotherapy.  It  may  be  present  from  the  outset, 
but  usually  does  not  develop  until  the  second  and  sometimes  not  until  the 
third  week.  It  may  be  sliglit  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet 
delirium,  though  there  are  cases  in  which  the  patient  is  very  noisy  and 
constantly  tries  to  get  out  of  bed,  and,  unless  carefully  watched,  may 
csciipe.  The  patient  does  not  often  become  maniacal.  In  heavy  drinkers 
the  delirium  may  have  the  character  of  delivium  tremens.  Even  in  cases 
which  have  no  positive  delirium,  the  mental  processes  are  usually  dulled 
and  the  patient  is  listless  and  apathetic.  In  severe  cases  the  patient  passes 
into  a  condition  of  unconsciousness.  The  eyes  may  be  open,  but  he  is  ob- 
livious to  all  surrounding  circumstances  and  neither  knows  nor  can  indi- 
cate his  wants.  The  urine  and  faeces  are  passed  involuntarily.  In  this 
])seudo-wakefiil  state,  or  coma  vigil  as  it  is  called,  the  eyes  are  open  and 
the  patient  is  constantly  muttering.  The  lips  and  tongue  are  tremulous; 
there  is  twitching  of  the  fingers  and  wrists  —  subsultus  tendinum  and 
carphologia.  He  picks  at  the  bedclothes  or  grasps  at  invisible  objects. 
Those  are  among  the  most  serious  symptoms  of  the  disease,  and  always 
indicate  danger. 

Among  important  complications  and  sequelas  are  several  nervous  af- 
fections. The  paralyses  are  due  in  the  majority  of  instances  to  neuritis. 
It  may  be  of  a  paraplegic  type,  or  may  involve  only  one  or  two  nerves. 
Occasionally,  as  in  a  case  reported  by  George  Ross,*  all  four  limbs  are 
affected. 

Possibly  some  of  these  cases  are  due  to  poliomyelitis,  not  to  neuritis. 
This  affection  does  not  always  follow,  but  may  come  on  at  the  height  of 
the  disease,  as  in  a  case  recently  under  my  care,  in  which  during  the 
second  week  neuritis  developed  in  both  arms.  Among  other  sequences 
may  be  mentioned  aphasia,  which  is  more  apt  to  occur  in  young  children, 
and  great  slowness  of  speech,  which  may  or  may  not  be  associated  with 
mental  weakness. 

Post-febrile  insanity  is  perhaps  more  frequent  after  typhoid  than  after 
any  other  disease.  Wood  regards  it  as  confusional  insanity,  the  result  of 
impaired  nutrition  and  exhaustion  of  the  nervous  centres.  Five  cases 
have  come  under  my  observation,  in  four  of  which  recovery  took  place. 

Disturbances  of  the  organs  of  the  special  senses  are  rare.  Otitis  media 
occasionally  develops.     Ocular  symptoms  are  uncommon. 

Renal  System. — Retention  of  urine  is  an  early  symptom  in  many 


•  Paralysis  in  Typhoid  Fever.    Transactions  of  the  Association  of  American  Physi- 
cians, vol.  iiL 


26 


SPECIFIC   INFECTIOUS  DISEASES. 


is 


'ii 


'i     I 


)t     'i 


cases,  and  is  more  frequent  in  some  epidemics  than  in  otliers.  The  urine 
is  usually  diminished  at  first,  has  the  ordinary  febrile  characters,  and  the 
])igment3  are  increased.  Later  in  the  disease  it  is  more  abundant  and 
lighter  in  color. 

Ehrlich  has  described  a  reaction,  wliich  he  believes  is  rarely  met  with 
except  in  typhoid  fever.  This  so-called  diazo-reaction  is  produced  as  fol- 
lows :  Two  solutions  are  employed,  kept  in  separate  bottles :  one  con- 
taining a  saturated  solution  of  sulphanilic  acid  in  a  solution  of  hydro- 
chloric acid  (50  c.  c.  to  1,000  c.  c.) ;  the  other  a  ^  per  cent  solution  of 
sodium  nitrite.  To  make  the  test,  a  few  cubic  centimetres  of  urine  are 
placed  in  a  small  test-tube  with  an  equal  quantity  of  a  mixture  of  solution 
of  the  sulphanilic  acid  (40  c.  c.)  and  the  sodium  nitrite  (1  c.  c),  the  whole 
being  thoroughly  shaken.  One  cubic  centimetre  of  ammonia  is  then 
allowed  to  flow  carefully  dov^n  the  side  of  the  tube,  forming  a  colorless 
zone  above  the  yellow  urine,  and  at  the  junction  of  the  two  a  deep  brown- 
ish-red ring  will  be  seen  if  the  reaction  is  present.  With  normal  urine  a 
lighter  brownish  ring  is  produced,  without  a  shade  of  red.  The  color  of 
the  foam  of  the  mixed  urine  and  reagent,  and  the  tint  they  produce  when 
largely  diluted  with  water,  are  characteristic,  being  in  both  cases  of  a  deli- 
cate rose-red  if  the  diazo-reaction  be  present ;  but  if  not,  brownish- 
yellow. 

In  twenty-six  cases  at  my  clinic,  Simon  found  the  reaction  in  twenty- 
two.  It  may  be  present  previous  to  the  occurrence  of  the  rash,  and  as  late 
as  the  twonty-second  day.  The  value  of  the  test  is  lessened  by  its  occur« 
rence  in  cases  of  miliary  tuberculosis,  and  occasionally  in  the  acute  dis- 
eases associated  with  high  fever. 

The  renal  complications  in  typhoid  fever  may  be  thus  grouped : 

(fl)  Febrile  albuminuria,  which  is  very  common  and  of  no  special  sig> 
nificance  ;  thus,  in  the  first  seventy-five  cases  admitted  to  the  Johns  Hop. 
kins  Hospital,  albumen  was  present  in  forty-six,  and  in  twenty-five  cases 
casts  were  also  found.  In  only  two  of  these  cases  were  there  indications 
of  an  acute  Bright's  disease. 

(i)  Acute  nephritis  occurring  at  the  onset  or  during  the  height  of  the 
disease — the  nephro-typhus  of  the  Germans,  the  jicvre  typho'ide  a  forme 
renale  of  the  French — may  set  in,  with  all  the  symptoms  of  the  most  in- 
tense Bright's  disease,  masking  in  many  instances  the  true  nature  of  the 
malady.  After  an  indisposition  of  a  few  days  there  may  be  fever,  pain  in 
the  back,  and  the  passage  of  a  small  amount  of  bloody  urine.  In  a  recent 
case  *  the  early  symptoms  were  all  those  of  the  most  severe  nephritis,  and 
death  occurred  on  the  fourteenth  day  from  perforation  of  the  bowel.  In 
other  instances,  as  in  a  case  reported  in  the  same  paper,  the  nephritis  sets 
in  at  the  end  of  the  first  or  during  the  second  week,  and  may  modify  con- 


1890. 


*  Acute  Nephritis  in  Typhoid  Fever.    Johns  Hopkins  Hosi)ital  Reports,  February, 


TYPHOID  FEVER. 


27 


siderably  the  character  of  the  disease,  and  even  render  the  diagnosis 
doubtful. 

{(■)  The  nephritis  of  convalescence.  Tliis  is  more  common  but  less 
serious.  It  develops  after  the  fall  of  the  fever,  and  is  usually  associated 
with  oedema.  It  does  not  present  characters  different  from  the  ordinary 
post-febrile  nephritis. 

{(l)  The  remarkable  lymphomatous  nephritis  described  by  E.  "Wagner 
and  others,  and  already  referred  to  in  the  section  on  morbid  anatomy,  pro- 
Muces,  as  a  rule,  no  symptoms. 

(e)  Post-typhoid  pyelitis. — In  this  the  pelves  of  the  kidney  and  the 
caliees  are  at  first  covered  with  a  membranous  exudation,  but  erosion  and 
ulceration  may  subsequently  occur.  There  may  be  blood  and  pus  in  the 
urine.  This  condition  occurred  in  three  of  my  cases,  in  one  of  which  it 
was  associated  with  extensive  membranous  inflammation  of  the  bladder. 

Simple  catarrh  of  the  bladder  is  rare. 

Orchitis  is  occasionally  met  with  during  convalescence.  Sadrain  col- 
lected sixteen  cases  in  the  literature.  It  is  usually  associated  with  a 
catarrhal  urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely 
suppuration. 

Osseous  System. — A  multiple  arthritis  occasionally  occurs ;  more  com- 
monly it  is  limited  to  a  single  joint,  and  may  pass  on  to  suppuration. 
Spontaneous  luxation  may  develop.  Necrosis  is  not  uncommon  during 
convalescence.  Keen  collected  thirty-seven  cases  after  typhoid  fever.  It 
is  probably  always  the  result  of  a  secondary  infection.  Its  most  usual 
seat  is  the  tibia. 

The  muscles  show  in  some  cases  the  degeneration  already  referred  to, 
but  it  does  not  cause  any  symptoms.  Haemorrhage  occasionally  occurs 
into  the  muscles,  and  late  in  the  disease  abscess  may  develop. 

Association  of  other  Diseabes. — Erysipelas  is  a  rare  complica- 
tion, most  commonly  met  with  during  convalescence.  In  1,420  cases  at 
Uasle  it  occurred  ten  times.  Griesinger  states  that  it  is  met  with  in  'Z 
))cr  cent.  . 

Measles  may  develop  during  the  fever  or  in  convalescence.  Chicken- 
pox  and  noma  have  been  reported  in  children.  Pseudo-membranous  in- 
flammations may  occur  in  the  pharynx,  larynx,  or  genitals.  Malarial  and 
typhoid  fevers  may  be  associated,  but  a  majority  of  the  cases  of  so-called 
typho-malarial  fever  are  either  remittent  or  true  typhoid. 

Varieties  of  Typhoid.- -Typhoid  fever  is  an  extremely  complex 
disease.  Many  forms  have  been  described,  some  of  which  prc-deiit  exag- 
geration of  common  symptoms,  others  modification  in  the  course,  others 
again  greater  intensity  of  action  on  certain  organs.  As  we  have  seen, 
when  the  nervous  system  is  specially  involved,  it  has  been  called  the 
cerebro-spinal  form ;  when  the  kidneys  are  early  and  severely  affected, 
nephro-typhoid ;  when  the  disease  begins  with  pulmonary  symptoms, 
})neumo-typhoid ;  when  the  disease  is  characterized  throughout  by  profuse 


as 


S1»P:CIFIC  JXFKCTIOUS   DISEASES. 


i 


^1 


sweats,  the  sudoral  form  of  the  disease.  It  is  a  mistake,  1  think,  to  rec- 
ognize or  speak  of  these  as  varieties.  It  is  enough  to  remember  that 
typhoid  may  set  in  occasionally  with  symptoms  localised  in  certain  organs, 
and  that  many  of  its  symptoms  are  extremely  inconstant — in  one  epidemic 
uniform  and  text-book-like,  in  another  slight  or  not  met  with.  This  di- 
versified symptomatology  has  led  to  many  clinical  errors,  and  in  the  ab- 
sence of  the  salutary  lessons  of  morbid  anatomy  it  is  not  surprising  that 
practitioners  have  so  often  been  led  astray.  We  may  recognize,  witli 
Murchison,  the  following  varieties  : 

1.  The  mild  and  abortive  forms.  It  is  very  important  for  the  practi- 
tioner to  recognize  the  mild  type  of  typhoid  fever,  often  spoken  of  as 
gastric  fever  or  even  regarded  as  shn^ils'  febricula.  In  this  form,  the 
typhus  levissiimiH  of  Griesinger,  the  symptoms  are  similar  in  kind  but 
altogether  less  intense  than  in  the  graver  attacks,  although  the  onset  may 
be  sudden  and  severe.  The  temperature  rarely  reaches  103°,  and  the 
fever  of  onset  may  not  show  the  gradual  ascending  evening  record.  The 
spleen  is  enlarged,  the  rose-sjwts  may  be  marked ;  often  they  are  very 
few  in  number.  Tlie  diarrh(ea  is  variable,  sometimes  it  is  not  present. 
In  such  cases  the  symptoms  may  persist  for  from  sixteen  to  twenty 
days.  ,  :' 

In  the  abortive  form  the  symptoms  of  onset  may  be  marked  with  shiv- 
ering and  fever  of  103°  or  even  higlier.  The  date  of  onset  is  often  defi- 
nite, a  point  upon  which  Jiirgensen  lays  great  stress.  Hose-spots  may  occur 
from  the  second  to  the  fifth  day.  Early  in  the  second  week  or  at  the  end 
of  the  first  week  the  fever  falls,  often  with  profuse  sweating,  and  conva- 
lescence is  established.  In  this  abortive  form  relapse  may  occur  and  may 
occasionally  prove  severe.  When  typhoid  fever  prevails  extensively  these 
cases  are  not  uncommon.  I  agree  m  ith  J.  C.  Wilson,  who  states  that  they 
are  not  nearly  so  common  in  this  country  as  in  Europe. 

2.  The  grave  form  is  usually  characterized  by  high  fever  and  pro- 
nounced nervous  syrnjitoms.  In  this  category,  too,  come  the  very  severe 
cases  setting  in  with  pneumonia  and  Bright's  disease,  and  with  the  very 
intense  gastro-intestinal  or  cerebro-spinal  symptoms. 

3.  The  latent  or  ambulatory  form  of  typhoid  fever,  which  is  particu- 
larly common  in  hospital  practice.  The  symptoms  are  often  very  slight, 
and  the  patient  scarcely  feels  ill  enough  to  go  to  bed.  He  has  languor, 
perhaps  slight  diarrhoea,  but  keeps  about  and  may  even  attend  to  his  work 
throughout  the  entire  attack.  In  other  instances  delirium  sets  in.  The 
worst  cases  of  this  form  are  seen  in  sailors,  who  keep  up  and  about,  though 
feeling  ill  and  feverish.  When  brought  to  the  hospital  they  often  develop 
symptoms  of  a  most  severe  type  of  the  disease.  Haemorrhage  or  perfora- 
tion may  be  the  first  symptom  of  this  ambulatory  type.  Sir  W.  Jenner 
has  called  attention  to  the  dangers  of  this  form,  and  particularly  to  the 
grave  prognosis  in  the  case  of  persons  who  have  travelled  far  with  the  dis- 
ease in  progress. 


TYPHOID  FEVER. 


29 


There  is  a  rare  and  fatal  form  of  typlioid  fever,  characterized  by 
cutaneous  and  mucous  ha*niorrhages. 

An  afehrile  typhoid  fever  is  recognized  by  autliors.  Lieberineister  says 
that  the  cases  were  not  uncommon  at  Basle.  The  patients  presented 
lassitude,  depression,  headache,  furred  tongue,  loss  of  api)etite,  slow  pulse, 
and  even  the  spots  and  enlarged  spleen.  1  have  no  personal  knowledge  of 
such  cases. 

Typhoid  Fever  in  Children. — Epistaxis  rarely  occurs;  the  rise  in 
temperature  is  less  gradual ;  the  initial  bronchial  catarrh  is  often  ob- 
served. Tlie  nervous  symptoms  are  often  prominent ;  there  are  wakeful- 
ness and  delirium ;  diarrhu;a  is  often  absent.  .The  rash  may  be  very  slight, 
but  the  most  copious  eruption  I  have  ever  seen  was  in  a  child  of  eight. 
Oddly  enough,  considering  the  readiness  with  which  the  lymph  elements 
of  the  intestine  in  children  are  involved,  the  abdominal  symptoms  are 
slighi.  Fatal  luwmorrhage  and  perforation  are  rare.  Among  the  sequela', 
apliasia  and  bone  lesions  may  be  mentioned  as  more  common  in  children 
tlian  in  adults,  'i'lie  mortality  of  typhoid  fever  in  children  is  low.  Forch- 
heimer,  in  the  Cincinnati  epidemic  in  1888,  treated  seventy  cases  without 
a  death. 

Tjrphoid  Fever  in  the  Aged. — After  the  fortieth  year  the  disease  runs 
a  less  favorable  course,  and  the  mortality  is  very  high.  Of  sixty-four 
fatal  cases,  seven  were  over  forty  years  of  age ;  one  was  aged  sixty-three, 
another  seventy.  The  fever  is  not  so  high,  but  complications  are  more 
common,  paiUcularly  pneumonia  and  heart  failure. 

Relapse. — llelapsea  vary  in  frequency  in  different  epidemics,  and,  it 
appears,  in  diTcrent  places.  The  percentages  of  different  authors  range 
from  3  per  cent  (Murchison),  11  per  cent  (Biiumler)  to  15  or  18  per  cent 
(Iinmermann).  In  Wagner's  clinic,  from  1882  to  1886,  there  were  40 
rela])ses  in  5Gl  cases.  F.  C.  Shattuck  reports  21  relapses  in  129  cases. 
R.  L.  MacDonnell  1  relapse  in  100  cases.  A  relapse  is  a  repetition, 
somet'mes  only  a  summary,  of  the  original  attack.  Von  Ziemssen  in- 
sists correctly  that  two  of  the  three  important  symptoms — step-like  tem- 
perature at  onset,  roseola,  and  enlarged  spleen — should  be  present  to  de- 
termine the  diagnosis  of  a  relapse.  The  intestinal  lesions  are  repeated, 
though  with  less  intensity  and  regularity.  It  is  to  be  carefully  distin- 
guislied  from  the  fever  of  convalescence — or  recrndescence — which  has 
already  been  described.  This  is  usually  transitory,  not  lasting  longer 
than  a  day  or  two.  There  are  occasional  instances  in  which  the  fever 
lasts  for  four  or  five  days  without  rose-spots,  or  without  enlargement  of 
the  spleen,  and  it  may  be  impossible  to  determine  whether  there  has  been 
a  relapse  or  not.  The  true  relapse  usually  sets  in  after  complete  deferves- 
cence. Irvine  noted  the  average  duration  of  the  interval  in  his  cases 
at  a  little  over  five  days.  In  eleven  of  Shattuck's  cases  the  relapse 
began  before  complete  defervescence.  The  onset  is  usually  abrupt, 
though  the  step-like  ascent  is  sometimes  well  seen,  as  in  Chart  I.    The 


'00' 


SPPX'IFIC   INFKfTIOUS  HISEASES. 


I 


jf 

■:i 
■ill 


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I 


eruption  may  bo  seen  as  early  aa  the  tliird  or  fourth  day.  The  attack 
is  usually  less  severe  and  of  shorter  duration.  Of  Murchison's  fifty-three 
cases  the  mean  duration  of  the  first  attack  was  about  twenty-six,  of  the 
interval  eleven,  of  the  relapse  fifteen  days.  The  mortality  of  the  relapse  is 
not  high.  The  rela])se  may  be  repeated,  and  a  third  and  fourth  relapse 
nuiy  occur. 

The  relapse  is  a  reinfection  from  within,  but  we  are  still  quite  ignorant 
of  the  conditions  favoring  its  occurrence.  It  is  not  at  all  likely  that  any 
special  methods  of  treatment  favor  the  relapse,  though  hydrotherapy  lias 
labored  under  this  reproach. 

Diagnosis. — If  the  patient  is  seen  from  the  outset  there  is  rarely  any 
difficulty  in  diagnosing  typhoid  fever  of  typical  course.  In  the  prefebrile 
period  the  headache,  weakness,  loss  of  appetite  and  epistaxis  are  extremely 
suggestive,  aiul,  with  an  ascending  pyrexia,  scarcely  need  the  distinctive 
rash  to  clinch  the  diagnosis, 

I'he  early  and  intense  localisation  of  the  symptoms  in  certain  organs  is 
a  frequent  source  of  error  in  diagnosis. 

Cases  coming  oix  with  severe  headache,  photophobia,  delirium,  twitch- 
ing of  the  muscles  and  retraction  of  the  head  are  almost  invariably 
regarded  as  cerebro-sjjinal  meningitis.  Under  sucli  circumstances  it  may 
for  a  few  days  be  impossible  to  nnike  a  satisfactory  diagnosis.  I  have 
thrice  performed  autopsies  o;i  cases  of  this  kind  in  which  no  suspicion  of 
typhoid  fever  had  been  preiicnt;  the  intense  cerebro-spinal  manifestations 
having  dominateil  tlio  ocene.  Until  the  appearance  of  abdomiiud  symp- 
toms or  the  rash,  it  may  be  quite  impossible  to  determine  the  nature  of 
the  ca.  '.  Cerebro-spinal  meningitis  is,  however,  a  rare  disease;  typhoid 
fever  a  very  common  one,  and  tlie  onset  with  severe  nervous  symptoms  is 
by  no  means  infrequent.  Fully  one  half  of  the  cases  of  the  so-called  brain- 
fever  belong  to  this  category. 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  which 
occasionally  develop  at  the  very  outset  of  the  disease.  'J'he  bronchitis 
rarely  causes  error,  though  it  may  be  intense  and  attract  the  chief  at- 
tention. More  difficult  are  the  cases  setting  in  with  chill  and  followed 
rapidly  by  pneumonia.  I  have  brought  such  a  case  before  the  class 
one  week  as  typical  pneumonia,  and  a  fortnight  later  shown  the  same 
case  as  undoubtedly  one  of  typhoid  fever.  In  another  case,  in  which  the 
onset  was  with  definite  pneumonia,  no  spots  developed,  and,  though  there 
were  diarrhoea,  meteorism,  and  the  most  pronounced  nervous  symptoms, 
the  doubt  still  remains  whether  it  was  a  case  of  typhoid  fever  or  one  of 
pneumonia  in  which  severe  secondary  symptoms  developed.  There  is 
less  danger  of  mistaking  the  pneumonia  which  develops  at  the  height  of 
the  disease,  and  yet  this  is  possible,  as  in  a  case  admitted  a  few  months 
ago  to  my  wards — a  man  aged  seventy,  insensible,  with  a  dry  tongue, 
tremor,  ecchymoses  upon  the  wrists  and  ankles,  no  rose-spots,  enlarge- 
ment of  the  spleen,  and  consolidation  of  his  right  lower  lobe.     It  was  very 


TYPHOID  FEVER. 


iiiitnral,  partioulurly  since  there  was  no  history,  to  regard  such  a  case  as 
senile  pneumonia  witli  profound  constitutional  disturbance,  but  the  au- 
topsy showed  the  cliaracteristic;  lesions  of  typhoid  fever. 

In  malarial  regions  typhoid  and  remittent  fevers  are  very  frequently 
confounded.  I  confess  myself  unable  to  differentiate  certain  eases  of  ma- 
liiriid  remittent  from  typhoid  fever,  v/ithout  the  blood  examination.  I 
liiive  repeatedly,  both  in  JMiiladelphia  and  lialtin^ore,  sent  cases  to  the 
wards  as  typhoid  fever  which  subsequently  proved  to  be  ordinary  malarial 
remittent.  The  patient  comes  with  a  history  of  malaise,  weakness,  diar- 
rhoea, perhaps  vomiting ;  the  tongue  is  furred  and  white,  the  checks  aro 
flushed,  the  spleen  is  slightly  enlarged,  temperature  1(W°  or  103°.  There 
may  indeed  be  delirium,  and  the  clinical  picture  of  the  early  stage  of  ty])hoid 
fever  may  be  complete.  On  at  least  two  occasions  I  have  shown  sucdi 
cases  to  my  class  as  typhoid  fever,  and  several  times  patients  have  been 
sent  to  the  wards  with  instructions  to  have  the  head  shaved  and  to  begin 
the  baths.  The  oidy  safeguard  against  error  is  i  i  -^  examination  of  the 
blood,  which  should  be  done  systematically  in  regions  in  which  malaria 
prevails.  The  presence  of  Laveran's  organisms  is  distinctive  and  abso- 
lutely diagnostic. 

Acute  miliary  tuberculosis  is  not  infrequently  mistaken  for  typhoid 
fever.  The  points  in  differential  diagnosis  will  be  discussed  under  that 
disease.  1'uberculous  peritonitis  in  certain  of  its  forms  may  closely  simu- 
late typhoid  fever. 

Puncture  of  the  spleen  for  the  purpose  of  obtaining  cultures  is  justifi- 
able only  in  exceptional  circumstances. 

Prognosis. — The  mortality  ranges  from  10  to  30  per  cent.  Of  the 
enormous  number  of  deaths  analyzed  by  Murchison,  the  mortality  was 
nearly  19  per  cent.  The  death-rate  at  the  Montreal  General  Hospital, 
for  twenty  years,  was  11'3  per  cent.  In  recent  years  the  mortality  in 
typhoid  fever  has  certainly  diminished,  and,  under  the  influence  of  Brand, 
the  reintroduction  of  hydrotherapy  has  reduced  the  mortality  in  institu- 
tions in  a  remarkable  manner,  even  as  low  as  5  or  G  per  cent.  Especially 
unfavorable  symptoms  are  high  fever,  delirium  with  toxic  symptoms, 
luemorrhage — though  by  some  this  is  not  thought  very  unfavorable — and 
peritonitis. 

Sxdden  Death. — It  is  difficult  in  many  cases  to  explain  this  rrost  lam- 
entable of  accidents  in  the  disease.  There  are  cases  in  whici.  neither 
cerebral,  renal,  nor  cardiac  changes  have  been  found,  and  instances  too  in 
which  it  does  not  seem  likely  that  there  could  have  been  a  special  localis-a- 
tion  of  the  toxic  poisons  in  the  pneumogastric  centres.  McPhedran,  in 
reporting  a  case  of  the  kind,  in  which  the  post-mortem  showed  no  ade- 
quate cause  of  death,  suggests  that  the  experiments  of  McWilliams  on 
sudden  cardiac  failure  probably  explain  the  occurrence  of  death  in  cer- 
tain of  these  cases  in  which  neither  embolism  nor  uraemia  is  present. 
Under  conditions  of  abnormal  nutrition  there  is  sometimes  induced  a  state 


82 


SPKCIFIC    INFKCTIOUS   OISKASES. 


|i 


of  (IfUrinm  rordix,  which  nuiy  develop  apojitaiiooiisly,  or,  in  tlio  case  of 
animals,  on  sli^^ht  irritation  of  the  heart,  with  the  result  of  extreme  irreg- 
ularity and  finally  failure  of  action.  It  occurs  more  frequently  in  men 
than  in  women,  a('C()rdin<(  to  Dewiivre's  statistics,  in  a  proportion  of  114 
to  "id.  It  may  occiiir  at  the  heijifht  of  the  fever,  and,  as  pointed  out  by 
Graves,  may  also  happen  during  convalescence. 

Fat  subjects  staiul  typhoid  fever  badly.  1'he  mortality  in  women  is 
greater  than  in  men.  The  complications  and  dangers  are  more  serious  in 
tlie  ambulatory  form  in  which  the  patient  has  kept  about  fora  week  or  ten 
days.  Karly  involvement  of  the  nervous  system  is  a  bad  indication ;  and 
the  low,  muttering  delirium  with  tremor  means  a  close  light  for  life.  Prog- 
nostic signs  from  the  fever  alone  are  deceptive,  A  temperature  above  104° 
may  be  well  borne  for  many  days  if  the  nervous  system  is  not  involved. 

Prophylaxis. — In  cities  the  prevalence  of  typhoid  fever  is  directly 
proportionate  to  the  inefficiency  of  the  drainage  aiul  the  water-supply. 
There  is  no  truer  indication  of  the  sanitary  condition  of  a  town  than  the 
returns  of  the  number  of  cases  of  this  disease.  With  the  improvement  in 
drainage  the  mortality  in  many  cities  has  been  reduced  one  half  or  even 
more.  One  of  the  most  striking  instances  is  afforded  by  the  city  of  Munich. 
Von  Ziemssen  has  published  charts  illustrating  the  extraordinary  reduc- 
tion in  the  prevalence  of  typhoid  fever  since  the  completion  of  the  drain- 
age systenx  of  that  city.  The  average  yearly  number  of  admissions  to 
hospital  of  cases  of  typhoid  fever  was,  between  the  years  18G6  and  188' 
51)4,  while  from  1881  to  1888  inclusive,  the  average  has  been  only  about 
100.  During  this  same  period  the  typhoid  mortality  of  the  whole  city 
presented  a  yearly  average  of  208,  but  from  1881  to  1888  the  yearly 
average  was  only  40. 

By  most  rigid  methods  of  disinfection  much  may  be  done  to  prevent 
the  spread  of  the  infection. 

The  following  procedures,  suggested  by  Fitz,  should  be  carried  out  in 
hospital  practice,  and,  with  modifications,  in  private  houses: 

1.  "  Mattresses  and  pillows  (when  liable  to  become  soiled)  are  to  be 
protected  by  close-fitting  rubber  covers. 

2.  "  Bed  and  body  linen  are  to  be  changed  daily.  Bed-spreads,  blank- 
ets, rubber  sheets  and  rubber  covers  are  to  be  changed  at  once  when  soiled. 
Avoid  shaking  any  of  the  articles. 

3.  "  All  changed  linens,  bath-towels,  rubber  sheets  and  covers  are  to 
be  immediately  wrapped  in  a  sheet  soaked  in  carbolic  acid  (one  to  forty). 
Remove  them  to  the  rinse-house  as  soon  as  possible,  and  soak  six  hours  in 
carbolic  acid  (one  to  forty).  Then  boil  the  linen  for  a  half-hour,  and  wash 
with  soft  soap.  The  rubber  sheets  and  covers  are  to  be  rinsed  in  cold 
water,  dried,  and  aired  for  eight  hours.  The  bed-spreads  and  blankets 
are  to  be  aired  eight  hours  daily. 

4.  "  Feeding-utensils,  immediately  after  using,  are  to  be  thoroughly 
cleansed  in  boiling  water. 


TYPnolI)   FKVKH. 


88 


f).  "  DejectionB  aro  to  be  received  into  u  bcd-pnn  containing  lialf  a 
pint  of  ciirbolie  aoid  (one  to  twenty).  Tlie  nates  are  to  be  cleansed  witb 
niiper,  and  afterward  witl»  a  compress  cloth  wet  with  carbolic  acid  (one  to 

forty). 

((.  "Add  two  quarts  of  carbolic  acid  (one  to  twenty),  in  dividcMl  por- 
tions, to  the  contents  of  the  beii-pan ;  mix  thoroughly  by  shaking  and 
throw  the  liquid  into  the  liopper.  The  bed-pan  and  hopp(!r  aro  to  bo 
cleiinsod  with  carbolic  acid  (one  to  twenty)  and  wijjcd  dry.  The  cloth 
used  for  the  above  purpose  is  to  be  at  once  burned. 

7.  "  The  corpse  is  to  be  covered  with  a  sheet  wet  with  carbolic  acid 
(one  to  forty). 

H.  "  After  the  discharge  of  the  patient  from  the  hospital,  the  mat- 
tresses aro  to  bo  aired  every  day  for  a  week.  The  bedstead  is  to  be  washed 
with  corrosive  sublimate  (one  to  one  thousand). 

n.  "  These  directions  aro  to  be  followed  until  the  patient  is  free  from 
fever." 

When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used 
in  families  should  be  boiled.  T'hese  precautions  should  bo  taken  also  by 
recent  residents  in  any  locality,  and  it  is  much  safer  for  travellers  to  drink 
light  wines  or  mineral  water  rather  than  ordinary  water  or  milk. 

Treatment.— ('0  General  Management. — 'i'  -^^  profession  was  long 
in  learning  that  typhoid  fever  is  TU)t  a  disease  to  be  treated  by  medicines. 
Careful  nursing  and  a  regulated  diet  are  the  essentials  in  a  majority  of  the 
ciisos.  The  patient  should  be  in  a  well-ventilated  room  (or  in  summer 
out  of  doors  during  the  day),  strictly  confined  to  bed  from  the  outset,  and 
tliere  remain  until  convalescence  is  well  established.  The  bed  should  be 
single,  not  too  high,  and  the  mattress  should  not  be  too  hard.  The  woven 
wire  bed,  with  soft  hair  mattress,  upon  which  are  two  folds  of  blanket, 
combines  the  two  great  qualities  of  a  sick-bed,  smoothness  and  elasticity. 
A  rubber  cloth  should  be  placed  under  the  sheet.  An  intelligent  nurse 
should  be  in  charge.  When  this  is  impossible,  the  attending  physician 
sliould  write  out  specific  instructions  regarding  diet,  treatment  of  the  dis- 
charges, and  the  bed-linen. 

{I))  Diet. — Those  forms  of  food  should  be  given  which  are  digested 
with  the  greatest  ease,  and  which  leave  behind  the  smallest  amount  of  resi- 
iliie  to  form  fajces.  Milk  is  the  most  suitable  food.  If  used  alone,  three 
j)iiits  at  hast  may  be  given  to  an  adult  in  twenty-four  hours,  always  diluted 
with  water,  lime-water,  or  aerated  waters.  Partially  peptonized  milk,  when 
not  distasteful  to  the  patient,  is  occasionally  serviceable.  Tlie  stools  of  a 
patient  on  a  strictly  milk  diet  should  bo  examined  from  time  to  time,  to  see 
if  the  milk  is  entirely  digested.  Fever  patients  often  receive  more  than 
they  can  utilize,  in  which  case  masses  of  curds  are  seen  in  the  stools,  or 
microscopically  fat-corpuscles  in  extraordinary  abundance.  Under  these 
circumstances  it  is  best  to  substitute,  for  part  of  the  milk,  mutton  or 
chicken  broths,  or  beef -juice,  or  a  clear  consomme^  all  of  which  may  be  made 


84 


SPECIFIC  INFECTIOUS  DISEASKS. 


it 


very  palatable  by  the  addition  of  fresh  vegetable  juices.  Some  patients 
will  take  wliey  or  buttermilk  when  the  ordinary  milk  is  distasteful.  Thin 
barley-gruel,  well  strained,  is  an  excellent  food  for  typhoid-fever  patients. 
Eggs  may  be  given,  either  beaten  up  in  milk  or,  better  still,  in  the  form  of 
albumen-water.  This  is  prepared  by  straining  the  whites  of  eggs  through 
a  cloth  and  mixing  them  with  an  equal  quantity  of  water.  It  may  be 
flavored  with  lemon,  and,  if  the  patient  is  taking  spirits,  whisky  or  brandy 
is  very  conveniently  given  with  this.  Patients  who  are  unable  to  take  milk 
can  subsist  for  a  time  on  this  alone. 

The  patient  should  bo  encouraged  to  drink  water  freely,  which  may  be 
pleasantly  cold.  Iced  tea,  barley-water,  or  lemonade  may  also  be  giver, 
and  there  ij  i^j  objection  to  coffee  or  cocoa  in  moderate  quantities.  Fruits 
are  not,  as  a  rule,  allowable,  though  the  juice  of  lemon  or  orange  may 
be  given.  Typhoid  patients  should  be  fed  at  stated  intervals  through 
the  day.  At  night  it  depends  upon  the  general  condition  of  the  patient 
whether  he  should  be  aroused  from  sleep,  or  not.  In  mild  cases  it  is 
not  well  to  disturb  the  patient.  When  there  is  stupor,  however,  the 
patient  should  be  roused  for  food  at  the  regular  intervals  night  and  day. 

Alcohol  is  not  necessary  in  all  cases,  but  may  be  given  when  the  weak- 
ness is  marked,  the  fever  high,  and  the  pulse  failing.  In  young  healthy 
adults,  without  nervous  symptoms  and  without  very  high  fever,  alcohol  is 
not  required  ;  but  in  any  case,  when  the  heart-beat  is  feeble  and  the  first 
sound  becomes  obscure,  if  there  is  a  muttering  delirium,  subsultus  tendi- 
num  and  a  dry  tongue,  brandy  or  whisky  should  be  freely  given.  In  such 
a  case  from  eight  to  twelve  ounces  of  brandy  in  the  twenty-four  hours  is  a 
moderate  amount. 

{c)  Treatment  of  the  Fever.— The  persistent  pyrexia  is  in  itself  a 
danger,  but  perhaps  not  the  chief  danger.  Cases  with  high  fever  alone, 
without  delirium  or  signs  of  involvement  of  the  nervous  system,  are  not 
nearly  so  serious  as  those  cases  in  which,  with  a  temperature  of .  104°,  thero 
are  pronounced  nervous  symptoms.  For  the  fever  and  its  concomitants 
there  is  no  treatment  so  efficacious  as  that  by  cold  water,  introduced  at 
the  end  of  the  last  century  by  Currie,  of  Liverpool,  and  of  late  years 
forced  upon  the  profession  by  Brand,  of  Stettin.  In  institutions  a  rigid 
system  of  hydrotherapy  should  be  carried  out.  At  my  clinic  the  follow- 
ing plan  is  followed  :  Every  third  hour,  if  the  temperature  is  above  102'5°, 
the  patient  is  placed  in  a  bath  (at  70°  Fahr.),  which  is  wheeled  to  the  bed- 
side. In  this  he  remains  from  fifteen  to  twenty  minutes,  and  is  then 
taken  out,  wrapped  in  a  dry  sheet  and  covered  with  a  ligli*-  blanket. 
Enough  water  is  used  to  cover  the  patient's  body  to  the  neck.  The  head 
is  sponged  during  the  bath,  and,  if  there  is  much  torpor,  cold  water  is 
poured  over  it  from  a  height  of  a  foot  or  two.  The  rectal  temperature  is 
taken  immediately  ffter  the  Oath,  and  ag.ain  three  quarters  of  an  hour 
later.  The  patient  often  complains  bitterly  when  in  the  bath,  and  shiver- 
ing and  blueness  are  almost  a  constant  sequence.    Food  is  usually  given 


w 

ni 

th 


TYPHOID  FEVER. 


86 


with  a  stimulant  after  the  bath.  The  only  contra-indications  are  perito- 
nitis iind  luemorrhage.  Neither  bronchitis  n  j  •  pneumonia  are  so  regard- 
ed. It  is  not  necessary  to  renew  the  water  in  the  bath  more  than  j  o  in 
the  twenty-four  hours.    The  accompanying  chart  shows  the  nuu.  er  of 

No.     JL^^a^ .^ /Ta^fi^^y^x''G7^       Admitted   CWit-y'.'"  7'  .  (D.^ 


.tune  ft 

n 

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Chart  V. 

baths  and  the  influence  on  the  fever  during  two  days  of  treatment.  The 
good  etfects  of  the  baths  are :  (1)  tlie  reduction  of  the  fever;  (2)  the  in- 
tellect becomes  clearer,  the  .stupor  lessens,  and  the  muscular  twitchings 
disappear;  (3)  a  general  tonic  action,  particularly  on  the  heart;  (4)  in- 
somnia is  lessened,  the  patient  usually  fallijig  asleti  for  two  or  three  hours 
.ifter  each  bath;  and  (5),  most  important  of  all,  the  mortality  is,  under 
this  plan  of  treatment,  reduced  to  a  minimum.  This  rigid  method  is  not, 
however,  without  serious  drawbacks,  and  personally  I  sympathize  with 
those  who  designate  it  as  entirely  barbarou.s.  To  transfer  a  patient  from 
a  warm  bed  to  a  tub  at  1()°  Kahr,,  and  to  keep  him  tiiere  twenty  minutes 
or  longer  in  spite  of  his  piteous  entreaties,  does  seem  harsh  treatment ;  and 
the  subseijuent  shivering  and  blueness  look  distressing.  A  majority  of  our 
patients  complain  of  it  bitterly,  and  in  private  practice  it  is  scarcely  feasible. 
The  convincing  statistics  of  the  lirand  method,  as  it  is  called,  have 


36 


SPKCIFIC  INFECTIOUS  DISEASKS. 


i 


#1 
i 


long  been  before  the  profession ;  but  so  far  they  have  made  but  little  im- 
pression in  English-speaking  communities.  Cayley,  of  London,  has  been 
a  warm  advocate,  but  the  rigid  treatment  is  not  often  carried  out  in  Eng- 
lish or  American  institutions.  J.  C.  Wilson,  of  I'hiladelphia,  and  Baruch, 
of  New  York,  have  pleaded  for  its  general  introduction  into  our  liospitala. 
Among  the  most  striking  figures  are  those  recently  published  by  Hare, 
from  the  lirisbaiu;  IIo8})ital,  Australia.  Under  the  expectant  plan,  1,838 
cases — mortality,  14*8  per  cent;  incomplete  bath  treatment,  171  cases — 
mortality,  12*;}  per  cent ;  strict  bath  treatment,  79T  cases — mortality,  7  per 
cent. 

The  lukewarm  bath,  gradually  cooled,  is  much  more  satisfactory  in 
private  practice.  A  bath  at  from  90°  to  80°,  and  cooled  down  10°  or  12° 
by  pouring  cold  water  on  the  patient,  will  be  found  very  satisfactory. 
When  an  insuperable  objection  to  the  bath  exists,  other  liydrotherapeutic 
measures  may  be  taken.  The  body  may  be  sponged  with  tepid  or  cold 
water  every  time  the  temperature  rises  above  102*5°.  If  done  thoroughly, 
taking  limb  by  limb  first,  and  then  the  trunk,  occupying  from  twenty 
minutes  to  half  an  hour  in  the  process,  the  rectal  temperature  may  be  re- 
duced two  or  even  three  degrees.  In  ])rivate  practice,  when  the  bath  is 
not  available,  the  cold-pack  is  a  goad  substitute.  IMie  patient  is  wrapped 
in  a  sheet  wrung  out  of  water  at  60°  or  05°,  and  cold  water  is  sprinkled 
over  him  with  an  ordinary  wate-ing-pot.  Tb.io  is  very  efficacious  in  cases 
with  pronounced  nervous  sympto.ns.  * 

Medicinal  antipyretics  are  rarely  indicated.  Quinine,  Avhich  was  em- 
ployed so  much  in  former  years,  has  a  slight  though  positive  action,  but 
its  use  has  very  wisely  been  restricted.  The  same  may  be  said  of  the 
n>ore  recent  antipyretics.  Personally,  I  abandoned  their  employment 
some  years  ago.  If  given,  antifebrin  is  the  most  suitable  in  doses  of  from 
four  to  eight  grains.  Tiio  action  is  prompt,  and  it  is  less  depressing  than 
antipyrin. 

(</)  Antiseptic  Medication. — Very  laudable  endeavors  have  been  made 
in  many  quart<'rs  to  introduce  methods  of  treatment  directed  toward  the 
destnu'tion  of  the  typhoid  bacilli,  or  the  toxic  agent  which  they  produce, 
but  I"  .ir  without  success.  Good  results  have  been  claimed  from  the  car- 
bolic and  iodine  treatment.  Others  advocate  corrosive  sublimate  or  calo- 
mel, /3-naphtliol,  atul  the  salicin  preparations.  I  can  testify  to  the  ineffi- 
ciency of  the  carbolic  iwid  and  iodine  and  of  the  /8-naphthol.  With  the 
mercurial  proj)arations  I  have  no  experience,  r'ortunately  for  the  patients, 
a  majority  of  these  modicines  meet  one  of  the  two  objects  which  Hip- 
pocrates sjiys  the  physician  should  always  have  in  view — they  do  no  harm. 
Recently  liurney  Yeo  has  advocated  the  use  of  chlorine  water  and  quinine 
as  having  a  marked  antiseptic  action. 

{f)  Treatment  of  the  Special  Symptoms. — The  abdominal  pain  and 
tympanites  are  bj'st  treated  by  fomentations  or  turpentine  stupes.  The 
latter,  if  well  applied,  give  great  relief.     Sir  William  Jenner,  at  his  clinic, 


TYPHOID  FEVER. 


87 


used  to  lay  great  stress  on  the  advantages  of  a  well-applied  turpentine 
stupe,  lie  directed  it  to  be  applied  as  follows :  A  flannel  roller  was  placed 
Ijeiieath  the  ])atient,  and  then  a  double  layer  of  thin  flannel,  wrung  out  of 
hot  water,  with  a  few  drops  of  turpentine  sprinkled  upon  it,  was  applied 
to  the  abdomen  and  covered  with  the  ends  of  the  roller. 

Tlie  vieteorisni  is  a  difficult  and  distressing  symptom  to  treat.  When 
the  gas  is  in  the  large  bowel,  a  tube  may  be  passed  or  a  turpentine  enema 
given.  For  tympanites,  with  a  dry  tongue,  turpentine  was  extensively 
used  by  tlie  older  Dublin  physicians,  and  it  was  introduced  into  this  country 
by  the  late  George  B.  Wood.  Unfortunately  it  is  of  very  little  service  in  the 
severer  cases,  which  too  often  resist  all  treatment.  The  routine  adminis- 
tration of  turpentine  in  all  cases  of  typhoid  fever  is  a  useless  practice,  for 
the  perpetuation  of  which,  in  this  generation,  II.  C.  Wood  is  largely  re- 
sponsible. Stokes  protested  against  it  in  his  day,  and  very  truly  said  that 
its  use  should  be  limited  to  the  later  periods  of  the  disease,  when  it  may 
sometimes  be  used  with  advantage,  as  Graves  directs,  in  drachm  doses 
every  six  hourd.  Sometimes,  if  beef-juice  and  albumen-water  are  substi- 
tuted for  milk,  the  distention  lessens.  Charcoal,  bismuth,  and  ^-naphthol 
may  be  tried. 

For  the  dinrrhoea,  if  severe — that  is,  if  there  are  more  than  three  or 
four  stools  daily — a  starch  and  opium  enema  may  be  given ;  or,  by  the 
mouth,  a  combination  of  bismuth,  in  large  doses,  with  Dover's  powder ;  or 
the  acid  diarrhoea  mixture,  acetate  of  lead  (grs.  2),  dilute  acetic  acid 
(iH  15-20),  and  acetate  of  morphia  (gr.  \—\).  The  stools  should  be  ex- 
amined to  see  that  tlie  diarrhuja  is  not  aggravated  liy  the  presence  of 
curds. 

Const ipat ion  is  present  in  many  cases,  and,  tb"'igh  I  have  never  seen  it 
do  harm,  yet  it  is  well  every  third  or  fourth  .ay  to  give  an  ordinary 
enema.  I  have  never  used  the  initial  dose  of  calu  ael,  whicli  is  so  highly 
recommended  by  some  practitioners.  If  a  laxative  is  m  =  ^  i  during  the 
course  of  the  disease,  the  Ilunyadi-janos  or  Friedrichshall  wat'  r  may  be 
given. 

If(emo)'r7tnf/e  from  the  bowels  is  best  treated  with  full  doses  of  acetate 
(if  load  and  opium.  As  absolute  rest  is  essential,  the  greatest  care  shduld 
bo  taken  in  the  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  lie 
patient  to  pass  the  motions  into  the  draw  sheet.  Ice  may  be  freely  given, 
and  the  amount  of  food  should  be  restricted  for  eight  or  ten  hours.  If 
there  is  a  tendency  to  collapse,  stimuhmts  should  be  given  and,  if  necessary, 
hypodermic  injections  of  ether.  The  patient  may  be  spared  the  usuai 
styptic  mixtures  with  which  he  is  so  often  drenched.  Turpentine  is 
warmly  recommended  by  certain  authors. 

Peritonitis, — In  a  majority  of  the  cases  this  is  an  inevitably  fatal 
cotnplication.  The  only  hope  lies  in  restriction  of  the  inflammation. 
Cases  have  unquestionably  recovered.  Morphia  should  bo  given  sub- 
cutaneously.    If  the  peritonitis  be  duo  to  perforation,  tho  question  of 


38 


SPECIFIC  INFECTIOUS  DISEASES. 


i 


1 


laparotomy  may  be  discussed.  If  perforation  has  occurred  in  the  second 
or  third  week,  it  would  be  useless  under  the  circumstances  to  attempt  to 
stitch  a  slit  in  the  intestine;  if,  on  the  other  hand,  it  occurs  during  con- 
valescence, it  is  only  right  to  give  the  patient  a  chance,  and  the  operation 
should  be  performed. 

Progressive  hen rf -fail are  is  one  of  the  most  frequent  and  perhaps  one 
of  the  most  serious  of  the  conditions  which  the  physician  has  to  combat. 
As  in  other  specific  alfections,  this  is  in  part  due  to  the  prolonged  action 
of  the  fever  and  iu  part  is  a  toxic  effect.  Alcohol  is  here  our  mainstay 
and  can  be  given  freely.  Strychnine  is  most  useful  and  may  be  given 
hypodermically  in  full  doses.  Whether  digitalis  is  indicated  in  the  failing 
heart  of  fevers  is  not  yet  settled.  I'ersonally,  I  am  by  no  me.ans  convinced 
that  it  does  good.  Hypodermic  injections  of  ether  may  be  resorted  to,  and 
are  sometimes  helpful  in  tiding  the  patient  over  a  critical  period. 

The  nervous  symptoms  of  typhoid  fever  are  best  treated  by  hydro- 
therapy. One  special  advantage  of  this  plan  is  that  the  restlessness  is 
allayed,  the  delirium  quieted,  and  sedatives  are  rarely  needed.  In  the 
cases  which  set  in  early  with  severe  headache,  meningeal  symptoms  and 
high  fever,  the  cold  bath,  or  in  private  practice  the  cold-pack,  should  be 
employed.  .  n  ice-cap  may  be  placed  on  the  head,  and  if  necessary  mor- 
phia administered  hypodermically.  The  practice,  in  such  cases,  of  apply- 
ing blisters  to  the  luipe  of  the  neck  and  to  the  extremities  is,  to  paraphrase 
Iluxham's  words,  an  umvholesome  severity,  which  should  long  ago  have 
been  discarded  by  the  profession.  For  the  nocturnal  restlessness,  so  dis- 
tressing in  some  cases,  Dover's  powder  should  be  given.  As  a  rule,  if  a 
hypnotic  is  indicated,  it  is  best  to  give  opium  in  some  form.  Pulmonary 
comjilications  should,  if  severe,  receive  appropriate  treatment. 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against 
bed-sores.  Absolute  cleanliness  and  careful  drying  of  the  parts  after  an 
evacuation  should  be  enjoined.  The  patient  should  be  turned  from  side  to 
side  and  propped  with  pillows,  and  the  back  can  then  be  sponged  with 
spirits.  On  the  first  appearance  of  a  sore,  the  water  or  air  bed  should  be 
used. 

(/)  The  Manag^ement  of  Convalescence.— With  the  fall  of  the  tem- 
perature  to  nornuil  in  the  evening,  and  the  disappearalice  of  the  other 
symptoms,  the  patient  enters  uj)on  a  stag*'  which  is  often  more  difficult  to 
manage  than  the  attack  itself.  Convalescents  from  typhoid  fever  frequently 
cause  greater  anxiety  than  patients  in  the  attack.  The  question  of  food 
has  to  be  met  at  once,  as  the  patient  develops  a  ravenous  appetite  and 
clamors  for  a  fuller  diet.  jNfy  custom  has  been  not  to  allow  solid  food 
until  the  temperature  has  been  normal  for  ten  days.  This  is,  I  think,  a 
safe  rule,  leaning  perhaps  to  the  side  of  extreme  caution ;  but  after  all 
with  eggs,  milk  toast,  milk  puddings,  and  jellies,  the  patient  can  take  a 
fairly  varied  diet.  Many  leading  practitioners  allow  solid  food  to  a 
patient  so  soon  as  he  desires  it.     Peabody  gives  it  on  'lie  disappearance  of 


TYPHOID  FEVER. 


88 


the  fever ;  the  late  Austin  Flint  was  also  in  favor  of  giving  solid  food 
early ;  and  Naunyn,  at  the  Strasburg  Medical  Clinic,  told  me  that  this 
was  his  practice.  I  had  an  early  lesson  in  this  matter  which  I  have  never 
forgotten.  A  young  lad  in  the  Montreal  General  Hospital,  in  whose  case 
I  WHS  much  interested,  passed  through  a  tolerably  sharp  attack  of  typhoid 
fever.  Two  weeks  after  the  evening  temperature  had  been  normal,  and 
only  a  day  or  two  before  his  intended  discharge,  he  ate  several  mutton 
cliops,  and  within  twenty-four  hours  was  in  a  state  of  collapse  from  per- 
foration. A  small  transverse  rent  was  found  at  the  bottom  of  an  ulcer 
which  was  in  process  of  healing.  It  is  not  easy  to  say  why  solid  food, 
particularly  meats,  should  disagree,  but  in  so  many  instances  an  indiscre- 
tion in  diet  is  followed  by  slight  fever,  the  so-called  febris  carnis,  that  it 
is  in  the  best  interests  of  the  patient^to  restrict  the  diet  for  some  time 
after  the  fever  has  fallen.  An  indiscretion  in  diet  may  indeed  precipitate 
a  relapse.  The  patient  may  be  allowed  to  sit  up  for  a  short  time  about  the 
end  of  the  first  week  of  convalescence,  and  the  period  may  be  prolonged 
with  a  gradual  return  of  strength.  He  should  move  about  slowly,  and 
when  the  weather  is  favorable  should  be  in  the  open  air  as  much  as 
possible.  The  patient  should  be  guarded  at  this  period  against  all  un- 
necessary excitement.  Emotional  disturbance  not  infrequently  is  the 
cause  of  a  recrudescence  of  the  fever.  Constipation  is  not  uncommon  in 
convalescence  and  is  best  treated  by  enemata.  A  protracted  diarrhoea, 
which  is  usually  due  to  ulceration  in  the  colon,  may  retard  recovery.  In 
such  cases  the  diet  should  be  restricted  to  milk,  and  the  patient  should 
be  confined  to  bed  ;  large  doses  of  bismuth  and  astringent  injections  will 
prove  useful. 

The  recrudescence  of  the  fever  does  not  require  special  treatment. 
The  treatment  of  the  relapse  is  essentially  that  of  the  original  attack. 

Among  the  dangers  of  convalescence  may  be  mentioned  tuberculosis, 
which  is  said  by  Murchison  to  be  more  common  after  this  than  after  any 
other  fever.  There  are  facts  in  the  literature  favoring  this  view,  but  it  is 
a  rare  sequence  in  this  country. 


II.  TYPHUS  FEVER. 


Definition. — An  acute  infectious  disease  characterised  by  sudden 
onset,  a  maculated  rash,  marked  nervous  symptoms,  and  a  termination, 
usually  by  crisis,  about  the  end  of  the  second  week. 

Etiol(^y. — The  disease  has  long  been  known  under  the  names  of 
hospital  fever,  spotted  fever,  jail  fever,  camp  fever,  and  ship  fever.  In 
(itTmany  it  is  known  as  exanthematic  typhus,  in  contradistinction  to 
abdominal  typhus. 

Typhus  is  now  a  rare  disease.  Sporadic  cases  occur  from  time  to  time 
iu  the  large  centres  of  population,  but  epidemics  are  infrequent.    In  this 


40 


SPECIFIC   INFECTIOUS  DISEASES. 


(1 


•I 


i 


country  during  the  past  ten  years  there  have  been  very  few  outbreaks.  In 
New  York  in  1881-'8:i  seven  hundred  and  thirty-five  cases  were  admitted 
into  the  Riverside  Hospital ;  in  Philadelphia  a  small  epidemic  occurred 
in  1883  at  the  Philadelphia  Hospital. 

The  special  elements  in  the  etiology  of  typhus  are  overcrowding  and 
poverty.  As  Hirsch  tersely  puts  it,  "  Die  Geschichte  dos  Typhus  ist  die 
des  menschlichen  Elends."  Overcrowding,  lack  of  cleanliness,  intem- 
perance and  bad  food  are  predisposing  causes.  The  disease  still  lurks  in 
the  worst  quarters  of  London  and  Glasgow,  and  is  seen  occasionally  in 
New  York  and  Philadelphia.  It  is  more  common  in  Great  Britain  and 
Ireland  than  in  other  parts  of  Europe.  Murchison  held  that  the  disease 
might  originate  spontaneously  under  favorable  conditions.  This  opinion 
is  suggested  by  the  occurrence  of. local  outbreaks  under  circumstances 
which  render  it  difficult  to  explain  its  importation,  but  the  analogy  of 
other  infectious  diseases  is  directly  against  it.  In  1877  there  occurred  a 
local  outbreak  of  typhus  at  the  House  of  Refuge,  in  Montreal,  in  which 
city  the  disease  had  not  existed  for  many  years.  The  overcrowding  was 
so  great  in  the  basement-rooms  of  the  refuge  that  at  night  there  were  not 
more  than  eighty-eight  cubic  feet  of  space  to  each  person.  Eleven  per- 
sons were  affected.     It  was  not  possible  to  trace  the  source  of  infection. 

Typhus  is  one  of  the  most  highly  contagious  of  febrile  affections.  In 
epidemics  nurses  and  doctors  in  attendance  upon  the  sick  are  almost  inva- 
riably attacked.  There  is  no  disease  which  has  so  many  victims  in  the 
profession.  In  the  extensive  epidemic  in  the  early  and  middle  part  of  this 
century  many  hundred  physicians  died  in  the  discharge  of  their  duty. 
Casual  attendance  upon  cases  in  limited  epidemics  does  not  appear  to  be 
very  risky,  but  when  cases  are  aggregated  together  in  wards  the  poison 
appears  concentrated  and  the  danger  of  infection  is  much  enhanced. 
Bedding  and  clothes  retain  the  poison  for  a  long  time. 

The  microbe  of  typhus  fever  has  not  yet  been  determined.  Hlava 
found  in  twenty  of  thirty-three  bodies,  and  twice  during  life,  a  strepto-ba- 
cillus,  the  relation  of  which  to  the  disease  has  not  yet  been  determined. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  result 
from  intense  fever.  The  blood  is  dark  and  fluid,  the  muscles  are  of  a  deep 
red  color  and  often  show  a  granular  degeneration,  particularly  in  the 
heart;  the  liver  is  enlarged  and  soft  and  may  have  a  dull  clay-like  lustre; 
the  kidneys  are  swollen ;  there  is  moderate  enlargement  of  the  spleen,  and 
a  general  hyperplasia  of  the  lymph-follicles.  Peyer's  glands  are  not  ulcer- 
ated. Bronchial  catarrh  is  usually,  and  hypostatic  congestion  of  the  lungs 
often,  present.     The  skin  shows  the  petechial  rash. 

Symptoms. — Incubation. — This  is  placed  at  about  twelve  days,  but 
it  may  be  less.  There  may  be  ill-defined  feelings  of  discomfort.  As  a  rule, 
however,  the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor, 
followed  by  fever.  The  chills  may  recur  during  the  first  few  days,  and 
there  is  headache  with  pains  in  the  back  and  legs.    There  is  early  pros- 


TYPHUS  FEVER. 


41 


tration,  and  the  patient  is  glad  to  take  to  his  bed  at  once.  The  tempera- 
ture is  high  at  lirst,  and  may  attain  its  maximum  on  the  second  or  third 
(lav.  The  pulse  is  full,  rapid,  and  not  so  frequently  dicrotic  as  in  typhoid. 
Tlic  tongue  is  furred  and  white,  and  there  is  an  early  tendency  to  dry- 
ness. The  face  is  flushed,  the  eyes  are  congested,  the  expression  is  dull 
and  stupid.  Vomiting  may  be  a  distressing  sym{)tom.  In  severe  cases 
mental  symptoms  are  present  from  the  outset,  either  a  mild  febrile  delir- 
ium or  an  excited,  active,  almost  maniacal  condition.  Bronchial  catarrh 
is  common. 

Stage  of  Eruption.— From  the  third  to  the  fifth  day  tUf  eruption  ap- 
pears— first  upon  the  abdomen  and  upper  part  of  the  chest,  and  then 
upon  the  extremities  and  face ;  developing  so  rapidly  that  in  two  or 
three  days  it  i3  all  out.  There  are  two  elements  in  the  eruption  :  a  sub- 
cuticular mottling,  "a  fine,  irregular,  dusky  red  mottling,  as  if  below 
tlie  surface  of  the  skin  some  little  distance,  and  seen  through  a  semi- 
opaque  medium "  (Buchanan) ;  and  distinct  papular  rose-spot.,  which 
change  to  petechias.  In  some  instances  the  petechial  rash  comes  out 
with  the  rose-spots.  Collie  describes  the  rash  as  consisting  of  three  parts 
— rose-colored  spots  which  disappear  on  pressure,  dark-red  spots  which 
are  modified  by  pressure,  and  petechiae  upon  which  pressure  produces 
no  effect.  In  children  the  rash  at  first  may  present  a  striking  resem- 
blance to  measles,  and  give  as  a  whole  a  curiously  mottled  appearance  to 
tlio  skin.  The  term  mulberry  rash  is  sometimes  applied  to  it.  In  mild 
cases  the  eruption  is  slight,  but  even  then  is  largely  petechial  in  character. 
As  the  rash  is  largely  haemorrhagic,  it  is  permanent  and  does  not  disappear 
after  death.  Usually  the  skin  is  dry,  so  that  sudaminal  vesicles  are  not 
common.  It  is  stated  by  soma  authors  that  a  distinctive  odor  is  present. 
During  the  second  week  the  general  symptoms  are  usually  much  aggra- 
vated. The  prostration  becomes  more  marked,  the  delirium  more  intense, 
and  the  fever  rises.  The  patient  lies  on  his  back  with  a  dull  expressionless 
face,  flushed  cheeks,  injected  conjunctivae,  and  contracted  pupils.  The 
pulse  increases  in  frequency  and  is  feebler,  the  face  is  dusky,  and  the 
oonditioif  becomes  more  serious.  Retention  of  urine  is  common.  Coma- 
vifjil  is  frequent,  a  condition  in  which  the  patient  lies  with  open  eyes,  but 
quite  unconscious.  Subsultus  tendinum  and  picking  at  the  bedclothes 
iire  frequently  seen.  The  tongue  is  dry,  brown,  and  cracked,  and  there  are 
sordes  on  the  teeth.  Respiration  is  accelerated,  the  heart's  action  becomes 
more  and  more  enfeebled,  and  death  takes  place  from  exhaustion.  In 
favorable  cases,  about  the  end  of  the  second  week  occurs  the  crisis,  in 
wliich,  often  after  a  deep  sleep,  the  patient  awakes  feeling  much  better 
and  with  a  clear  mind.  The  temperature  falls,  and  although  the  prostra- 
tion may  be  extreme,  convalescence  is  rapid  and  relapse  very  rare.  This 
abrupt  termination  by  crisis  is  in  striking  contrast  to  the  mode  of  termi- 
imtion  in  typhoid  fever. 

Fever, — The  temperature  rises  steadily  during  the  first  four  or  five 


I 


ifflM 


mmM 


42 


SPECIFIC  INFECTIOUS  DISEASES. 


days,  and  the  morning  remissions  are  not  marked.  The  maximum  tem- 
perature is  usually  reached  by  the  fifth  day,  when  the  temperature  may 
reach  105°,  10G°,  or  107*.  In  mild  cases  it  seldom  rises  above  103°. 
After  reaching  its  maximum  the  temperature  generally  continues  with 
slight  morning  remissions  until  the  twelfth  or  fourteenth  day,  when  the 
crisis  occurs,  during  which  the  temperature  may  fall  below  normal  with- 
in twelve  or  twenty-four  hours.  Preceding  a  fatal  termination,  there  is 
usually  a  rapid  rise  in  the  fever  to  108°  or  even  109°. 

The  heart  may  early  show  signs  of  weakness.  The  first  sound  becomes 
feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is  not  in- 
frequent.    Hypostatic  congestion  of  the  lungs  occurs  in  all  severe  cases. 

The  brain  symptoms  are  usually  more  pronounced  than  in  typhoid, 
and  the  delirium  is  more  constant. 

The  urine  in  typhus  shows  the  usual  febrile  increase  of  urea  aiid  uric 
acid.  The  chlorides  diminish  or  disappear.  Albumen  is  present  in  a 
large  proportion  of  the  cases,  but  nephritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There 
are  malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days ; 
the  so-called  typhus  siderans.  On  the  other  hand,  during  epidemics  there 
are  extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent, 
and  convalescence  is  established  by  the  tenth  day. 

Complications  and  Sequelae. — Broncho-pneumonia  is  perhaps 
the  most  common  complication.  It  may  pass  on  to  gangrene.  In  certain 
epidemics  gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children 
noma  or  cancrum  oris,  have  occurred.  Meningitis  is  rare.  Paralyses, 
which  are  probably  due  to  the  post-febrile  neuritis,  are  not  very  uncommon. 
Septic  processes,  such  as  parotitis  and  abscesses  in  the  subcutaneous  tissues 
and  in  the  joints,  are  occasionally  met.  Nephritis  is  rare.  Haematemesis 
may  occur. 

Prognosis. — The  mortality  ranges  in  dififerent  epidemics  from  12  to 
20  per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as 
frequently  attacked  as  adults,  rarely  die.  After  middle  age  the  mortality 
is  high,  in  some  epidemics  50  per  cent.  Death  usually  occurs  toward  the 
close  of  the  second  week  and  is  due  to  the  toxaemia.  In  the  third  week 
it  is  more  commonly  due  to  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the 
disease  presents  distinctive  general  characters.  Isolated  cases  may  be  very 
difficult  to  distinguish  from  typhoid  fever.  While  in  typical  instances 
the  eruption  in  the  two  affections  is  very  different,  yet  taken  alone  it  may 
be  deceptive,  since  in  typhoid  fever  a  roseolous  rash  may  be  abundant  and 
there  is  occasionally  a  subcuticular  mottling  and  even  petechiae.  The 
difference  in  the  onset,  particularly  in  the  temperature,  is  marked ;  but 
cases  in  which  it  is  important  to  make  an  accurate  diagnosis  are  not  usu- 
ally seen  until  the  fourth  or  fifth  day.  The  suddenness  of  the  onset,  the 
greater  frequency  of  the  chill,  and  the  early  prostration  are  the  distinctive 


TYPHUS  FEVER. 


m 


features  in  typhus.  The  brain  symptoms  too  are  earlier.  It  is  easy  to 
put  down  on  paper  elaborate  differential  distinctions,  which  are  prac- 
tically useless  at  the  bedside,  particularly  when  the  disease  is  not  pre- 
vailing as  an  epidemic.  In  sporadic  cases  the  diagnosis  is  sometimes 
extremely  ditficult.  I  have  seen  Murchison  himself  in  doubt,  and  more 
than  once  1  have  known  a  diagnosis  to  be  deferred  until  the  ticciio  cada- 
veric. Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  out- 
.set,  but  the  diagnosis  is  usually  clear  within  a  few  days.  Malignant  vari- 
ola also  has  certain  features  in  common  with  severe  typhus,  but  the 
greater  extent  of  the  haemorrhages  and  the  bleeding  from  the  mucous 
membranes  make  the  diagnosis  clear  within  a  short  time.  The  rash  at 
first  resembles  that  of  measles,  but  in  this  disease  the  eru})tion  is  brighter 
red  in  color,  often  crescentic  or  irregular  in  arrangement,  and  appears 
first  in  the  face. 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is 
shown  by  the  fact  that  during  and  following  the  epidemic  of  1881  in  New 
York  one  hundred  and  eight  cases  were  wrongly  diagnosed — one  eighth 
of  tlie  entire  number — and  sent  to  the  Riverside  Hospital  (F.  \V.  Chapin). 

Treatment. — Practically  the  general  management  of  the  disease  is 
like  that  of  typhoid  fever.  Hydrotherapy  should  be  thoroughly  and  sys- 
tematically employed.  Judging  from  the  good  results  which  Ave  have 
obtained  by  this  method  in  typhoid  cases  with  nervous  symptoms  much 
may  be  expected  from  it.  Certain  authorities  have  spoken  against  it,  but 
it  should  be  given  a  more  extended  trial.  Medicinal  antipyretics  are  less 
suitable  than  in  typhoid,  as  the  tendency  to  heart-weakness  is  often  more 
pronounced.  As  a  rule  the  patients  require  from  the  outset  a  supporting 
treatment ;  water  should  be  freely  given,  and  alcohol  in  suitable  doses 
according  to  the  condition  of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  spe- 
cific medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is 
not  commended  by  those  who  have  had  the  largest  experience.  The  spe- 
cial nervous  symptoms  and  the  pulmonary  symptoms  should  be  dealt  with 
as  in  t3^)hoid  fever.  In  epidemics,  when  the  conditions  of  the  climate 
are  suitable,  the  cases  are  best  treated  in  tents  in  the  open  air. 


III.  RELAPSING    FEVER  (Febris  recutrem). 

Definition. — A  specific  infectious  disease  caused  by  the  spirochaete 
(spirillum)  of  Obermeier,  characterised  by  definite  febrile  paroxysms  which 
usually  last  six  days  and  are  followed  by  a  remission  of  about  the  same 
length  of  time,  then  by  a  second  paroxysm,  which  may  be  repeated  three 
or  even  four  times,  whence  the  name  relapsing  fever. 

Etiology. — This  disease,  which  has  also  the  names  "  fannne  fever  " 
and  "seven-day  fever,"  has  been  known  since  the  early  part  of  the 


44 


SPEClPiC  INFECTIOUS  DISEASES. 


*. 

i^ 


eighteenth  century,  und  has  from  time  to  time  extensively  prevailed  in 
Europe  and  in  Ireland.  It  is  common  in  India,  where  the  conditions  for 
its  development  seem  always  to  bo  present.  The  subject  has  been  spe- 
cially studied  by  V^andyke  Carter,  of  Bombay.  It  was  first  seen  in  this 
country  in  1844,  when  cases  were  admitted  to  the  Philadelphia  Hospital, 
which  are  described  by  Meredith  Clymer  in  his  work  on  fevers,  Flint  saw* 
cases  in  IHoO-'Al.  In  lH«»!i  it  prevailed  extensively  in  epidemic  form  in 
New  Y'ork  and  Philudolphia;  since  then  it  has  not  appeared. 

The  special  (ionditions  under  which  it  develops  are  very  similar  to 
those  of  typhus  fever.  Overcrowding  and  deficient  food  are  the  condi- 
tions which  seem  to  ])romote  the  rapid  spread  of  the  virus.  Neither  age, 
sex,  nor  season  seems  to  have  any  special  influence.  It  is  a  contagious 
disease  and  may  be  communicated  from  person  to  person,  but  is  not  so 
contagious  as  typhus.  Murchison  thinks  it  may  be  transported  by  fomites. 
One  attack  does  not  confer  immunity  from  subsequent  attacks.  In  18T;J 
Obermeier  described  an  organism  in  the  blood  which  is  now  recognised 
as  the  specific  agent.  This  spirillum,  or  more  correctly  spirochiete,  is 
from  three  to  six  times  the  length  of  the  diameter  of  a  red  blood-cor- 
puscle, and  forms  a  narrow  spiral  filament  which  is  readily  seen  moving 
among  the  red  corpuscles  during  a  paroxysm.  They  are  present  in  the 
blood  only  during  the  fever.  Shortly  before  the  crisis  and  in  the  inter- 
vals they  are  not  found,  though  small  glistening  bodies,  which  are  stated 
to  be  their  spores,  appear  in  the  blood.  The  disease  has  been  produced 
in  human  beings  by  inoculation  of  the  blood  during  the  paroxysm.  It 
has  also  been  produced  in  monkeys.  Nothing  is  yet  known  with  refer- 
ence to  the  life  history  of  the  spirochaete. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appear- 
ances in  relapsing  fever.  If  death  takes  place  during  the  paroxysm  the 
spleen  is  large  and  soft,  and  the  liver,  kidneys  and  heart  show  cloudy 
swelling.  There  may  be  infarcts  in  the  kidneys  and  spleen.  The  bone 
marrow  has  been  found  in  a  condition  of  hyperplasia.  Ecchymoses  are 
not  uncommon. 

Symptoms. — Incubation  appears  to  be  short,  and  in  some  instances 
the  attack  develops  promptly  after  exposure ;  more  frequently,  however, 
from  five  to  seven  days  elapse. 

The  invasion  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  may  be  nausea,  vomiting,  and  convul- 
sions. The  temperature  rises  rapidly  and  may  reach  104°  on  the  evening 
of  the  first  day.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from 
110  to  i;30.  There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the 
spleen  can  be  detected  early.  Jaundice  is  common  in  some  epidemics. 
The  gastric  symptoms  may  be  severe.  There  are  seldom  intestinal  syn.p- 
toms.  Cough  may  be  present.  Occasionally  herpes  is  noted,  and  there 
may  be  miliary  vesicles  and  petechiae.  During  the  paroxysm  the  blood 
invariably  shows  the  spirochaste.    After  persisting  with  severity  or  even 


REL/.PSING   PKVER. 


45 


with  an  increasing  intensity  for  five  or  six  (lays  the  crisis  occurs.  In  the 
(loiirse  of  a  few  hours,  accompanied  hy  profuse  sweating,  sometimes  by 
(liiirrlKi'ft,  the  temperature  falls  to  normal  or  even  subnormal,  and  the 
ptTiuil  of  apyrexia  begins. 


12     a    4    n    n 


H      ft      10     II     I'J     13     14     Ift     Ifi     17     18     10    ao    ai     !K    VBl    24 


Chart  VI. — Relapsing  fever  (Murchison). 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth;  it  usually  comes,  however,  about  the  end  of  the  first  week. 
In  delicate  and  elderly  persons  there  may  be  collapse.  The  convalesceiuu? 
is  nipid,  and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  week, 
usiiuiiy  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills; 
the  fever  returns  and  the  attack  is  repeated.  A  second  crisis  occurs  from 
the  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers 
mpidly.  As  a  rule  the  relapse  is  shorter  than  the  original  attack.  A 
second  and  a  third  may  occur,  and  there  are  instances  on  record  of  even  a 
fourth  and  a  fifth.  In  epidemics  there  are  cases  terminating  by  crisis  on 
the  seventh  or  eighth  day  without  the  occurrence  of  relapse.  In  pro- 
tnicted  cases  the  convalescence  is  very  tedious,  as  the  patient  is  much 
exhausted. 

Relapsing  fever  is  not  a  very  fatal  disease.  Murchison  states  that  the 
mortality  is  about  4  per  cent.  In  the  enfeebled  and  old,  death  may  occur 
lit  the  height  of  the  original  attack. 

Complications  are  not  frequent.  In  some  epidemics  nephritis  and 
lia'inaturia  have  occurred.  Pneumonia  appears  to  be  frequent  and  may 
interrupt  the  typical  course  of  the  disease.  The  acute  enlargement  of  the 
spleen  may  end  in  ruptu'*e,  and  the  hsemorrhage  from  the  stomach  which 
Ikis  been  met  with  occasionally  is  probably  associated  with  this  eidargc- 
nii'iit.  Post-febrile  paralyses  may  occur.  Ophthalmia  has  followed  cer- 
tiiin  epidemics,  and  may  prove  a  very  tedious  and  serious  complication. 
Jaundice  has  already  been  mentioned.  In  pregnant  women  abortion  usu- 
ally takes  place. 


■  t 


46 


SPKCIPIC  INFECTIOUS  DISEASES. 


Diagnosifl. — Tho  onHot  and  general  symptoma  may  not  at  flrst  be 
distinctive.  At  tho  beginning  of  an  epidemic  the  cases  are  usually 
regarded  as  anomalous  typhoid ;  but  once  tho  typical  course  is  followed 
in  a  case  tho  diagnosis  is  clear.  Tho  blood  examination,  which  should  be 
made  in  all  doubtful  cases  of  fevor,  affords  a  dotiuito  oriterion  by  which 
the  diagnosis  can  readily  bo  made. 

Treatment. — The  paroxysm  can  neither  be  cut  short  nor  its  recur- 
rence prevented.  It  might  bo  thought  that  quinine,  with  its  powerful  ac- 
tion, would  certainly  meet  the  indications,  but  it  does  not  seem  to  have  the 
slightest  influence.  The  disease  must  be  treated  like  any  other  continued 
fever  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic  measures. 
Of  special  symptoms,  pains  in  the  back  and  in  the  limbs  and  joints  demand 
opium.  In  enfeebled  persons  the  collapse  at  the  crisis  may  be  serious,  and 
stimulants  with  ammonia  and  digitalis  should  be  given  freely. 


IV.  SMALL-POX  (Variola). 


u 


iiE 

1 

■A      .   ■ 

Deflnition. — An  acute  infectious  disease  characterised  by  an  erup- 
tion which  passes  through  the  »tagea  of  papule,  vesicle,  pustule  and 
crust.  The  mucous  membranes  in  contact  with  tho  air  may  also  be 
affected.  Severe  cases  may  be  complicated  with  cutaneous  and  visceral 
haemorrhages. 

Etiology. — It  has  not  yet  been  determined  in  what  country  small- 
pox originated.  The  disease  is  said  to  have  existed  in  China  many  centu- 
ries before  Christ.  The  pesta  magna  described  by  Galen  (and  of  which 
Marcus  Aurelius  died)  is  believed  to  be  small-pox.  In  the  sixth  century 
it  prevailed,  and  subsequently,  at  the  time  of  the  Crusades,  became  wide- 
spread. It  was  brought  to  America  by  the  Spaniards  early  in  the  sixteenth 
century.  The  first  accurate  account  was  given  by  Rhazes,  an  Arabian  phy- 
sician who  lived  in  the  ninth  century,  and  whose  admirable  description  is 
available  in  Greenhill's  translation  for  the  Sydenham  Society.  In  the 
seventeenth  century  a  thorough  study  of  the  disease  was  made  by  the  illus- 
trious Sydenham,  who  still  remains  one  of  the  most  trustworthy  authori- 
ties on  the  subject. 

Special  events  in  the  history  of  the  disease  are  the  introduction  of 
inoculation  into  Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and 
the  discovery  of  vaccination  by  Jenner,  in  1798. 

Small-pox  is  one  of  the  most  virulent  of  contagious  diseases,  and  per- 
sons exposed,  if  unprotected  by  vaccination,  are  almost  invariably  attacked. 
'L'here  are  instances  on  record  of  persons  insusceptible  to  the  disease.  It 
is  said  that  Diemerbrock,  a  celebrated  Utrecht  professor  in  the  seventeenth 
century,  was  not  only  himself  exempt,  but  likewise  many  members  of  his 
family.  One  of  the  nurses  in  the  small-pox  department  of  the  Montreal 
General  Hospital  stated  that  she  had  never  been  successfully  vaccinated, 


SMALIi-POX. 


47 


and  she  certainly  liad  no  mark.  Such  instances,  however,  of  natural  im- 
rii unity  arc  very  rare. 

ji/c, — Small-pox  is  common  at  all  ages,  but  is  partitMilarly  fatal  to 
younfj  children;  thus,  in  the  Montreal  epidemic  of  1885,  Ht;  per  cent  of 
the  deaths  were  of  children  under  ten  years  of  age.  The  /(eius  in  vtero 
miV  be  iittucked,  but  only  if  the  molli  r  herself  is  the  subject  of  the  dia- 
( use.  Tlie  child  may  bo  born  with  the  rash  out  or  with  the  soars.  More 
(smunonly  the  faitus  is  not  affected,  and  children  born  in  a  small-pox  hos- 
pital, if  vaccinated  immediately,  may  escape  the  disease  ;  usually,  however, 
tiiey  die  early. 

iSVx.— Males  ond  females  are  equally  affected. 

Jidce. — Among  .'boriginal  races  small-jwx  is  terribly  fatal.  When 
the  diseiuse  was  first  introduced  into  America  the  Mexicans  died  by 
thousands,  and  the  North  American  Indians  have  also  been  frequently 
(K'cimated  by  this  plague.  It  is  stated  that  the  negro  is  especially  sus- 
ceptible. 

The  Contiujium  develops  in  the  system  of  the  small-pox  patient  and 
is  reproduced  in  the  pustules.  It  exists  in  the  secretions  and  excretions, 
and  in  the  exhalations  from  the  lungs  and  the  skin.  The  dried  scales  con- 
stitute by  far  the  most  important  element,  and  as  a  dust-like  powder  are 
distributed  everywhere  in  the  room  during  convalescence,  becoming  at- 
tached to  clothing  and  various  articles  of  furniture.  The  disease  is  proba- 
bly contagious  from  a  very  early  stage,  though  I  think  it  has  not  yet  been 
.lotormined  whether  the  contagion  is  active  before  the  eruption  develops. 
\'.\Q  poison  is  of  unusual  tenacity  and  clings  to  infected  localities.  It  is 
conveyed  by  persons  who  have  been  in  contact  with  the  sick  and  by  fomites. 
During  epidemics  it  is  no  doubt  widely  spread  in  street-cars  and  public  con- 
veyances. It  must  not  be  forgotten  that  an  unprotected  person  may  con- 
tract a  very  virulent  form  of  the  disease  from  the  mild  varioloid. 

The  disease  smoulders  here  and  there  in  different  localities,  and  when 
conditions  are  favorable  becomes  epidemic.  Perhaps  the  most  remarkable 
instance  in  modern  times  of  the  rapid  extension  of  the  disease  occurred  in 
Montreal  in  1885.  Small-pox  had  been  prevalent  in  that  city  between 
18T0  and  1875,  when  it  died  out,  in  part  owing  to  the  exhaustion  of  suit- 
able material  and  in  part  owing  to  the  introduction  of  animal  vaccination. 
The  health  reports  show  that  the  city  was  free  from  the  disease  until  1885. 
During  these  years  vaccination,  to  wiiich  many  of  the  P^'ench  Canadians 
are  opposed,  was  much  neglected,  so  that  a  large  unprotected  population 
grew  up  in  the  city.  On  February  28th  a  Pullman-car  conductor,  who  had 
travelled  from  Chicago,  where  the  disease  had  been  slightly  prevalent,  was 
admitted  into  the  H6tel-Dieu,  the  civic  small-pox  hospital  being  at  the 
time  closed.  Isolation  was  not  carried  out,  and  on  the  1st  of  April  a  serv- 
ant in  the  hospital  died  of  small-pox.  Following  her  decease,  with  a  neg- 
lipjence  absolutely  criminal,  the  authorities  of  the  hospital  dismissed  all 
patients  presenting  no  symptoms  of  contagion,  who  could  go  home.     The 


48 


SPECIFIC  INFECTIOUS  DISEASES. 


4  u:.  - 


disease  spread  like  fire  in  dry  grass,  and  within  nine  months  there  died  in 
the  city,  of  small-pox,  3,164  persons. 

The  nature  of  the  contagion  of  small-pox  is  still  unknown.  Weigert 
and  others  have  described  micro-organisms  in  the  pock,  but  they  are  the 
ordinary  pus  cocci,  and  the  part  which  they  play  in  the  affection  is  by 
no  means  certain.  Still  less  definite  ire  the  observations  on  the  occur- 
rence of  sporozoa  in  the  pocks.  It  is  not  a  little  remarkable  that  in  a 
disease  which  is  riglitly  regarded  as  the  type  of  all  infectious  maladies, 
the  specific  virus  still  remains  unknown. 

Morbid  Anatomy. — A  section  of  a  papule  as  it  is  passing  into  the 
vesicular  stage  shows  in  the  rete  mncosum,  close  t(  *ho  true  skin,  an  area 
in  which  the  cells  are  smooth,  granular,  and  do  not  take  the  staining  fluid. 
This  represents  a  focus  of  coagulation-necrosis  due,  according  to  Weigert, 
to  the  presence  of  micrococc .  Around  this  area  there  is  active  inflamma- 
tory reaction,  and  in  the  vesicular  stage  the  rete  mucosum  presents  re- 
ticuli,  or  spaces,  which  contain  serum,  leucocytes  and  fibrin  filaments.  The 
central  depression  or  umbilication  corresponds  to  the  area  of  primary 
necrosis.  In  the  stage  of  maturation  the  reticular  spaces  become  filled 
with  leucocytes  and  many  of  the  cells  of  the  rete  mucosum  become  vesicu- 
lar. The  papillie  of  the  true  skin  below  the  pustule  are  swollen  and  infil- 
trated with  embryonic  cells  to  a  variable  degree.  If  the  suppuration  ex- 
tends into  this  layer,  scarring  inevitably  results;  but  if  it  is  confined  to  the 
upper  Layer,  it  does  not  necessarily  follow.  In  the  haemorrhagic  cases, 
red  corpuscles  pass  out  in  large  numbers  from  the  vessels  and  occupy  the 
vesicular  spaces.  They  infiltrate  also  the  deeper  layers  of  the  epidermis 
in  the  skin  adjacent  to  the  papules.  Frequently  a  hai/-follicle  passes 
through  the  centre  of  a  papule. 

In  the  mouth  the  pustules  may  be  seen  upon  the  tongue  and  Mie  buccal 
mucosa,  and  on  the  palate.  T^e  eruption  may  be  abundant  also  in  the 
pharynx  and  the  upper  part  of  the  ajsophagus.  In  exceptionally  rare 
cases  the  eruption  extends  down  the  resophagus  and  even  into  the  stom- 
ach. Swelling  of  the  Peyer's  follicles  is  not  uncommon;  '-he  pustules 
have  been  seen  in  the  rectum.      .  ..(  j,  . 

In  the  larynx  the  eruption  may  be  associated  with  a  fibrinous  exudate 
and  sometimes  with  a'dema.  Occasionally  the  inflammation  passes  deeply 
and  involves  the  cartilages.  In  the  trachea  t  nd  bronchi  there  may  be 
ulcerative  erosions,  but  truj  pock  ,  such  as  are  seen  ou  the  skin,  do  not 
occur.  Tl'.ere  are  no  special  lesions  of  the  lungs,  bi.c  congestion  and  bron- 
cho-prt'umonia  are  very  common.  The  liver  is  sometimes  fatty.  A  diffuse 
hepatitis,  asKooiated  with  intense  congestion  of  the  vessels  and  migration 
of  the  leucocytes,  has  been  described;  Weigert  has  noted  small  areas  of 
necrosis. 

'J'here  is  nothing  special  in  the  condition  of  the  blood,  and  even  '>i  the 
most  malignant  cases  there  are  no  microscopic  alterations.  In  the  blood- 
drop,  however,  it  viil  be  seen  that  the  corpuscles,  instead  of  forming 


SMAI.L-POX. 


49 


rouleaux,  aggregate  together  iu  irregular  clumps.  The  heart  occasionally 
shows  myocardial  changes,  parenchymatous  and  fatty ;  endocarditis  and 
pericarditis  are  uncommon.  French  writers  have  described  an  endarteritis 
of  the  coronary  vessels  in  connection  with  small-pox.  The  spleen  is  mark- 
edly enlarged.  Apart  from  the  cloudy  swelling  and  areas  of  coagulation- 
necrosis,  lesions  of  the  kidneys  are  not  common.  Nephritis  may  occur 
during  convalescence.  Chiari  has  called  attention  to  the  frequency  of 
orchitis  in  this  disease.  There  are  scattered  areas  of  necrosis  with  cell  in- 
filtration. 

In  the  haemorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
and  about  the  nerve-sheaths.  In  one  instance  I  found  the  entire  retro- 
peritoneal tissue  infiltrated  with  a  large  coagulum,  and  there  were  also  ex- 
tensive extravasations  in  the  course  of  the  thoracic  aorta.  Haemorrhages 
in  tlie  bone-marrow  have  also  been  described  by  Golgi.  There  may  be 
hiemorrhages  into  the  muscles.  Poiifick  has  described  the  spleen  as  vciy 
firm  and  hard  in  hajmorrhagic  small-pox,  and  such  was  the  case  in  seven 
instances  which  I  examined.  The  liver  has  been  described  as  fatty  in 
these  rapid  cases,  but  in  five  of  my  seven  cases  it  was  of  normal  size, 
dense,  and  firm.  In  two  it  was  large  and  fatty  ;  but  one  man  had  necro- 
sis of  the  tibia,  and  tht:  other  was  a  drunkard.  The  ecchymoses  are  scat- 
tered over  the  meninges  of  the  brain  and  cord,  and  iu  one  case  there  was 
a  clot  in  tlie  right  ventricle.  In  five  of  the  cases  there  were  areas  of  haem- 
oriliagic  infarction  of  the  lung.  In  four  instances  the  pelves  of  the 
kidney  were  blocked  with  dark  clots,  which  extended  into  the  calices  and 
down  the  ureters.  In  one  ini>  ance  the  coats  of  the  bladder  were  uni- 
formly hajmo/rhagic  and  not  a  trace  of  normal  tissue  could  be  seen.  The 
oxtravusations  in  the  mucous  membrane  of  the  stomach  and  intestines 
wore  numerous  and  large.  Peyer's  glands  were  swollen  and  prominent  in 
four  instances. 

Symptoms. — Three  forms  of  small- pox  are  described  :      .  ,  .      ,  , 

1.  Variula  vira  ;  (a)  Discrete,  {b)  Confluent. 

2.  Variula  hmnorrhagica  ;  («)  Purpura  variolosa  or  black  small-pox ; 
{b)  Iljfimorrhagic  pustular  form,  variola  ha;morrhagica  pustulosa. 

3.  Varioloid,  or  small-pox  modified  by  vaccination. 

1-  Variola  Vera. — The  aftr  )tion  may  be  conveniently  described  under 
various  s'ages :  (a)  Inciibatiou.  This  is  variously  estinujted  at  from  seven 
to  twelve  days,  or  even  longer.  I  have  seen  it  develop  on  the  eighth  day 
after  exposure  to  infection,  and  there  are  well-authenticated  instances  in 
wliicli  the  stage  of  incubation  h»jj  been  prolonged  to  twenty  days.  It  is 
lumsiial  for  patients  to  complain  of  an^  symptoms  in  this  stage. 

[h)  Invasion. — In  adults  a  chill  and  in  children  a  convulsion  are  com- 
iMdii  initial  symptoms.  There  may  be  repeated  chills  within  the  first 
twenty-four  hours.  Intense  frontal  headache,  severe  lumbar  pains  and 
vomiting  are  very  constant  features.     The  pains  iu  the  back  anf!  in  the 


50 


SPFX'IPIC   INFECTIOUS  DISEASES. 


limbs  are  more  severe  in  the  initial  stage  of  this  than  of  any  other  erup- 
tive fever,  and  their  combination  Avith  headache  and  vomiting  is  so  sug- 


e       10       11       12       18       14       15       10       17 


18 


I 


40  0* 


39  0» 


180» 


37-0» 


Initial  Fever  Eruption. 


Suppurative  Fever. 
Chart  VII. — Tnie  small-pox. 


gestive  that  in  epidemics  precautionary  measures  may  often  be  taken 
several  days  before  the  eruption  decides  positively  the  nature  of  the  dis- 
ease. The  temperature  rises  quickly,  and  may  on  the  first  day  be  103° 
or  104°.  The  pulse  is  rapid  and  full,  not  often  dicrotic.  In  severe  cases 
there  may  be  marked  delirium,  particularly  if  the  fever  is  high.  The 
patient  is  restless  and  distressed,  the  face  is  flushed,  and  the  eyes  are 
bright  and  clear.  The  skin  is  usually  dry,  though  occasionally  there  are 
profuse  sweats.  One  cannot  judge  from  these  initial  symptoms  whether  a 
case  is  likely  to  V)e  discrete  or  confluent,  as  the  most  intense  backache  and 
fever  may  precede  a  very  mild  attack.  Convulsions  are  not  uncommon  in 
children. 

In  this  stage  of  invasion  the  so-called  initial  rashes  may  occur,  of 
which  two  forms  can  be  distinguished — the  diffuse,  scarlatinal,  and  the 
macular  or  measly  form ;  either  of  which  may  be  associated  with  petechia^ 
and  occupy  a  variable  extent  of  surface.  In  some  instances  they  are  gen- 
eral, but  as  a  rule  they  are  limited,  as  pointed  out  by  Simon,  either  to  the 
lower  abdominal  areas,  to  the  inner  surfaces  of  the  thighs,  and  to  the  lat- 
eral thoracic  region  or  to  the  axillae.  Occasionally  they  are  found  over 
the  extensor  surfaces,  particularly  in  the  neighborhood  of  the  knees  and 
elbows.  These  rashes,  usually  purpuric,  are  often  associated  with  an 
erythematous  or  erysipelatous  blush.  The  scarlatinal  rash  may  come  out 
as  early  as  the  second  day  and  be  as  diffuse  and  vivid  as  in  a  true  scarla- 
tina. The  measly  rash  may  also  be  diffuse  and  identical  in  character  with 
that  of  measles.  Urticaria  is  only  occasionally  seen.  It  was  present  once 
in  my  Montreal  cases.  Apparently  these  initial  rashes  are  more  abundant 
in  some  epidemics  than  in  others;  thus  they  were  certainly  more  numerous 
in  the  Montreal  epidemics  between  1870  and  1875  than  they  were  in  the 
more  extensive  epidemic  in  1885.     They  occur  in  from  10  to  16  per  cent 


SMALL-POX. 


51 


18 


of  cases.  In  the  cases  under  my  care  in  the  small-pox  department  at  the 
Mo!itreal  General  Hospital  the  percentage  was  13.*  As  will  be  subse- 
quently mentioned  these  initial  rashes  have  considerable  diagnostic  value. 

{(•)  Eruption. — (1)  In  the  discrete  form,  usually  on  the  fourth  day, 
small  red  spots  appear  on  the  forehead,  particularly  at  the  junction  with 
tlio  hair,  and  on  the  wrists.  Within  the  first  twenty-four  hours  from  their 
appoaranoe  they  occur  on  other  parts  of  the  face  and  on  the  extremities, 
ami  a  few  are  seen  on  the  trunk.  As  the  rash  comes  out  the  temperature 
falls,  the  general  symptoms  subside,  and  the  patient  feels  comfortable.  On 
the  fifth  or  sixth  day  the  papules  change  into  vesicles  with  clear  summits. 
Each  one  is  elevated,  circular,  and  presents  a  little  depression  in  the  cen- 
tre, the  so-called  umbilication.  About  the  eighth  day  the  vesicles  change 
into  pustules,  the  umbih'cation  disappears,  the  flat  top  assumes  a  globular 
form  and  becomes  grayish  yellow  in  color,  owing  to  the  contained  pus. 
There  is  an  areola  of  injection  about  the  pustules  and  the  skin  between 
them  is  swollen.  This  maturation  first  takes  place  on  the  face,  and  follows 
the  order  of  the  appearance  of  the  eruption.  The  temperature  now  rises — 
secondary  fever — and  the  general  symptoms  return.  The  swelling  about 
the  pustules  is  attended  with  a  good  deal  of  tension  and  pain  in  the  face ; 
the  eyelids  become  swollen  and  closed.  In  the  discrete  form  the  temper- 
ature of  maturation  does  not  usually  remain  high  for  more  than  twenty- 
four  or  twenty-six  hours,  so  that  on  the  tenth  or  eleventh  day  the  fever 
disappears  and  the  stage  of  convalescence  begins.  The  pustules  rapidly 
dry,  first  on  the  face  and  then  on  the  other  parts,  and  by  the  fourteenth  or 
fifteenth  day  desquamation  may  be  far  advanced  on  the  face.  There  may 
be  in  addition  vesicles  in  the  mouth,  pharynx,  and  larynx,  causing  sore- 
ness and  swelling  in  these  parts,  with  loss  of  voice.  Whether  pitting  takes 
place  depends  a  good  deal  upon  the  severity  of  the  disease.  In  a  majority 
of  cases  Sydenham's  statement  holds  good,  that  "  it  is  very  rarely  the  case 
that  the  distinct  small-pox  leaves  its  mark." 

(2)  Tlie  Confltient  Form. — With  the  same  initial  symptoms,  though 
usually  of  greater  severity,  the  rash  appears  on  the  fourth,  or,  according  to 
Sydenham,  on  the  third  day.  The  more  the  eruption  shows  itself  before 
the  fourth  day,  the  more  sure  it  is  to  become  confluent  (Sydenham).  The 
papules  at  first  may  be  isolated  and  it  is  only  later  in  the  stage  of  matu- 
ration that  the  eruption  is  confluent.  But  in  severer  cases  the  skin  is 
swollen  and  hypen«mic  and  the  papules  are  very  close  together.  On  the 
foot  and  hands,  too,  the  papules  are  thickly  set ;  more  scattered  on  the 
limbs;  and  quite  discrete  on  the  trunk.  With  the  appearance  of 
tlio  eruption  the  symptoms  subside  and  the  fever  remits,  but  not  to  the 
same  extent  as  in  the  discrete  form.  Occasionally  the  temperature  falls 
to  normal  and  the  patient  may  be  very  comfortable.  Then,  usually  on 
the  eighth  day,  the  temperature  again  rises,  the  vesicles  begin  to  change  to 


*Tho  Initial  Rushes  of  Smiiil-pox.    Canada  Medical  and  Surgical  Journal,  1875. 


69 


SPECIFIC  INFECTIOUS  DISEASES. 


'vi:.. 


Ul 


pustules,  the  hyperoemia  about  them  becomes  intense,  the  swelling  of  the 
face  and  hands  increases,  and  by  the  tenth  day  the  pustules  have  fully 
maturated,  many  of  them  have  coalesced  and  the  entire  skin  of  the  head 
and  extremities  is  a  superficial  abscess.  The  fever  rises  to  103°  or  104°, 
the  pulse  is  from  110  to  120,  and  there  is  often  delirium.  As  pointed  out 
by  Sydenham,  salivation  in  adults  and  diarrhcoa  in  children  are  common 
symptoms  of  this  stage.  There  is  usually  much  thirst.  The  eruption 
may  also  be  present  in  the  mouth,  and  usually  the  pharynx  and  larynx  are 
involved  and  the  voice  is  husky.  Great  swelling  of  the  cervical  lymphatic 
glands  occurs.  At  this  stage  the  patient  presents  a  terrible  picture,  un- 
equalled in  any  other  disease ;  one  which  fully  justifies  the  horror  and 
fright  with  which  small-jmx  is  associated  in  the  public  mind.  Even  when 
the  rash  is  confluent  on  the  face,  hands,  and  feet,  the  pustules  remain 
discrete  on  the  trunk.  The  danger,  as  pointed  out  by  Sydenham,  is  in 
proportion  to  the  number  upon  the  face.  "  If  upon  the  face  they  are  as 
thick  as  sand  it  is  no  advantage  to  have  them  few  and  far  between  on  the 
rest  of  the  body."  In  fatal  cases,  by  the  tenth  or  eleventh  day  the  pulse 
gets  feebler  and  more  rapid,  the  delirium  is  marked,  there  is  snbsultus, 
sometimes  diarrhani,  and  with  these  symptoms  the  patient  dies.  In  other 
instances  between  the  eighth  and  eleventh  day  luemorrhagic  symptoms 
develop.  When  recovery  takes  place,  the  patient  enters  on  the  eleventh 
or  twelfth  day  the  period  of — 

(d)  Desiccation. — The  pustules  break  and  the  pus  exudes  and  forms 
crusts.  Throughout  the  third  week  the  desiccation  proceeds  and  in  cases 
of  moderate  severity  the  secondary  fever  subsides ;  but  in  others  it  may 
persist  until  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere 
for  a  long  time  and  the  process  of  scarring  may'  take  three  or  four  weeks. 
The  crusts  on  the  face  fall  off,  but  the  tough  epidermis  of  the  hands  and 
feet  may  be  shed  entire.  We  had  in  the  small-pox  department  of  the  Mon- 
treal General  Hospital  several  moulds  in  epithelium  of  the  hands  and  feet. 

2.  HsBmorrhagio  small-pox  occurs  in  two  forms.  In  one  the  special 
symptoms  appear  early  and  death  follows  in  from  two  to  six  days.  This 
is  the  so-called  petechial  or  black  small-pox — pitrjmra  variolosa.  In  the 
other  form  the  case  progresses  as  one  of  ordinary  variola,  and  it  is  not 
until  the  vesicular  or  pustular  stage  that  haemorrhage  takes  place  into  the 
pocks  or  from  the  mucous  membranes.  This  is  sometimes  called  variola 
hmrnorrhacjica  pustulosa. 

Haemorrhagic  small-pox  is  more  common  in  some  epidemics  than  in 
others.  It  is  less  frequent  in  children  than  in  adults.  Of  twenty-seven 
cases  admitted  to  the  small-pox  department  of  the  Montreal  General  Hos- 
pital there  were  three  under  ten  years,  four  between  fifteen  and  twenty, 
nine  between  twenty  and  twenty-five,  seven  between  twenty-five  and  thirty- 
five,  three  between  thirty  five  and  forty-five,  and  one  above  fifty.  Young 
and  vigorous  persons  seem  more  liable  to  this  form.  Several  of  my  cases 
were  above  the  average  in  muscular  development.     Men  are  more  fre- 


w;    « 


SMALL-POX. 


53 


qnently  affected  than  women ;  thus  in  my  Hat  tliere  were  twenty-one 
males  and  only  six  females.  The  influence  of  vaccination  is  shown  in  the 
fact  that  of  the  cases  fourteen  were  unvaccinated,  while  not  ojie  of  the 
thirteen  who  had  scars  had  been  revacciuated. 

The  clinical  features  of  the  forms  of  h«morrhagic  small-pox  are  some- 
what different. 

In  purpura  variolosa  the  illness  starts  with  the  usual  symptoms,  but 
with  more  intense  constitutional  disturbance.  On  the  evening  of  the 
second  or  on  the  third  day  there  is  a  diffuse  hyperaemic  rash,  particularly 
in  the  groins,  with  small  punctiform  haemorrhages.  The  rash  extends, 
becomes  more  distinctly  haemorrhagic,  and  the  spots  increase  in  size. 
Eochymoses  appear  on  the  conjunctivae,  and  as  early  as  the  third  day 
tliere  may  be  haemorrhages  from  the  mucous  membranes.  i)eath  may 
take  place  before  the  rash  appears.  This  is  truly  a  terrible  affection  and 
well  developed  cases  present  a  frightful  appearance.  The  skin  may  have 
a  uniformly  purplish  hue  and  the  unfortunate  victim  may  even  look  plum- 
colored.  The  face  is  swollen  and  large  conjunctival  haemorrhages  with 
the  deeply  sunken  cornea;  give  a  ghastly  appearance  to  the  features. 

The  mind  may  remain  clear  to  the  end.  Death  occurs  from  the  third 
to  the  sixth  day ;  thus  in  thirteen  of  my  cases  death  took  place  on  or  be- 
fore this  date.  The  earliest  death  was  on  the  third  day  and  there  were 
no  traces  of  papules.  There  may  be  no  mucous  haemorrhages ;  thus  in 
one  case  of  a  most  virulent  character  death  occurred  without  bleeding 
early  on  tlie  fourth  day.  Haematuria  is  perhaps  most  common,  next  hae- 
mateniesis,  and  meltena  was  noticed  in  a  third  of  the  cases.  Metrorrhagia 
was  noticed  in  one  only  of  the  six  females  on  my  list.  Ila'moptysis  oc- 
curred in  five  cases.  The  pulse  in  this  form  of  small-pox  is  rapid  and 
often  hard  and  small.     The  respira-  ^ 

tions  are  greatly  increased  in  fre- 
quency and  out  of  all  proportion  to 
tlie  intensity  of  the  fever.  In  the 
case  of  a  negro,  whoso  respirations 
the  morning  after  admission  were 
•VI  and  temperature  101°,  after  ex- 
amining the  lungs  and  finding  noth- 
ing to  account  for  the  increased 
Ineathing,  my  suspicions  were 
xnmsed,  and  even  on  the  dark  skin 
1  was  able  on  careful  inspection  to 
ilctcct  haemorrhages  in  and  about 
the  papules. 

The  annexed  chart  is  from  a 
case  of  malignant  small-pox  which 

came  on  abruptly  on  Thursday,  October  24,  1874,  and  which  terminated 
early  on  the  fourth  day.     It  shows  the  moderate  temperature  range. 


lOA 

p.  „  • 

*s 

N 

» 

103 

i i i 1 i i j 1 i 

...a:T"7^i I \ \ 

Ids 

i 

J 

:\ 

i\ 

j 

101 
100 

y 

• 

i 

I-..- 

i 

i'  ' 

i 

i 

i 

■ 

i 

w 

Day  of 
DIatuue. 

1 

8 

3 

4 

CiiAKT  VI II. — TTii'inorrhngic  small-pox. 


54 


SPECIFIC  INFECTIOUS  DISEASEa 


I 


hiy 


In  variola  pustulosa  hemorrhagica  the  disease  progresses  as  an  ordi- 
nary case  of  severe  variola,  and  the  haemorrhages  do  not  develop  until  the 
vesicular  or  pustular  stage.  The  earlier  the  haemorrhage  the  greater  is 
the  danger.  There  are  undoubtedly  instances  of  recovery  when  the  bleed- 
ing has  taken  place  at  the  stage  of  maturation.  Bleeding  from  the  mu- 
cous membranes  is  also  common  in  this  form,  and  the  great  majority  of 
the  cases  prove  fatal,  usually  on  the  seventh,  eighth,  or  ninth  day. 

There  is  a  form  of  hemorrhagic  small-pox  in  which  bleeding  takes 
place  into  the  pocks  in  the  vesicular  stage  and  is  followed  by  a  rapid 
abortion  of  the  rash  and  a  speedy  recovery.  Six  instances  of  this  kind 
came  under  my  observation.*  In  four  the  haemorrhage  took  place  on  the 
fourth  day ;  in  two  on  the  fifth  day,  just  at  the  time  of  transition  of  the 
papule  into  the  vesicle.  Extravasation  takes  place  chiefly  into  the  pocks 
on  the  lower  extremities  and  trunk,  in  only  two  instances  occurring  in 
those  of  the  arms.  The  eruption  in  all  proved  abortive,  and  no  patients 
under  my  care  with  an  equal  extent  of  eruption  made  such  rapid  recover- 
ies. With  these  cases  are  to  be  grouped  those  in  which  the  haemorrhages 
occur  in  the  pustules  of  the  legs  in  patients  who  have  in  their  delirium 
got  out  of  bed  and  wandered  about.  This  modified  form  of  hsemorrhagic 
small-pox  is  also  described  by  Scheby-Buck. 

3.  Varioloid. — This  term  is  applied  to  the  modified  form  of  small-pox 
which  affects  persons  who  have  been  vaccinated.  It  may  set  in  with 
abruptness  and  severity,  the  temperature  reaching  103°.  More  common- 
ly it  is  in  every  respect  milder  in  its  initial  symptoms,  though  the  head- 
ache and  backache  may  be  very  distressing.  The  papules  appear  on  the 
evening  of  the  third  or  on  the  fourth  day.  They  are  few  in  number  and 
may  be  confined  to  the  face  and  hands.  The  fever  drops  at  once  and 
the  patient  feels  perfectly  comfortable.  The  vesiculation  and  maturation 
of  the  pocks  take  place  rapidly  and  there  is  no  secondary  fever.  There 
is  rarely  any  scarring.  As  a  rule,  when  small-pox  attacks  a  person  who 
has  been  vaccinated  within  five  or  six  years  the  disease  is  mild,  but  there 
are  instances  in  which  it  is  very  severe,  and  it  may  even  prove  fatal. 

There  are  several  forms  of  rash ;  thus  in  what  has  been  known  as  horn- 
pox,  crystalline  pox,  and  wart-pox  the  papules  come  out  in  numbers  on 
the  third  or  fourth  day,  and  by  the  fifth  or  sixth  day  have  dried  to  a  hard, 
horny  consistence. 

Writers  describe  a  variola  sine  eruptione,  which  is  met  with  during 
epidemics  in  young  persons  who  have  been  well  vaccinated,  and  who  pre- 
sent simply  the  initial  symptoms  of  fever,  headache  and  backache.  In 
a  somewhat  extensive  experience  in  Montreal  I  do  not  remember  to  have 
met  with  an  instance  of  this  kind  or  to  have  heard  of  one. 

We  do  not  now  see  the  modified  form  of  small-pox,  resulting  from 
inoculation,  in  which  by  the  seventh  or  eighth  day  a  pustule  forms  at  the 

*  Clinical  Notes  on  Small-pox.    Montreal,  1870. 


;s  ' 


m 


SMALL-POX. 


65 


seat  of  inoculation;  then  general  fever  sets  in,  and  with  it,  about  the 
I'leventh  day,  a  general  eruption,  usually  limited  in  degree. 

Complications. — Considering  the  severity  of  many  of  the  cases 
mul  the  general  character  of  the  disease,  associated  with  multiple 
fuci  of  suppuration,  the  complications  in  small-pox  are  remarkably 
few. 

Laryngitis  is  serious  in  three  ways  :  it  may  produce  a  fatal  ccdema  of 
the  glottis ;  it  is  liable  to  extend  and  involve  the  cartilages,  producing 
m-crosis ;  and  by  diminishing  the  sensibility  of  the  larynx,  it  allows  irri- 
liitiiig  particles  to  reach  the  lower  air-passages,  where  they  excite  bron- 
t'hitis  or  broncho-pneumonia. 

Broncho-pneumonia  is  indeed  one  of  the  most  common  complications, 
imd  is  almost  invariably  present  in  fatal  cases.  Lobar  pneumonia  is  rare. 
Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  In  the  height  of  the  fever  a 
systolic  murmur  at  the  aj)ex  is  not  uncommon ;  but  endocarditis,  either 
simple  or  malignant,  is  rarely  met  with.  Pericarditis  too  is  very  uncom- 
mon. Myocarditis  seems  to  be  more  frequent,  and  may  be  associated  with 
endarteritis  of  the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe 
cases  there  is  extensive  pseudo-diphtheritic  angina.  Vomiting,  which  is 
so  marked  a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea 
is  not  uncommon,  as  noted  by  Sydenham,  and  is  very  constantly  present 
in  cliildren. 

Albuniijuiria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of 
the  testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  per- 
taining to  the  nervous  system.  In  children  convulsions  are  common.  In 
ikUiUs  the  delirium  of  the  early  stage  may  persist  and  become  violent,  and 
lliially  subside  into  a  fatal  coma.  Post-febrile  insanity  is  occasionally  met 
with  during  convalescence,  and  very  rarely  epilepsy.  Many  of  the  old 
writers  spoke  of  paraplegia  in  connection  with  the  intense  backache  of 
tlie  early  stage,  but  it  is  probably  associated  with  the  severe  agonising 
lumbar  and  crural  pains  and  is  not  a  true  paraplegia.  It  must  be  sepa- 
rated from  the  form  occurring  in  convalescence,  which  may  be  due  to 
peripheral  neuritis  or  to  a  diffuse  myelitis  (Westphal).  The  neuritis 
may  as  in  diphtheria  involve  the  pharynx  alone,  or  it  may  be  multiple. 
Of  tliis  nature,  in  all  probability,  is  the  so-called  pseudo-tabes,  or  ataxie- 
vnrinlique.  Hemiplegia  and  aphasia  have  been  met  with  in  a  few  in- 
stances, the  result  of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  of  small-pox 
are  those  involving  the  skin.  During  convalescence  boils  are  very  fre- 
quent and  may  be  severe.  Acne  and  ecthyma  are  also  met  with.  Local 
gangrene  in  various  parts  may  occur. 

Arthritis  may  develop,  usually  in  the  period  of  desquamation.  It  is 
6 


66 


SPECIFIC  INFECTIOUS  DISEASES. 


!•'■;,  !r.. 


probably  not  a  genuine  rheumatism.  Acute  necrosis  of  the  bone  is  some- 
times met  with. 

Spei'ud  Senses. — The  eye  affections  which  were  formerly  so  common 
and  serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to 
keeping  the  conjunctivae  clean.  A  catarrhal  and  purulent  conjuuctivitiH 
is  common  in  severe  cases.  The  secretions  cause  adhesions  of  the  eyelids, 
and  unless  great  care  is  taken  a  diffuse  keratitis  is  excited,  which  may  go 
on  to  ulceration  and  perforation.  Iritis  is  not  very  uncommon.  Otitis 
media  is  an  occasional  complication,  and  usually  results  from  an  extension 
of  disease  through  the  Eustachian  tubes. 

Frog^OSiB. — In  unprotected  persons  small-pox  is  a  very  fatal  disease. 
In  different  epidemics  the  death-rate  is  from  25  to  35  per  cent.  The 
haemorrhagic  form  is  invariably  fatal,  and  a  majority  of  those  attacked 
with  the  severer  confluent  forms  die.  In  young  children  it  is  particularly 
fatal.  In  the  Montreal  epidemic  of  1885  and  188G,  of  3,164  deaths  there 
were  2,717  under  ten  years.  Tlie  intemperate  and  debilitated  succumb 
more  readily  to  the  disease.  As  Sydenham  observed,  the  danger  is  direct- 
ly proportionate  to  the  intensity  of  the  disease  on  the  face  and  hands. 
"  When  the  fever  increases  after  the  appearance  of  the  pustules,  it  is  a  bad 
sign;  but,  if  it  is  lessened  on  their  appearance,  that  is  a  good  sign" 
(Rhazes).  In  the  confluent  cases,  when  maturation  does  not  proceed 
and  the  pocks  are  flat  and  if  haemorrhage  occurs,  the  outlook  is  usually 
bad.  In  such  cases  the  general  symptoms  are  apt  to  be  severe.  Very 
high  fever,  with  delirium  and  subsultus,  are  symptoms  of  ill  omen.  The 
disease  is  particularly  fatal  in  pregnant  women  and  abortion  usually  takes 
place.  It  is  not,  however,  uniformly  fatal,  and  I  have  twice  known  severe 
cases  to  recover  after  miscarriage.  Moreover,  abortion  is  not  inevitable. 
Very  severe  pharyngitis  and  laryngitis  are  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh 
or  twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasion- 
ally in  adults,  the  laryngeal  and  pulmonary  complications  prove  fatal. 

Diagnosis. — During  an  epidemic,  the  initial  chill,  followed  by  fever, 
headache,  vomiting,  and  the  severe  pain  in  the  back,  are  symptoms  which 
should  put  the  attending  physician  on  his  guard.  Mistakes  arise  in  the 
initial  stage  owing  to  the  presence  of  the  scarlatinal  or  measly  rashes 
which  may  be  extremely  deceptive.  The  scarlatinal  rash  has  not  always 
the  intensity  of  the  true  rash  of  this  disease.  In  my  Montreal  experience 
I  did  not  meet  with  an  instance  in  which  this  rash  led  to  an  error,  though 
I  heard  of  several  cases  in  which  the  mistake  was  made.  These  are  doubt- 
less the  instances  to  which  the  older  writers  refer  of  scarlet  fever  and 
small-pox  occurring  together.  The  measly  rash  cannot  always  be  dis- 
tinguished from  true  measles,  instances  of  which  may  be  mistaken  for  the 
initial  rash.  I  found  in  the  ward  one  morning  a  young  man  who  had 
been  sent  in  on  the  previous  evening  with  a  diagnosis  of  small-pox.    Ho 


51  li^  ,i: 


SMALL-POX. 


57 


had  a  fading  macular  rash  with  distinct  small  papules,  which  had  not 
liowcver  the  shotty  hardness  of  variola.  In  the  evening  this  rash  was  less 
marked,  and  as  I  felt  sure  that  a  mistake  had  been  made,  he  was  disin- 
fi'C'tod  and  sent  home.  In  another  instance  a  cliild  believed  to  have  small- 
pox was  admitted,  but  it  i)roved  to  have  simply  measles.  Neither  of  these 
(•a«s  took  small-pox.  In  a  third  case,  which  I  saw  at  the  City  Hospital, 
tlie  mottled  papular  nish  was  mistaken  for  small-pox  and  tho  young  man 
MMit  to  tho  hospital.  I  saw  him  the  day  after  admission,  when  there  was 
11(1  question  that  the  disease  was  measles  and  not  variola.  Less  fortunate 
tluiu  tho  other  cases,  he  took  small-pox  in  a  very  severe  form.  The  gen- 
eral condition  of  the  patient  and  the  nature  of  the  prodromal  symptoms 
are  often  bettor  guides  than  the  character  of  the  rash.  In  any  case  it  is 
not  well,  as  a  rule,  to  send  a  patient  to  a  small-pox  hospital  until  the  char- 
acteristic papules  appear  about  the  forehead  and  on  the  wrists. 

In  the  most  malignant  type  of  h»morrhagic  small-pox  tho  patient  may 
(lie  before  the  characteristic  rash  develops,  though  as  a  rule  small,  shotty 
papules  may  be  felt  about  the  wrists  or  at  the  roots  of  the  hair.  In  only 
one  of  twenty-seven  cases  of  haemorrhagic  small-pox,  in  which  death 
occurred  on  the  third  day,  did  inspection  fail  to  reveal  the  papules.  In 
throe  cases  in  which  death  took  place  on  the  fourth  day  the  characteristic 
rush  wsis  beginning  to  appear. 

The  disease  may  be  mistaken  for  cerebro-spinal  fever,  in  which  purpuric 
symjitoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly 
ill  with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day 
petechiae  appeared  on  the  skin.  There  waa  retraction  of  tho  head,  and 
marked  rigidity  of  the  limbs.  The  haemorrhages  became  more  abundant ; 
and  finally  hoBmatemesis  occurred  and  the  child  died  on  tho  sixth  day.  At 
the  post-mortem  there  were  no  lesions  of  cerebro-spinal  fever  and  in  tho 
deeply  hemorrhagic  skin  the  papules  could  be  readily  seen.  The  post- 
mortem diagnosis  of  small-pox  was  unhappily  confirmed  by  the  mother 
taking  the  disease  and  dying  of  it. 

It  might  be  thought  scarcely  possible  to  mistake  any  other  disease  for 
Rmall-pox  in  the  pustular  stage.  Yet  I  had  an  instance  of  a  young  man 
sent  to  me  with  a  copious  pustular  eruption,  chiefly  on  the  trunk  and  cov- 
ered portions  of  the  body,  which,  so  far  as  the  pustules  themselves  were 
concerned,  was  almost  identical  with  that  of  variola ;  but  the  history  and 
tiic  distribution  left  no  question  that  it  was  a  pustular  syphilide.  It  is  not 
to  be  forgotten,  however,  that  fever,  which  was  absent  in  this  case,  may  be 
present  in  certain  instances  of  diiTuse  pustular  syphilis.  Lastly,  chicken- 
pox  and  small-pox  may  be  confounded.  Indeed,  sometimes  it  is  not  easy 
to  distinguish  between  them,  though  in  well-defined  coses  of  varicella  the 
more  vesicular  character  of  the  pustules,  their  irregularity,  the  short  stage 
of  invasion,  tho  slight  constitutional  disturbance,  and  the  greater  intensity 
of  the  rash  on  the  trunk,  should  make  the  diagnosis  clear.  It  is  stated 
that  the  Chicago  case,  which  was  the  starting-point  in  Montreal  of  the 


58 


SPECIFIC  INFECTIOUS  DISEASES. 


i 


;S  I  ■  I  ■ 

1:^1 


f'  m 


epidemic  of  1885,  was  regarded  an  varicella  and  not  isolated.  If  so,  the 
mistake  was  one  which  led  to  cue  of  the  most  fatal  uf  modern  outbreaks 
of  the  disease. 

Glanders  in  tlie  pustular  form  has  been  mistaken  for  small-pox,  and  I 
know  of  an  instance  (during  an  epidemic)  which  was  isolated  on  the  sup- 
position that  it  was  variola. 

Treatment. — In  the  interests  of  public  health  cases  of  small-pox 
should  invariably  bo  removed  to  special  hospitals,  since  it  is  impossible  to 
take  the  proper  precautions  in  private  houses.  The  general  hygienic 
arrangements  of  the  room  should  bo  suitable  for  an  infectious  disease. 
All  unnecessary  furniture  and  the  curtains  and  cari)ets  should  be  removed. 
The  greatest  care  should  ha  taken  to  keej)  the  patient  thoroughly  clean, 
and  the  linen  should  be  frequently  changed.  Tlie  bedclothing  should  be 
light.  It  is  curious  that  the  old-fashioned  notion,  which  Sydenham  tried 
so  hard  to  combat,  that  small-pox  patients  should  bo  kept  hot  and  warm, 
still  prevails ;  and  I  have  frequently  had  to  protest  against  the  patient 
being,  as  Sydenham  expresses  it,  stifled  in  his  bed.  Special  care  should  bo 
taken  to  sterilize  thoroughly  everything  that  has  been  in  contact  with 
the  patient. 

In  the  early  stage  the  pain  in  the  back  and  limbs  requires  opium, 
which,  as  advised  by  Sydenham,  may  bo  freely  ven.  The  diet  should 
consist  of  milk  and  broths,  and  of  "  all  articles  which  give  no  trouble  to 
digestion."  Cold  drinks  may  be  freely  given.  Barley-water  and  the 
Scotch  borse  (oatmeal  and  water)  are  both  nutritious  and  palatable. 
After  the  preliminary  vomiting,  which  is  often  very  hard  to  check  by 
ordinary  measures,  the  appetite  is  usually  good,  and,  if  the  throat  is  not 
very  sore,  patients  with  the  confluent  form  take  nourishment  well.  In 
the  haemorrhagio  cases  the  vomiting  is  usually  aggravating  and  per- 
sistent. 

The  fever  when  high  must  be  kept  within  limits,  and  it  is  best  to  use 
either  cold  sponging  or  the  cold  bath.  When  the  pyrexia  is  combined 
with  delirium  and  subsultus,  the  patient  sliould  be  placed  in  a  bath  at  70°, 
and  this  repeated  as  often  as  every  three  hours  if  the  temperature  rises 
above  103°.  \V  hen  it  is  not  practicable  to  give  the  cold  bath,  the  cold  pack 
can  be  employed.  These  measures  are  much  preferable  in  small-pox  to 
the  administration  of  medicinal  antipyretics. 

The  treatment  of  the  eruption  has  naturally  engaged  the  special  atten- 
tion of  the  profession.  The  question  of  the  preventing  of  pitting,  so  much 
discussed,  is  really  not  in  the  hands  of  the  physician.  It  depends  entirely 
upon  the  depth  to  which  the  individual  pustules  reach.  After  trying  all 
sorts  of  remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or 
treating  tliem  with  iodine  and  various  ointments,  I  came  to  Sydenham's 
conclusion  that  in  guarding  the  face  against  being  disfigured  by  the  scars 
"  the  only  effect  of  oils,  liniments,  and  the  like,  was  to  make  the  white 
scurfs  slower  in  coming  off.'*    There  is,  I  believe,  something  in  protecting 


ii 


8MALL-P0X. 


69 


,0  use          ; 

)ined          i 

b  70°, 

rises          -^ 

puck         1 

)X  to          J 

tten-        ^ 
nuch        1- 

tirely 

ig  all 

Br,  or 

lam's 

scars 

vhito 

cting 

tlie  ri])ot)ing  papules  from  the  light,  and  the  constant  application  on  the 
fno.o  iind  hands  of  lint  soaked  in  cold  water,  to  which  antiseptics  such  as 
ciubolic  acid  or  bichloride  may  be  added,  is  perhaps  the  moat  suitahle 
trcatinent.  It  is  very  pleasant  to  the  patient,  and  for  the  face  it  is 
will  to  make  a  mask  in  lint,  which  can  then  be  covered  with  oiled  silk. 
When  the  crusts  begin  to  form,  the  chief  point  is  to  keep  them  thoroughly 
moist,  which  may  be  done  I'V  oil  or  glycerin.  This  prevents  the  desicca- 
tion .uid  (hlfusion  f  the  flakes  of  epidermis.  Vaseline  is  jjarticularly  use- 
ful, and  at  this  stage  may  be  freely  ustnl  upon  the  face.  It  frequently 
relieves  the  itching  also.  For  the  odor,  which  is  sometimes  so  character- 
istic and  disagreeable,  the  dilute  carbolic  solutions  are  probably  best.  If 
the  eruption  is  abundant  on  the  scalp,  the  hair  should  be  cut  short  to 
prevent  matting  and  decomposition  of  the  crusts.  During  convalescence 
frequent  bathing  is  advisable,  because  it  helps  to  soften  the  crusts.  The 
care  of  the  eyes  is  particularly  important.  The  lids  should  be  thoroughly 
cleansed  three  or  four  times  a  day,  and  the  conjunctivae  washed  with  some 
antiseptic  solution.  In  the  confluent  cases,  when  the  eyelids  are  much 
swollen  and  the  lids  glued  together,  it  is  only  by  watchfulness  that  kerati- 
tis can  be  prevented.  The  mouth  and  throat  should  be  kept  clean,  and  if 
crusts  form  in  the  nose  they  should  be  softened  by  frequent  injections. 
Ice  can  be  given,  and  is  very  grateful  when  there  is  much  angina.  In 
moderate  cases,  so  soon  as  the  fever  subsides  the  patient  should  be  allowed 
to  get  up,  a  practice  which  Sydenham  warmly  urged.  The  diarrheoa,  when 
severe,  should  bo  checked  with  paregoric.  When  the  pulse  becomes  feeble 
and  rapid,  stimulants  may  be  freely  given.  The  delirium  is  occasionally 
maniacal  and  may  require  chloroform,  but  for  the  nervous  symptoms  the 
bath  or  cold  pack  is  the  best.  For  the  severe  haemorrhages  of  the  malig- 
nant cases  nothing  can  be  done,  and  it  is  only  cruel  to  drench  the  unfortu- 
nate patient  with  iron,  ergot,  and  other  drugs.  Symptoms  of  obstruction  in 
the  larynx,  usually  from  oedema,  may  call  for  tracheotomy.  In  the  late 
stages  of  the  disease,  should  the  patient  be  extremely  debilitated  and  the 
subject  of  abscesses  and  bed-sores,  he  may  bo  placed  on  a  water-bed  or 
treated  by  the  continuous  warm  bath.  During  convalescence  the  patient 
should  bathe  daily  and  use  carbolic  soap  freely  in  order  to  get  rid  of  the 
crusts  and  scabs.  The  patient  should  not  bo  considered  free  from  danger 
to  others  until  the  skin  is  perfectly  smooth  and  clean,  and  free  from  .my 
trace  of  scabs.  I  have  not  mentioned  any  of  the  so-called  specifics  or  the 
iiitornal  antiseptics,  which  have  been  advised  in  such  numbers ;  because, 
so  fur  as  I  know,  the  experience  of  those  who  have  seen  the  most  of  the 
ilisease  does  not  favor  their  use. 


60 


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SPECIFIC  INFECTIOUS  DISEASES. 


V.  VACCINIA  {Cowpoxy-W ACCINATION. 


Definition. — An  eruptive  disease  of  the  cow,  the  vims  of  which,  inocu- 
lated into  man  (vaccination),  produces  a  local  pock  with  constitutional  dis- 
turbance, which  affords  protection,  more  or  less  permanent,  from  small-pox. 

The  vaccine  is  got  either  directly  from  the  calf — animal  lymph — in 
which  the  disease  is  propagated  at  regular  stations,  or  is  obtained  from 
persons  vaccinated  (humanised  lymph). 

It  was  in  1798  that  Edward  Jenner,  a  friend  and  pupil  of  Hunter, 
practising  in  Gloucestershire,  announced  that  persons  accidentally  inocu- 
lated with  the  cow-pox  were  subsequently  insusceptible  to  small-pox. 
From  that  time  the  process  has  extended  over  the  civilized  world  and 
proved  an  incalculable  boon  to  humanity.  For  many  years  arm-to-arni 
vaccination  was  practised,  or  the  lymph  was  collected  from  the  vesicle  of 
a  child,  or  the  dried  scabs  were  used.  The  humanised  lymph  in  all  proba- 
bility underwent  changes  and  was  certainly  more  frequently  followed  by 
evil  results.  Of  lato  years  animal  vaccination  has  superseded  it  in  great 
part,  and  now  the  lymph  is  derived  either  directly  from  the  calf  or  from 
one  or  two  removes. 

The  precise  nature  of  the  vaccination  virus  is  as  yet  unknown.  Sev- 
eral forms  of  micro-organisms  have  been  isolated,  and  Quist  has  cultivated 
micrococci  which,  ho  states,  produce  in  the  child  a  typical  vaccine  vesicle. 
Several  attempts  have  since  been  made  to  isolate  the  virus,  but  without 
definite  success.  Ernst  and  Martin,  of  IJoston,  have  isolated  from  the 
bovine  lymph  a  germ  which  grows  on  culture  media  and  produces,  when 
inoculated  in  the  calf  or  in  children,  characteristic  vesicles. 

Phenomena  of  Vaccination. — In  a  })ri'mary  vaccination,  at  the 
end  of  twenty-four  or  thirty-six  hours  there  is  seen  at  the  point  of  inser- 
tion of  the  virus  a  slight  papular  elevation  surrounded  by  a  reddish  zone. 
The  papule  gradually  increases  and  on  the  fifth  or  sixth  day  showt;  a  defi- 
nite vesicle,  the  margins  of  which  are  raised  while  the  centre  is  depressed. 
By  the  eighth  day  the  vesicle  has  attained  its  maximum  size.  It  is  round 
aiid  distended  with  a  limpid  fluid,  the  margin  hard  and  prominent,  and 
tiro  umbilication  is  more  distinct.  By  the  tenth  day  the  vesicle  is  still 
largo  and  is  surrounded  by  an  extensive  areola.  The  skin  is  also  swollen, 
indurated,  and  often  painful.  On  the  eleventh  or  twelfth  day  the  hyperae- 
mia  diminishes,  the  lymph  becomes  more  opaque  and  begins  to  dry.  By 
the  end  of  the  second  week  the  vesicle  is  converted  into  a  brownish  scab 
Avhich  gradually  becomes  diy  and  hard,  and  in  about  a  week  (that  is,  about 
the  twenty-first  or  twenty-fifth  day  from  the  vaccination)  separates  and 
leaves  a  circular  pitted  scar.  If  the  points  of  inoculation  have  been  close 
together,  the  vesicles  fuse  and  may  form  a  large  combined  vesicle.  Con- 
stitutional symptoms  of  a  more  or  less  marked  degree  follow  the  vaccina- 
tion. Usually  on  the  third  or  fourth  day  the  temperature  rises,  and  may 
persist,  increasing  until  the  eighth  or  ninth  day.    In  children  it  is  common 


VACCINIA— VACCINATION. 


to  have  with  tlio  fovor  rostlesflnesa,  particinhirly  at  niglit,  and  irritability; 
but  as  a  riiio  these  symptoma  arc  trivial.  If  tlio  inocuhition  it)  made  on  tlio 
arm,  the  axillary  j(lan(l«  become  large  and  Horc ;  if  on  the  leg,  the  inguinal 
glands.  The  above  may  be  taken  as  representing  the  typical  course  of  vac- 
cination, whether  i)erformed  with  the  humanised  or  with  the  aninud  lymph. 

Successful  vacciiuition  is,  for  n  time  at  least,  an  infallible  protection 
against  small-pox.  The  duration  of  the  immunity  is  extremely  variable,  dif- 
fering in  different  individuals.  In  some  instatices  it  is  permanent,  but  a 
majority  of  persons  within  ten  or  twelve  years  again  become  susceptible. 

Kevaccination  should  be  performed  betwetm  the  tenth  und  tifteenth 
veur,  and  whenever  small-pox  is  epidemic.  The  8usce]>tibility  to  revacci- 
iiation  is  curiously  variable,  and  when  small-pox  is  jjrevalcnt  it  is  not  well, 
if  unsuccessful,  to  be  content  with  a  single  attempt.  The  vesicle  in  re- 
vac(;ination  is  usually  smaller,  lias  less  induration  and  hypenemia,  and  the 
roHulting  scar  is  less  perfect.  Particular  care  shoidd  be  taken  to  watch 
the  vesicle  of  revaccination,  as  it  not  infrequently  luippens  that  a  spurious 
pock  is  formed,  which  reaches  its  height  early  and  dries  to  a  scab  by  th  ' 
ciglith  or  ninth  day.  The  constitutional  symptoms  in  revacciiuition  are 
sometimes  quite  severe. 

An  irregular  course  is  nncommon  in  primary  vaccination,  but  we  occa- 
sionally meet  with  instances  in  which  the  vesicle  develops  rapidly  with 
much  itching,  has  not  the  characteristic  flattened  appearance,  the  lymph 
early  becomes  opaque,  and  the  crust  forms  by  the  seventh  or  eighth  day. 
In  such  cases  the  operation  should  again  bo  performed  with  fresh  lymj)!). 

Complications. — In  nnhealthy  subjects,  or  as  a  result  of  undeanli- 
ness,  or  sometimes  injury,  the  vesicles  inflame  and  deep  excavated  ulcers 
result.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  chil- 
dren there  may  bo  with  this  a  purpuric  rash.  Erysipelas  may  occur,  or 
there  may  be  deep  gangrenous  ulceration.  Such  instances  are  rare,  but 
I  have  seen  two  which  proved  fatal.  In  one  there  was  deej)  sloughing  and 
in  the  other  erysipelas.  Cases  of  local  dermatitis  must  not  be  mistaken 
for  erysipelas.  Among  the  most  common  complications  are  certain  skin 
eruptions,  some  of  which  are  due  to  the  vaccine  virus;  others  result  from 
a  mixed  infection.  Vaccine  vesicles  not  infrequently  break  out  in  the 
immediate  vicinity  of  the  primary  sores.  Less  commoidy  there  is  a  gen- 
eral eruption  of  vesicles — generalized  vaccinia — due  to  absorption  of  the 
virus.  More  frequent,  perhaps,  is  the  erythematous  or  roseolous  rash, 
(^ontagious  impetigo  can  also  be  inoculated  with  the  virus,  and  may 
appear  as  a  general  eruption. 

A  question  of  special  importance  with  reference  to  vaccination  is  the 
transmission  of  other  diseases.  For  ft  time  physicians  were  unwilling  to 
acknowledge  that  constitutional  disorders  could  be  transmitted  by  vaccina- 
tion, but  it  is  now  universally  recognized  that  such  transmission  may  take 
place,  and  this  has  emphasised  the  scrupulous  care  which  should  bo  taken 
ill  tho  performance  of  the  operation. 


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62 


SPECIFIC  INFECTIOUS  DISEASES, 


Vaocino-Syphilis. — For  a  knowledge  of  this  most  serious  of  all  accidents 
during  vaccination  we  are  largely  inaobted  to  Jonathan  Hutchinson.  It  is 
a  true  instance  of  a  mixed  infection.  The  vaccine  vesicles  take  as  a  rule 
their  usual  course,  and  it  is  not  until  they  have  healed  or  are  in  process  of 
healing  that  the  local  changes  characteristic  of  syphilis  are  manifested. 
The  fact  that  syphilis  may  be  transmitted  in  this  way  should  put  the  prac- 
titioner on  his  j^uard  in  selecting  humani'ed  lymph.  He  should  take  it 
only  from  subjects  with  whose  constitution  he  is  perfectly  familiar. 
Fortunately,  the  instances  are  extremely  rare.  They  are,  in  fact,  much 
less  frequent  than  is  usually  supposed,  and  in  a  majority  of  the  cases  in 
which  vaccino-syphilis  is  suspected  the  condition  is  really  that  of  inflamed 
and  indurated  vaccinal  ulcer.  As  the  subject  is  of  daily  interest  to  the 
practitioner,  and  one  which  he  may  at  any  moment  be  called  upon  to  de- 
cide, I  here  insert  a  table  of  differential  features  between  vaccinal  ulcers 
and  vaccino-syphilis,  and  between  tne  vaccination  rashes  and  the  secondary 
syphilitic  eruptions,  compiled  by  C.  E.  Shelly  *  from  Fournier's  lectures. 


VACCINO-SYPIIILIS. 

Chancre  developed  on  ''^e  site  of 
usually  one  or  two  only  of  the  vac- 
cination punctures. 

Inflammation  is  slight. 

Loss  of  substance  superficial  only. 

Suppuration  scanty  or  absent, 
scabs  or  crusts  formed. 

Border  of  chancre  smooth,  slight- 
ly elevated,  gradually  merging  into 
floor. 

Surface  of  floor  smooth. 

Induration    "  parchment  -  like  " 

and  specific,  notmerely  inflammatory. 

Inflammatory  areola  very  slight. 

Gland  swelling  constant,  indo- 
lent (syphilitic)  bubo. 
Complications  rare. 

Chancre  never  developed  before 
the  fifteenth  day  after  vaccinations 
usually  not  until  after  three  to  live 
weeks ;  still  in  its  earlier  stage 
twenty  days  after  vaccination. 


VACCINATIOX    ULCERS. 

Ulceration  affects  all  the  punct- 
ures as  a  rule. 

Inflammation  and  ulceration  se- 
vere. 

Ulcer  deeply  excavated. 
Much  suppuration. 

Margin  of  ulcer  irregular,  as  in 
"  soft  chancre." 


mg. 


Floor  of  uLer  uneven,  suppurat- 
Induration  inflammatory  only. 


Areola  inflammatory  and  ery- 
sipelatous in  character. 

Gland  swelling  often  absent;  if 
present,  merely  inflammatory. 

Complications — sloughing,  ery- 
sipelas, etc. — often  present. 

Ulceration  is  present  twelve  or 
fifteen  days  after  vaccination  and  is 
fully  developed  by  the  twentieth 
day  af t  ;r  vaccination. 


•  Fowler's  Dictioimry  of  Medicine.    Article  Vaccinfttion. 


VACCINIA-VACCINATION. 


03 


SECONDARY   SYPHILITIC   ERUPTION 

due  to  true  vaccino-syphilis. 


Appears,  at  the  earliest,  nine  or 
U>n  weeks  after  vaccination. 

Ileqiiires,  in  every  case,  the  pre- 
existcnce  of  a  specific  ulcer  (chancre) 
at  the  site  of  vaccination. 

Exhibits  the  characters  of  a  true 
specific  eruption. 

Fever  often  slight. 

Lasts  for  a  long  time. 

Usually  accompanied  by  specific 
appearances  on  mucous  membranes. 


VACCINO-SYPHILIS. 


Bfgins  with  a  local  infection, 
oliancre  and  indolent  bubo. 

Typical  development  in  four 
stages,  viz.,  incubation,  chancre, 
Kocond  incubation,  gen,  ralization 
(secondary  eruptions,  etc.). 

Never  appears  earlier  th.in  the 
ninth  or  tenth  week  after  vaccina- 
tion. 


VACCINATION    RASHES 

(including  roseola  vaccinalis,  miliaria 
vaccinalis,  vaccinia  bullosa,  vaccinia 
haemorrhag'ca);  also  accidental  erup- 
tions—  rubeola,  scarlatina,  lichen, 
urticaria,  etc. 

A  true  vaccinal  rash  appears  be- 
tween the  ninth  and  fifteenth  day 
after  vaccination. 

Absence  of  inoculation  chancre. 


Eruption  does  not  exhibit  spe- 
cific char'i<  ters. 

Fever  always  present. 
Evanescent. 


HEREDITARY  SYPHILIS  SHOWING 
ITSELF  ABOUT  THE  TIME  OK 
VACCINATION. 

No  chancre ;  begins   with   gen- 
eral phenomena. 

Has  no  typical  development  in 
connection  with  vaccination. 


Time  of  development  quite  inde- 
pendent of  vaccination. 

Is  attended  by  the  characteristic 
syphilitic  bodily  aspect. 

Other  manifestations  of  heredi- 
tiry  syphilis  may  be  present. 

The  history  may  indicate  syphilis. 


Choice  of  Lymph. — Humanised  lymph  should  be  taken  on  the 
eighth  day  and  only  from  perfectly  formed  unbroken  vesicles,  which  have 
had  a  typical  course,  and  have  not  yet  developed  areola?.  Pricking  or 
Rcnitching  the  surface,  the  greatest  care  being  taken  not  to  draw  blood, 
allows  the  lymph  to  exude,  and  it  may  tlien  be  collected  on  ivory  points  or 
in  capillary  tubes.  \i  iie  child  from  which  the  lymph  is  taken  should  be 
Healthy,  strong,  and  known  to  be  of  good  stock,  free  from  tuberculous  or 
Rypliilitic  taint.     Under  these  circumstances  humanised  lymph,  one  or 


SPECIFIC   INFECTIOUS  DISEASES. 


m 


two  removes  from  the  calf,  ia  usually  very  satisfactory  in  its  action  and  is 
perfectly  reliable.  ' 

In  the  case  of  the  calf  the  most  scrupulous  care  should  be  exercised  in 
the  vaccine  farms  tu  secure  animals  which  are  healthy  and  strong.  The 
risk,  however,  tliat  the  calf  has  any  disease  which  can  be  transmitted  to 
man  is  exceedingly  slight,  as  tubercidosis  is  very  rare  in  cattle  when  young. 
Unquestionably,  however,  there  may  be  risk  in  the  case  of  a  calf  born  of 
tuberculous  parents,  and  sjjecial  care  should  be  taken  in  the  selection  of 
proper  auirnids.  There  is  no  essential  difference  in  the  pocks  which  fol- 
low humanised  lymph  and  bovine  lymph.  It  was,  I  believe,  a  common 
experience  in  Montreal  that  children  inoculated  with  bovine  lymph  had 
more  constitutional  disturbance  and  often  sorer  arms  than  those  vaccinated 
with  humanised  lymph  at  one  or  two  removes. 

In  the  performance  of  the  operation  that  part  of  the  arm  about  the  in- 
sertion of  tl.e  deltoid  is  usually  selected  Mothers  "  in  society  "  prefer  to 
have  girl  babies  vaccinated  on  the  leg.  The  skin  should  be  cleansed 
and  put  upon  the  stretch.  Then,  with  a  lancet  or  the  ivory  point,  cross- 
scratches  should  be  made  in  one  or  more  places.  When  the  lym})h  has 
dried  on  the  points  it  is  best  to  moisten  it  in  warm  water.  The  clothing 
of  the  child  should  not  be  adjusted  until  the  spot  has  dried,  and  it  should 
be  protected  for  a  day  or  two  with  lint  or  a  soft  handkerchief.  If  erysipe- 
las is  prevalent,  or  if  there  are  cases  of  suppuration  in  the  same  house,  it 
is  well  to  apply  i:  i)ad  of  antiseptic  cotton.  Vaccination  is  usually  per- 
formed at  the  second  or  third  month.  If  unsuccessful,  it  should  be  re- 
peated from  time  to  time.  A  person  exposed  to  the  contagion  of  small- 
pox should  always  be  revaccinated.  This,  if  successful,  will  usually  pro- 
tect; but  not  always,  as  th"re  are  many  instances  in  which,  though  the 
vacfdiiation  takes,  variola  also  appears. 

The  Value  ofVaccination. — Vaccination  is  not  claimed  to  be  an 
invarial)le  an<l  jiernuinent  preventive  of  small-pox,  but  in  an  immense  ma- 
jority of  cases  suc^cessful  inoculation  renders  the  person  for  many  years 
insusceptible,  (.'omnmnities  in  which  vacciriation  and  revaccination  are 
thoroughly  and  systematically  carried  out  arc  those  in  whi(di  small-pox 
has  the  fewest  victims.  On  tho  other  hand  communities  in  .vhich  vacci- 
nation and  revaccination  are  persistently  neglected  are  those  in  which  epi- 
demi(!s  are  most  prevalent.  I>i  the  (Jerman  army  the  praotict;  of  revacciiui- 
tion  has  stamped  out  the  disease.  Nothing  in  recent  times  has  been  more 
instructive  in  this  eonnection  than  the  fatal  statistics  of  Montreal.  'J'ln' 
epidemic  which  started  in  1870-'7I  was  severe  in  Lower  (Canada,  and  per- 
sisted in  Montreal  until  1875.  A  great  deal  of  feeling  had  been  aroused 
among  the  Fn-nch  ('anadians  by  the  occurrence  of  several  serious  cases  of 
ulceration,  i)ossibiy  of  sypliilitic  disease,  following  vaccination;  and  severul 
agitators,  atnong  them  a  French  physician  of  some  standing,  aroused  ii 
popular  and  wide-spread  prejudice  against  the  practi(H\  'IMiere  were  in- 
deed vaccination  riots.     The  introduction  of  animal  lympii  was  distinctly 


VACCINIA— VACCINATION. 


65 


boneficial  in  extending  the  practice  among  the  lower  classes,  but  compul- 
Korv  vaccination  could  not  be  carried  out.  Between  the  years  1876  and 
lSh4  a  considerable  unprotected  population  grew  up  and  the  materiuls 
were  ripe  for  an  extensive  epidemic.  The  soil  had  been  prepared  witli 
the  greatest  care  and  it  only  needed  the  introduction  of  the  seed,  M'hich  in 
due  time  came  as  already  stated  with  the  Pullman-car  conductor  from 
Cliicafjo,  on  the  SJStli  of  February,  1885.  Within  the  next  ten  months 
thousands  of  persons  were  strick  n  with  th«  disease,  and  3,1(14  died. 

Although  tiie  feffecta  of  a  single  vaccination  may  wear  out,  as  we  say, 
iiiid  the  individual  again  become  susceptible  to  small-pox,  yet  the  mortal- 
it  v  in  such  cases  is  very  much  lower  than  in  persons  who  have  never  been 
viiccinat'.'d.  The  mortality  in  persons  who  have  been  vaccinated  is  from 
(!  to  8  per  cent,  whereas  in  the  unvnccinatcd  it  is  at  least  3.5  per  cent. 
Marson  pointed  out  some  years  ago  that  there  is  a  definite  ratio  between 
tlu'  mirnber  of  deaths  and  the  number  of  good  vaccination  marks  in  post- 
vaccinal small-pox.  With  good  marks  the  mortality  is  between  3  and  4 
per  cent,  and  with  indifferent  marks  at  least  10  or  11  per  cent. 


VI.  VARICELLA  {Vhicken-pox). 

Definition. — An  acute  contagious  disease  of  children,  characterised 
l»y  an  eruption  of  vesicles  on  the  skin. 

Etiology. — The  disease  occurs  in  epidemics,  bn*^  sp  iradic  cases  are 
also  met  with.  It  may  prevail  at  the  same  time  as  sinali-pox  or  may  fol- 
low or  precede  ejiidemics  of  this  disease.  An  attack  of  chicken-pox  is  no 
protection  against  small-pox.  It  is  a  disease  of  childhood  ;  a  majority  of 
the  cases  occur  between  tlie  second  and  sixth  years.  It  is  rarely  seen  in 
adults.  The  bacteriological  examinutirm  of  the  vesii-les  has  shown  the 
presence  of  micrococci  in  the  contents  of  the  vesicles,  but  tlie  specific  germ 
lias  not  yet  been  discovered. 

Tliere  can  be  no  question  that  varicella  is  an  affection  quite  distinct 
from  variola  and  without  at  present  any  relation  whatevei-  to  A.  An  at- 
tack of  tiui  one  does  not  confer  immunity  froin  an  attack  of  the  other. 
Tlie  ctise  which  Sharkey  reported  is  of  special  inijmrtancc  in  this  connec- 
tion. A  boy,  aged  five,  was  admittf^d  to  8t.  Thomas'  Hospital  with  a 
vesicular  eruption,  and  was  isolated  in  a  ward  on  the  same  floor  as  the 
small-pox  ward.  The  disease  was  jjronounced  chicken-pox,  however,  by 
Sir  liisdon  liennett  and  Dr.  Bristowe.  The  patient  was  then  removed 
and  vaccinated,  with  a  result  of  four  vesicles  which  ran  a  pretty  normal 
(bourse.  On  the  eighth  day  from  the  vaccination  the  child  b*"'ame  fever- 
ish. On  the  foMowing  day  the  papules  appeared  aiid  the  child  had  a  woll- 
(ievelopod  uttuck  of  small-pox  with  secondary  fever, 

Symptoma.  -  A f ter  a  period  of  incubation  of  ten  or  fifteen  days  the 
I'liiki  becomes  feverish  and  in  some  instances  has  a  slight  chill.     There 


66 


SPECIFIC  INFECTIOUS  DISEASES. 


may  bo  vomiting  and  pains  in  the  back  and  legs.  Convulsions  are  rare. 
The  eruption  usually  develops  within  twenty-four  hours.  It  is  first  seen 
upon  tiic  trunk,  cither  on  the  back  or  on  the  chest.  I  have  seen  it,  however, 
appear  first  on  the  forehead  and  face.  At  first  in  the  form  of  raised  red 
papules,  they  are  in  a  few  hours  transformed  into  hemispherical  vesicles 
containing  a  clear  or  turbid  f  uid.  There  is  no  umbilication  as  in  the 
vesicles  of  small-pox.  They  are  often  ovoid  in  shape  and  look  more  super- 
ficial than  the  variolous  vesicles.  The  skin  in  the  neighborhood  is  neither 
infiltrated  nor  hyperaemic.  At  the  end  of  thirty-six  or  forty-eight  hours 
the  contents  of  the  vesicles  are  purulent.  They  begin  to  shrivel  and  dur- 
ing the  third  and  fourth  days  are  converted  into  dark  brownish  crustw, 
which  fall  off  and  as  a  rule  leave  no  scar.  Fresh  crops  appear  durin<; 
the  first  two  or  three  days  of  the  illness,  so  that  on  the  fourth  day  one  can 
usually  see  pocks  in  all  stages  of  development  and  decay.  They  are  al- 
ways discrete  and  the  number  may  vary  from  eight  or  ten  to  several  hun- 
dreds. As  in  variola,  a  scarlatinal  rash  occasionally  precedes  the  develop- 
ment of  the  eruption. 

There  are  one  or  two  modifications  of  the  rash  which  are  interesting. 
The  vesicles  may  become  very  large  and  develop  into  regular  bullae,  look- 
ing not  unlike  ecthynui.  The  irritation  of  the  rash  may  be  excessive,  and 
if  the  child  scratches  the  pocks  ulcerating  sores  may  form,  which  un  heal- 
ing leave  ugly  scars.  Indeed,  cicatrices  after  chicken-pox  are  not  so  verv 
uncommon.  They  are  in  my  experience  more  common  than  after  vario- 
loid. Tlic  fever  in  varicella  is  slight,  but  it  does  not  as  a  rule  disappear 
with  the  appearance  of  the  rash.  The  course  of  the  disease  is  in  a  larjic 
majority  of  the  cases  favorable  and  no  ill  effects  follow.  The  disease  mav 
recur  in  the  same  individual.  There  are  instances  in  which  a  person  hius 
had  three  attacks. 

There  are  one  or  two  interesting  complications  of  chicken-pox.  In 
delicate  ciiildren,  particularly  the  tuberculous,  gangrene  may  occur  about 
the  vesicles  (Abercrornbie). 

Cases  have  been  described  (Andrew)  of  hiBmorrhagic  varicella  witli 
cutaneous  ei;(!liyiuoses  and  bleeding  from  the  mucous  membranes. 

Nephritis  nuiy  occur.  Infantile  hemiplegia  has  developed  during  an 
attack  of  tiie  disease. 

Tlio  fluff/nosis  is  as  a  rule  easy,  particularly  if  the  patient  has  been 
Keen  from  the  outset.  Wljcn  a  case  comes  under  olworvation  for  the  first 
time  with  the  rash  well  out,  there  may  be  considerable  dilliculty.  The 
pocks  in  varifH'lla  are  more  superficial,  more  bleb-like,  have  not  the 
infiltrated  areola  about  them,  aiul  may  usually  be  seen  in  all  stages  of 
development.  They  rarely  at  the  outset  have  the  hard,  shotty  feeling  of 
small-pox.  The  general  symptoms,  the  greater  intensity  of  the  onset,  tlu' 
prolonged  period  of  invasion,  atul  the  more  frequent  occurrence  of  prodro- 
mal rashes  in  small-pox  are  importimt  points  in  the  diagnosis. 

No  special  treatment  is  required.     If  the  rash  is  abundant  on  the 


SCARLET  FEVEU. 


67 


face  great  care  should  be  taken  to  prevent  the  child  from  scratching  the 
pustules.    A  soothing  lotion  should  be  applied  on  lint. 


In 
about 


s  been 
10  first 
Th.' 
:)t  the 
ges  of 
ing  (if 
t,  the 
rodro- 

|)n  the 


VII.  SCARLET  FEVER. 

Definition. — An  infectious  disease  characterised  by  a  diffuse  exan- 
ilu'iu  and  an  angina  of  variable  intensity. 

Etiology. — We  owe  the  recognition  of  scarlet  fever  as  a  distinct  dis- 
t!iiso  to  Sydeiilmin,  before  whose  time  it  was  confounded  with  measles.  It 
is  a  wi»le-sj)read  affection,  occurring  in  nearly  all  parts  of  the  globe  and 
aitacking  uU  races. 

'I'he  disease  occurs  sporadically  from  time  to  time,  and  then  under 
unknown  conditions  becomes  wido-sprad.     Epidemics  vary  in  severity. 

Among  predisposing  factors  age  is  most  important,  A  hirgo  propor- 
tion of  the  cases  occur  before  the  tenth  year.  Of  an  enormous  number  of 
fatal  casos  tabulated  by  Murchison  over  90  per  cent  occurred  in  children 
iiiiuiT  this  age.  Adi'lts,  however,  are  by  no  means  exempt.  Very  young 
infants  are  rarely  attacked.  A  certain  number  exposed  to  the  contagion 
escape.  In  a  family  of  children  all  more  or  less  exposed  one  or  two  may 
not  take  the  disease,  whereas  all  as  a  rule,  if  exposed,  take  the  measles, 
'i'lie  susceptibility  seems  to  vary  in  families,  and  we  meet  occasionally  with 
sad  instances  in  which  three  or  more  members  of  a  family  succumb  in 
rapid  succession. 

Males  and  females  are  equally  affected. 

Epidemics  prevail  at  all  seasons,  but  perhaps  with  greater  intensity  in 
autumn  and  winter. 

The  contiigion  of  scarlet  fever  is  probably  not  developed  until  the  erup- 
tirm  appears,  and  is  particularly  to  be  dreaded  during  destpiamation.  No 
(loul)t  the  poison  is  spread  largely  by  tho  fine  scaly  jmrticdes  which  are 
liitTuscd  with  the  dust  throughout  the  roo'n.  Even  late  in  the  disease, 
lifter  desquamation  has  been  apparently  co?nj)Ieted,  a  patient  has  con- 
veyed the  contagion.  The  poiwii  clingK  with  great  persistence  to  cloth- 
iiii,'  of  all  kiiuls  and  to  articles  of  furniture  it',  the  room.  In  no  disease  is 
a  uM-eater  tenacity  displayed.  Bedding  and  clothes  which  have  been  ])iit 
away  for  months  or  even  for  years  may,  unless  thoroughly  disinfected, 
cMwvy  cci.cagion.  Physicians,  nurses,  and  others  in  contact  with  the 
silk  may  cirry  the  poison  to  persons  at  a  distance.  It  is  remarkable  that 
in  th'^  ase  '  physicians  this  does  not  more  frequently  occur.  I  k)iow  of 
111  inaian:;e  in  which  I  carried  the  contagion  of  this  disease.  The 
t  .son  probably  is  not  widely  spread  in  the  atmosphere.  Observations 
!).'ve  heoi  n-cently  made  which  indicate  that  the  poison  may  bo  conveyed 
in  milk.  The  epidemic  investigated  by  Power  and  Klein  in  London  in 
ISS")  W.18  traced  by  thetn  to  milk  obtained  from  a  dairy  at  Ilondon,  in 
wliicii  the  cows  were  found  to  be  suffering  from  a  vesicular  affection  of 


■  ; 

II 

i  ^1 

;''!      ^^H 

i 

^ 


■^,  gPECIFlC  INFECTIOUS  DISEASES. 

the  udder.  The  nature  of  this  disease  of  the  cow  is  doubtful,  however. 
Crookshatik  maintains  that  it  was  cow-pox,  and  hud  nothing  to  do  with 
scarlet  fever. 

Some  writers  maintain  that  scarlet  fever  may  be  associated  with  de- 
fective house-drainage.  Possibly  the  virus  may  occasionally  gain  entrance 
in  this  way. 

The  attack  does  not  necessarily  protect  permanently.  There  are  in- 
stances of  a  second  and  even  a  third  attack. 

Surgical  and  puerperal  scarlatinas,  so  called,  demand  a  word  under  this 
section.  While  scarlet  fever  may  attack  a  person  after  operation,  or  u 
woman  in  childbed,  the  majority  of  the  cases  described  as  such  represent, 
I  believe,  only  the  red  rash  of  septicaemia.  In  the  cases  which  I  have  seen 
the  rash  was  rarely  so  widespread  as  in  scarlet  fever ;  the  tongue  had  not 
the  special  features,  nor  was  the  throat  affected.  Desquamation  is  no  cri- 
terion, jw  it  occurs  whenever  hyperajmia  of  the  skin  persists  for  any  length 
of  time.  It  is  interesting  to  note  that  these  cases  have  become  rare  witli 
the  gradual  disappearance  of  septicaemia.  I.  E.  Atkinson  suggests  that 
these  rashes  are  in  many  cases  due  to  quinine. 

Attempts  to  determine  the  specific  germ  of  scarlet  fever  have  so  far 
proved  ineffectual.  Occasionally  streptococci  are  found  in  the  blood,  and 
in  fatal  cases  they  are  found  in  the  lymph-glands  and  in  the  kidneys.  It 
will  no  doubt  soon  be  determined  whether  Loeffler's  bacillus  of  diphthe- 
ria exists  in  the  pseudo-membranes  in  the  throat.  Cornil  and  Babes  state 
that  it  does,  and  that  in  the  angina  without  diphtheria  there  ar"  only 
streptococci.  In  some  cases  the  bacillus  of  diphtheria  has  been  fou».d  late 
in  the  disease.  The  point  is  one  of  great  importance,  and  could  be  set- 
tled by  careful  observations. 

Morbid  Anatomy. — Except  in  the  haemorrhagic  form,  the  skin 
after  death  shows  no  traces  of  the  rash.  There  are  no  specific  lesions. 
Those  which  occur  in  the  internal  organs  are  due  partly  to  the  fever  and 
partly  to  infection  with  pus-organisms. 

The  anatomical  changes  in  the  throat  are  those  of  simple  inflamma- 
tion, follicular  tonsillitis,  and,  in  extreme  grades,  of  pseudo-membranous 
angina.  In  severe  cases  there  is  intense  lymphadenitis  and  much  inflam- 
matory u'dema  of  the  tissues  of  the  neck,  which  may  go  on  to  suppuration, 
or  even  to  gangrene.  Streptococci  are  found  abundantly  in  the  glands 
and  in  the  areas  of  suppuration.  Of  changes  in  the  digestive  organs,  ;i 
catarrhal  state  of  the  gostro-intestinal  mucosa  is  not  uncommon.  Tlic 
liver  may  show  interstitial  changes  (Klein).     The  spleen  is  often  enlargoil. 

Endocarditis  and  pericarditis  are  not  infrequent.     Myocardial  changes 
are  less  common.     The  renal  changes  are  the  most  important,  and  havr 
been  thoroughly  studied  by  Coats,  Klebs,  Wagner,  and  others.     The  spe 
cial  nephritis  of  the  disease  will  be  consiuered  with  the  diseases  of  tin 
kidney. 

Affections  of  the  respiratory  organs  are  not  frequent.     When  death 


SCARLET  FEVER. 


69 


results  from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not 
uncommon.    Cercbro-spinal  changes  are  rare. 

Symptoms. — Incubation. — On  this  point  there  is  great  discrepancy. 
Tlio  iK'iiod  is  undoubtedly  very  variable.  From  three  to  twelve  days  is 
i)r()bably  tlie  limit,  though  it  may  in  exceptional  cases  bo  extended.  In 
one  case,  tlie  circumstances  of  which  made  it  perfectly  clear  that  I  had 
myself  conveyed  the  infection,  the  incubation  was  twelve  days. 

Invasion. — The  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a  slight 
scarcely  notioeable  indisposition.  An  actual  chill  is  rare.  Vomiting  and, 
in  young  children,  convulsions  are  common.  The  fever  is  intense  ;  rising 
rapidly,  it  nuvy  on  the  first  day  reach  104°  or  even  105°.  The  skin  is  un- 
usually dry  and  to  the  touch  gives  a  sensation  of  very  pungent  heat.  The 
tongue  is  furred,  and  as  early  as  the  first  day  there  may  be  complaint  of 
dryness  of  the  throat.  Cough  and  catarrhal  symptoms  are  uncommon. 
'I'lie  face  is  often  Hushed  and  the  patient  has  all  the  objective  features  of 
an  acute  fever. 

Eruption. — Usually  on  the  second  day,  in  some  instances  within  twen- 
tv-foiir  lioiirs,  the  rash  develops  in  the  form  of  scattered  red  points  on  a 
deep  sidxiiticular  Hush.  It  appears  first  on  the  neck  and  chest,  and 
spreads  so  rapidly  that  by  the  evening  of  the  second  day  it  may  have  in- 
vailed  the  entire  skin.  In  pronounced  cases  the  rash  at  its  height  has 
a  vivid  scarlet  hue,  quite  distinctive  and  uidike  that  seen  in  any  other 
eruptive  disease.  It  is  entirely  hypersemic,  and  the  anaemia  produced  by 
pressure  instantly  disappears.  In  some  cases  the  rash  does  not  become 
uniform  but  remains  patchy,  and  intervals  of  normal  skin  separate  large 
liyper!t'niic  areas.  Tiny  papular  elevations  may  sometimes  be  seen,  but 
th(>y  are  not  so  common  as  in  measles.  At  the  height  of  the  eruption 
sudaniinal  vesicles  may  develop,  the  fluid  of  which  nuvy  become  turbid. 
'Die  entire  skin  may  at  the  same  time  bo  covered  with  small  yellow  vesi- 
cles on  a  deej)  red  background.  PronoUiiced  cases  of  this  typo  were 
culled  by  the  older  writers  scarlatina  miliar ix. 

Occasionally  there  are  petechiiB,  which  in  the  malignant  type  of  the 
disease  become  wide-spread  and  large.  Tiie  eru[)tion  does  not  always  ap- 
pear upon  the  face.  There  may  be  a  good  deal  of  swelling  of  the  skin 
wiiicl;  teels  uncomfortable  and  tense.  The  itching  is  .variable ;  not  as  a 
rule  intense  at  the  height  of  the  eruption.  After  persisting  for  two  or 
tluve  days  the  rash  gradually  fades.  The  rash  can  often  be  seen  on  the 
nuicous  membranes  of  the  palate,  the  cheeks  and  the  tonsils,  giving  to 
tlu'se  parts  a  vivid  red,  punctiform  appearance.  The  tongue  is  red  at  the 
lip  and  edges,  furred  in  the  centre;  and  through  the  white  fur  are  often 
si  I'M  the  swollen  i)apilup,  which  give  the  so-called  "  strawberry  "  appear- 
iuice  to  the  tongue.     The  breath  often  has  a  very  heavy,  sweet  odor. 

The  pluiryngeal  symptoms  vary  extremely.     Tli^re  may  be — 

1.  Slight  redness,  with  swelling  of  the  pillars  of  the  fauces  and  of  the 
tonsils. 


i 


70 


SPECIFIC  INFECTIOUS  DISEASES. 


104'0» 


tas-8' 


100-4' 


98-6' 


Eruption. 
Chart  IX.— Scarlet  fever  (Strttmpell). 


2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts 
with  a  follicular  tonsillitis. 

3.  Membranous  angina  with  intense  inflammation  of  all  the  pharyn- 
geal structures  and  swelling  of  the  glands  below  the  jaw,  and  in  very  se- 
vere cases  a  thick  brawny  induration  of  all  the  tissues  of  the  neck. 

1'he    fever,  which   sets   in 

105 &■> [^gi^^^^^^^iMHBBggsn  ^i^^^  ^*i^^>  suddenness  and  in- 
tensity, may  reach  105°  or  even 
10G°.  It  persists  with  slight 
morning  remissions,  gradually 
declining  with  the  disappear- 
ance of  the  rasli.  In  mild  cases 
the  tempeniturc  may  not  reach 
103° ;  on  the  other  hand,  in 
very  severe  cases  there  may  bo 
hyperpyrexia,  tlie  thermometer 
registering  108°  or  even  before 
death  109°. 

The  pulse  presents  the  ordi- 
nary febrile  characters,  ranging 
in  children  from  120°  to  150°,  or  even  higher.  The  respirations  show  an 
increase  proportionate  to  the  intensity  of  the  fever.  The  gastro-intestinal 
symptoms  are  not  marked  after  the  initial  vomiting,  and  food  is  usually 
well  taken.  In  some  instances  there  are  abdominal  pains.  The  edge  of 
the  spleen  may  be  palpable.  The  liver  is  not  often  enlarged.  With  the 
initial  fever  nervous  symptoms  are  present  in  a  majority  of  the  cases ;  but 
as  the  rash  comes  out  the  headache  and  the  slight  nocturnal  wandering  dis- 
appear. The  urine  has  the  ordinary  febrile  characters,  being  scanty  and 
high  colored.  Albuminuria  is  by  no  means  infrequent  during  the  stage  of 
eruption,  but  the  amount  is  slight.  Careful  examination  of  the  urine 
should  be  made  every  day.  There  is  no  cause  for  alarm  in  the  slight  trace 
of  albumen  which  is  so  often  present,  not  even  if  it  is  associated  with  a 
few  tube-casts. 

Desquamation. — With  the  disappearance  of  the  rash  and  the  fever  tho 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  up- 
per layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins 
about  the  neck  and  chest,  and  flakes  are  gradually  detached.  The  degree 
and  character  of  the  desquamation  bear  some  relation  to  the  intensity  of 
the  eruption.  When  the  latter  has  been  very  vivid  and  of  long-standin<r, 
largo  flakes  may  be  detached.  In  rare  instances  tho  hair  and  even  tin- 
nails  have  been  shod.  It  must  not  bo  forgotten  that  there  are  cases  in 
which  the  desquamation  has  been  prolonged,  according  to  Trousseau  even 
to  the  seventh  or  eighth  week.  The  entire  process  lasts  from  ten  to  fifteen 
or  even  twenty  days. 

There  are  cases  of  exceptional  mildness  in  which  the  rash  may  bo 


SCAKLKT   KKVER. 


71 


8('un''oly  perceptible.  During  cpiilcmics,  when  several  chilJren  of  ii  lioiise- 
holil  arc  iiflectedjit  somotimcrt  Imppens  that  a  child  sickens  us  if  of  scarlot 
ftvpr,  aiul  has  u  sore  tliroiit  and  the  "  strawberry  tongue  "  witliout  the  do- 
vt'lojunont  of  any  rasli.     This  is  the  so-called  scarlatina  sine  eruptione. 

'i'lu'se  sliglit  cases  of  scarlet  fever  may  bo  followed  by  the  severest  at- 
tacks of  ncj)hritis. 

MALIGNANT  SCARLET  FKVEIl. 

Ataxic  Form. — This  presents  all  the  characteristics  of  an  acute  intoxi- 
fution.  The  patient  overwhelmed  by  the  intensity  of  the  poison  may  die 
within  twenty-four  or  thirty-six  hours.  The  disease  sets  in  with  great 
severity — high  fever,  extreme  restlessness,  headache,  and  delirium.  The 
temi)orature  may  rise  to  107°  or  even  108°,  and  rare  cases  have  been  ob- 
served in  which  the  thermometer  has  registered  even  higiier.  Convulsions 
may  occur  in  children.  The  initial  delirium  rapidly  gives  place  to  coma. 
Tlic  dyspnoea  may  be  urgent;  the  pulse  is  very  rapid  and  feeble. 

Hsmorrhagio  Form. — In  some  instances  hjemorrhages  occur  into  the 
skin.  There  is  hsematuria,  and  epistaxis.  In  the  erythematous  rush  there 
lire  at  first  scattered  petechia?,  which  gradually  become  more  extensive, 
and  ultimately  the  skin  may  be  universally  involved.  Death  may  take 
|iliu'e  on  the  second  or  on  the  third  day.  While  this  form  is  perhaps 
more  common  in  enfeebled  children,  I  have  twice  known  it  to  attack  per- 
sons apparently  in  full  health. 

Anginose  Form. — The  throat  symptoms  may  appear  early  and  progress 
rapidly.  The  fauces  and  tonsils  are  swollen.  Membranous  exudation 
forms.  It  may  extend  to  the  posterior  wall  of  the  pharynx,  forward 
into  the  mouth,  and  upward  into  the  nostrils.  The  glands  of  the  neck 
rapidly  enlai'ge.  Necrosis  occurs  in  the  tissues  of  the  throut,  the  f(«tor  is 
extreme,  the  constitutional  disturbance  profound,  and  the  child  dies  with 
tlio  clinical  picture  of  a  malignant  diphtheria.  Occasionally  the  mem- 
brane extends  into  the  trachea  and  the  bronchi.  The  Eustachian  tubes 
:uul  the  middle  ear  are  usually  involved.  In  cases  in  which  death  does 
not  take  place  rapidly  from  toxjumia  there  may  be  extensive  abscess  forma- 
tiiin  in  the  tissues  of  the  neck  and  sloughing.  In  the  separation  of  deep 
slmi^dis  about  the  tonsils  the  carotid  artery  may  be  opened,  causing  futal 
lui'inorrhage. 

As  already  mentioned,  scarlatinal  angina,  thougli  resembling  diphthe- 
ria and  not  to  bo  distinguished  from  it  anatomically,  is  probably  due  to 
I  lie  scarlatinal  and  not  to  the  diphtheritic  poison. 

Complications  and  Sequelae. — (a)  A'ejjhrilis. — At  the  height  of 
tlio  ffver  there  is  often  a  slight  trace  of  albumen  in  the  urine,  which  is 
not  of  special  significance.  In  a  majority  of  cases  the  kidneys  escape 
v-iiliout  greater  damage  than  occurs  in  other  acute  febrile  aiTections. 

NCpliritis  is  most  common  in  the  second  or  third  Meek  and  may  de- 
vtlop  after  a  very  mild  attack.  It  may  be  delavcd  until  the  third  or 
6 


72 


SPKCIFIC   INFECTIOUS  DISKASKS. 


i!  -  '4f    • 
1,1    , 


fourth  wci'k.  As  a  nilo,  tlio  enrlior  it  develops  in  the  disenso  tho  more 
intense  it  in.  It  varies  greatly  in  intensity,  und  three  grades  of  eases  may 
be  recognized  : 

1.  Very  t^evoro  rases  with  suppression  of  urine  or  tho  passage  of  a 
small  quantity  of  dark  bloody  urine  laden  with  all)Uinen  and  tube-casts. 
V%in)iting  is  constant,  there  are  convulsions,  und  the  child  dies  with  the 
symptoms  of  acute  ura-mia. 

5J.  licss  severe  crises  without  any  serious  acute  symptoms.  Tlicre  is  a 
puffy  apj)earan('e  of  the  eyelids,  with  slight  a'dema  of  the  feet ;  the  urine 
is  diminished  in  quantity,  smoky  in  appearance,  and  contains  albumen 
and  tube-cajits.  The  kidney  symptoms  then  dominate  the  entire  case,  the 
dropsy  persists,  and  there  nuiy  be  effusion  into  the  serous  sacs.  Tho  case 
may  ilrag  on  and  become  chronic,  or  the  patient  nuiy  succumb  to  uraemic 
a<;cidents.  Fijrtuiuitely,  in  a  majority  of  the  cases  tho  disease  yields  to 
jiulicious  treatment  and  recovery  takes  place. 

3.  Cases  so  milil  that  they  can  scarcely  be  termed  nephritis.  The 
urine  shows  a  moderate  amount  of  albumen.  There  may  be  tube-casts, 
rarely  blooil.  'J'he  u>dema  is  extremely  slight  or  transient,  and  the  conva- 
lescence is  scarcely  interrupted.  Occasionally,  however,  in  these  mild  at- 
tacks serious  symptoms  may  supervene.  CEdemu  of  the  glottis  may  prove 
rapidly  fatal,  and  in  one  case  of  the  kind  a  child  under  my  care  died  of 
acute  effusion  into  the  pleural  sacs. 

There  are  instances  of  a^dema  without  albuminuria  or  signs  of  nephri- 
tis. Possibly  in  some  of  these  cases  the  (cdema  nuiy  be  ha?niic  and  duo  to 
the  anannia;  but  there  are  instances  in  which  marked  changes  have  boon 
found  in  the  kidney  after  death,  even  when  tho  urine  did  not  show  tho 
features  characteristic  of  nephritis. 

(b)  Arthritis. — During  the  subsidence  of  tho  fever,  rarely  at  its 
height,  pains  and  swelling  in  tho  joints  may  develop  and  present  all  tho 
characteristi(!s  of  acute  rheumatism.  In  all  probability  it  is  not  however 
true  rheumatism,  but  is  analogous  to  gonorrhoml  synovitis.  It  may  pass  on 
to  suppuration,  in  which  case  it  most  commonly  involves  only  a  single  joint. 

(6-)  (htrdiae  Complicntions. — Simple  endocarditis  is  not  uncommon, 
and  many  cases  of  chronic  valvular  disease  originate  probably  in  the  latent 
endocarditis  of  this  disease.  Malignant  endocarditis  is  rare.  Pericarditis 
is  probably  not  more  frequent,  but  is  less  likely  to  be  overlooked  than  endn- 
carditis.  It  usually  develops  during  convalescence,  and  may  be  sero-fibrin- 
ous  or  ))urulont.  Tho  cardiac  complications  are  sometimes  found  in 
association  with  arthritis.     Myocarditis  is  not  uncommon. 

{d)  rjpurifii/  may  follow  pneumonia,  though  this  is  rare.  More  often 
it  occurs  during  convalescence,  is  insidious  in  its  course,  and  as  a  nil*' 
purulent.  This  serious  complication  of  scarlet  fever  is  not  sufficiently 
recognized.     It  was  one  ui)on  which  my  teacher,  R.  P.  Howard,*  in  Mont- 

*  Canada  Medical  and  Surgical  Journal,  Deceml)er,  1873. 


J.  ft  (*.     itM*? 


SCARLKT   FEVKR. 


real,  spccinlly  insisted  in  his  loctiircH.  Slioriff,  in  a  nnmbcr  of  tho  mnw. 
journal,  roportH  two  cilscs,  occurring  at  the  sumo  time  in  brotiiers,  one  of 
wlioiii  ilii'J  Huddenly  after  a  slight  exertion. 

(/■)  K(ir  I'ottiplinitions. — U'heso  arc  common  and  serious.  They  arc  due 
t.i  extension  of  the  intlamniation  from  the  throat  through  tho  KuHtachian 
lubes.  It  is  one  of  tho  most  frequent  causea  of  deafness.  Tiie  severe 
foriiis  of  inemhranoUH  angina  are  almost  always  associated  with  intlamma- 
tioii  of  the  middle  ear,  which  goes  on  to  suppuration  aiul  j)erforation  of 
the  drum.  'I'he  suppuration  may  extend  to  tho  labyrinth  and  rapidly 
produce  deafnesfl.  \\\  other  instances  there  is  suppuration  in  tho  mastoid 
cells.  In  the  necrosis  which  follows  the  middle-ear  disease,  tho  facial 
nerve  may  he  involved  and  paralysis  follow.  Later,  still  more  serious 
eoiuplicatitiiis  nuiy  follow  the  otitis;  such  as  thrombosis  of  the  lateral 
sinus,  meningitis,  or  abscess  of  tho  brain. 

( /■)  Ailfiti/is. — In  comparatively  mild  cases  of  scarlet  fever  the  sub- 
maxillary Ivniph-glands  may  be  swollen.  In  severer  cases  the  swelling 
of  the  lock.  Iiccomes  extreme  and  extends  beyond  the  limits  of  the  glands. 
Acute  phlegmonoua  inflammations  may  occur,  leading  to  wide-spread  de- 
ytruction  (tf  tissue,  in  which  ve.«sels  nuiy  be  eroded  and  fatal  hivmorrhago 
ensue.  The  suppurative  processes  may  also  involve  the  retro-pharyngeal 
tissues. 

Tho  swelling  of  the  lymph-glands  usually  subsides,  and  within  a  few 
weeks  oven  the  most  extensive  enlargement  gradually  disappears.  There 
lire  rare  instances,  however,  iu  which  tho  lymphadenitis  becomes  clironic 
and  th((  neck  renuiins  with  a  glandular  collar  which  almost  obliterates  its 
outline.  This  nuiy  prove  intractable  to  all  ordinary  measures  of  treat- 
ment. A  case  came  under  my  observation  in  which,  two  years  after  scar- 
let fever,  tho  neck  was  enormously  enlarged  and  surrounded  by  a  mass  of 
firm  brawny  glands. 

(//)  Ncrrons  Complications. — Chorea  occasionally  develops  in  connec- 
tion with  the  arthritis  and  endocarditis.  Sudden  convulsions  followed 
by  liomiplogia  may  occur.  Two  instances  of  progressive  paralysis  of  the 
limbs  with  wasting  came  under  my  observation  at  the  Philadelphia  In- 
firmary for  Nervous  Diseases.  The  history  was  that  of  subacute  ascending 
spinul  paralysis,  but  it  is  probable  that  they  were  instances  of  multiple 
neuritis,     ^fental  symptoms,  mania  and  melancholia,  have  been  described. 

(//)  Other  rare  compiicatious  and  seqnelas  are  eye  nlTections,  symmet- 
rical gangrene,  enteritis,  and  noma. 

Diagnosis.— The  din^nosis  of  scarlet  fever  is  not  difficult,  but  there 
are  cases  in  which  the  true  'iiture  of  the  disease  is  for  a  time  doubtful. 
The  following  are  tho  iiost  •  .mmon  conditions  with  which  it  may  be 
ooiifoundod. 

1.  Arntc  Exfolinling  I»,'rmatitis.—T\\»  pseudo-exanthem  simulates 
scarlet  fever  very  closely.  It  has  a  sudden  onset,  witb  fever.  The  erup- 
tion spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days 


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SPECIFIC   INFECTIOUS  DISEASES. 


begins  to  fade.  Even  before  it  has  entirely  gone,  desquamation  usually 
begins.  Some  of  these  cases  cannot  be  distinguished  from  scarlet  fever  in 
the  stage  of  eruption.  The  throat  symptoms,  however,  are  usually  absent, 
and  tiie  tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet 
fever.  In  the  desquamation  of  this  affection  the  hair  and  nails  are  com- 
monly affected.  It  is,  too,  a  disease  liable  to  recur.  Some  of  the  instances 
of  second  and  third  attacks  of  scarlet  fever  have  been  cases  of  this  form  of 
dermatitis. 

2.  Measles,  which  is  distinguished  by  the  longer  period  of  invasion, 
the  characteristic  nature  of  the  prodromes,  and  the  later  appearance  of  the 
rash.  The  greater  intensity  of  the  measly  rash  upon  the  face,  the  more 
papular  character,  the  irregular  crescentic  distribution,  are  distinguishing 
features  in  a  majority  of  the  cases.  Other  points  are  the  absence  of  the 
sore  throat  in  measles  and  tlie  peculiar  character  of  the  desquamation. 

3.  Rutheln. — The  rash  of  rubella  is  sometimes  strikingly  like  that  of 
scarlet  fever,  but  in  the  great  majority  of  cases  the  mistake  could  not 
arise.     In  cases  of  doubt  the  general  symptoms  are  our  best  guide. 

4.  Septicmmia. — As  already  mentioned,  the  so-called  puerperal  or  sur- 
gical scarlatina  shows  an  eruption  which  may  be  identical  in  appearance 
with  that  of  true  scarlet  fever. 

5.  Diphtheria. — The  practitioner  may  be  in  doubt  whether  he  is  deal- 
ing with  a  case  of  scarlet  fever  with  intense  membranous  angina,  or  a  true 
diphtheria  with  an  erythematous  rash.  The  erythema  in  diphtheria  may 
appear  early,  before  the  throat  symptoms  are  well  developed,  or  as  they 
are  appearing,  in  whir^h  case  it  is  usually  slight  and  disappears  quickly. 
There  is  also,  when  the  disease  is  at  its  height,  a  later  erythema,  which 
may  be  very  diffuse  and  intense.  The  subsequent  desquamation  can  not 
always  be  relied  upon  to  make  clear  the  diagnosis,  for  any  intense  erythema 
of  sufficient  duration  will  be  followed  by  this  process.  None  of  the  pre- 
ceding conditions  offer  difficulties  so  great  as  these  cases  of  angina  with 
erythematous  rash,  and  it  may  be  impossible  to  determine  satisfactorily 
the  true  nature  of  the  trouble.  Fortunately,  so  far  as  treatment  is  con- 
cerned, this  does  not  make  much  difference.  A  bacteriological  examina- 
tion of  the  exudate  should  be  made  in  doubtful  cases. 

6.  Drug  Rashes. — These  are  partial,  and  seldom  more  than  a  transient 
hyperaemia  of  the  skin.  Occasionally  they  are  diffuse  and  intenr.e,  and  in 
such  cases  very  deceptive.  They  are  not  associated,  however,  with  the 
characteristic  symptoms  of  invasion.  There  is  no  fever,  and  with  care  the 
distinction  can  usually  be  made.  They  are  most  apt  to  follow  the  use  of 
belladonna,  quinine,  and  iodide  of  potassium. 

Prognosis. — Epidemics  differ  in  severity  and  the  death-rate  is  ex- 
tremely variable.  Among  the  better  classes  the  death-rate  is  much  less 
than  in  hospital  practice.  There  are  physicians  who  have  treated  consecu- 
tively a  hundred  or  more  cases  without  a  death.  On  the  other  hand,  in 
hospitals  and  among  the  poorer  classes  the  death-rate  is  considerable, 


A  -f 


SCARLET  FEVP:R. 


75 


ranging  i'lom  5  to  10  per  cent  in  mild  epidemics  to  20  or  30  per  cent  in 
the  verj  severe. 

The  younger  the  child  the  greater  the  danger.  In  infants  under  one 
voar  the  death-rate  is  very  high.  The  great  proportion  of  fatal  cases  oc- 
curs in  children  under  six  years  of  age. 

The  unfavorable  symptoms  are  very  liigh  fever,  early  mental  disturb- 
ance with  great  jactitation,  the  occurrence  of  haemorrhages  (cutaneous  or 
visceral),  intense  pseudo-membranous  angina  with  cervical  bubo,  and 
signs  of  laryngeal  obstruction. 

Nephritis  is  always  a  serious  complication  and  when  setting  in  with  sup- 
pression of  the  urine  may  quickly  prove  fatal.  It  is  noteworthy,  however, 
tliat  a  large  majority  of  the  cases  of  scarlatinal  nephritis  recover. 

Treatment. — The  disease  cannot  be  cut  short.  In  the  presence  of 
the  severer  forms  we  are  still  too  often  helpless.  There  is  no  disease  in 
which  the  successful  issue  and  the  avoidance  of  complications  depends 
more  upon  the  skilled  judgment  of  the  physician  and  the  care  with  which 
his  instructions  are  carried  out. 

.  The  child  should  be  isolated  and  placed  in  charge  of  a  competent 
nurse.  The  temperature  of  the  room  should  be  constant  and  the  ventila- 
tion thorough.  The  child  should  wear  a  light  flannel  night-gown,  and 
tlie  bedclothing  should  not  be  too  heavy.  The  diet  should  consist  of 
milk,  broths,  and  fresh  fruits,  and  water  should  be  freely  given.  With 
tlie  fall  of  the  temperature,  the  diet  may  be  increased  and  the  child  may 
gradually  return  to  ordinary  fare.  When  desquamation  begins  the  child 
sliould  be  thoroughly  rubbed  every  day,  or  every  second  day,  with  sweet 
oil,  Avhich  prevents  the  drying  and  the  diffusion  of  the  scales.  An  occa- 
sional wctrm  bath  may  then  be  given.  At  any  time  during  the  attack  the 
skin  may  be  sponged  with  warm  water.  The  patient  may  be  allowed  to 
get  up  after  the  temperature  has  been  normal  for  ten  days,  but  for  at 
least  three  weeks  from  this  time  great  care  should  be  exercised  to  prevent 
exposure  to  cold.  It  must  not  be  forgotten,  also,  that  the  renal  complica- 
tions are  very  apt  to  develop  during  the  convalescence,  and  after  all  dan- 
ger is  apparently  past.  Ordinary  cases  do  not  require  any  medicine,  or  at 
the  most  a  simple  fever  mixture,  and  during  convalescence  a  bitter  tonic. 
The  bowels  should  be  carefully  regulated,  either  with  small  doses  of  calo- 
mel or  with  mild  aperients. 

Special  symptoms  in  the  severe  cases  call  for  treatment. 

When  the  temperature  is  above  103°  the  extremitipa  may  be  sponged 
witli  tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this 
will  not  sufl[ice,  and  more  thorough  measures  of  hydrotherapy  should  be 
practised.  With  pronounced  delirium  and  nervous  symptoms  the  cold- 
jiaok  should  be  used.  When  the  temperature  is  rising  rapidly  but  the 
ohild  is  not  delirious,  he  should  be  placed  in  a  warm  bath,  the  temperature 
of  which  can  be  gradually  lowered.  The  bath  at  a  temperature  of  80°  is 
beneficial.    In  giving  the  cold-pack  a  rubber  sheet  and  a  thick  layer  of 


'  IjE!  li^Jik. 


h']i  '' 


T6 


SPECIFIC   INFECTIOUS  DISEASES. 


blanket  should  be  laid  upon  a  sofa  or  a  bed,  and  upon  this  a  sheet, 
wrung  out  of  cold  water.  The  naked  child  is  then  laid  upon  it  and 
wrapped  in  the  blankets.  An  intense  glow  of  heat  quickly  follows  the 
preliminary  chilling,  and  from  time  to  time  the  blankets  may  be  un- 
folded and  the  child  sprinkled  with  cold  water.  The  good  effects  which 
follow  this  plan  of  treatment  are  often  striking,  particularly  in  allaying 
the  delirium  and  jactitation,  and  procuring  quiet  and  refreshing  sleep. 
Parents  will  object  less,  as  a.  rule,  to  the  warm  bath  gradually  cooled  than 
to  any  other  form  of  hydrotherapy.  The  child  may  be  removed  from  the 
warm  bath,  placed  upon  a  sheet  wrung  out  of  tolerably  cold  water,  and 
then  folded  in  blankets.  The  ice-cap  is  very  useful  and  may  be  kept  con- 
stantly applied  in  cases  in  which  there  is  high  fever.  Medicinal  antipy- 
retics are  not  of  much  -service  in  comparison  with  cold  water. 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  Ap- 
plications may  be  made  with  a  spray,  and  if  the  laryngitis  becomes  severe 
the  measures  should  be  used  which  will  be  mentioned  under  croup.  Cold 
applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  sometimes 
difficult  to  get  a  child  to  submit  to  them.  In  connection  with  the  throat 
symptoms  the  ears  should  be  specially  looked  after,  and  a  careful  disinfec- 
tion of  the  throat  by  suitable  antiseptic  solutions  should  be  practised. 
When  the  inflammation  extends  through  the  tubes  to  the  middle  ear,  the 
practitioner  should  either  himself  daily  examine  the  conditions  of  the 
drum,  or,  when  available,  a  specialist  should  be  called  in  to  assist  him  in 
the  case.  The  careful  watching  of  this  membrane  day  by  day  and  the 
puncturing  of  it  if  the  tension  becomes  too  great  may  save  the  hearing  of 
the  child.  With  the  aid  of  cocaine  the  drum  is  readily  punctured.  The 
operation  may  be  repeated  at  intervals  if  tlie  pain  and  distention  return. 
No  complication  of  the  disease  is  more  serious  than  this  extension  of  the 
inflammatory  process  to  the  car. 

The  nephritis  should  be  dealt  with  as  in  ordinary  cases,  and  indications 
for  treahnent  will  be  found  under  the  appropi'iate  section.  It  is  worth 
mentioning,  however,  that  Jaccoud  insists  upon  the  great  value  of  milk 
diet  in  scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weak- 
ness, Avhich  is  usually  the  result  of  the  direct  action  of  the  poison,  and  is 
best  met  by  stimulants. 

Many  specifics  have  been  vaunted  in  scarlet  fever,  but  they  are  all  use- 
less. J.  C.  Wilson  recommends  chloral  in  one  or  two  grain  doses  for  a 
child  of  two  or  three  years. 


MEASLES. 


77 


VIII.  MEASLES. 

Definition. — An  acute,  higlily  infectious  disorder,  clianicteriscd  by 
nil  initial  coryza  and  a  rapidly  spreading  eruption. 

Stiology. — The  infection  of  measles  is  very  intense  and  immunity 
jigainst  attack  not  nearly  so  common  as  in  scarlet  fever.  It  is  a  disease  of 
childhood,  but  unprotected  adults  are  liable  to  the  infection.  Indeed, 
measles  is  more  frequent  in  adults  than  is  scarlet  fever.  Within  the  first 
six  months  of  life  the  liability  is  ''ot  so  marked,  though  I  have  known  in- 
fants Oa  a  month  and  of  six  weeks  to  be  attacked.  The  sexes  are  equally 
affected.  The  contagion  is  communicated  by  the  breath  and  by  the  secre- 
tions, particularly  those  of  the  nose.  It  may  be  conveyed  by  a  third  per- 
son and  by  foniites. 

The  disease  is  practically  endemic  in  large  centres  of  population,  and 
from  time  to  time  spreads  and  prevails  epidemically.  It  occurs  at  all  sea- 
sons, but  prevails  more  extensively  during  the  colder  months.  There  is 
no  infectious  disease  in  which  recurrence  is  more  frequent.  Tliero  may 
be  a  second,  tliird,  or  even  a  fourth  attack. 

The  contagion  of  the  disease  is  unknown.  No  one  of  the  various  or- 
ganisms which  have  been  described  meets  the  requirements  of  Koch's  law. 

Morbid  Anatomy. — Measles  itself  rarely  kills,  but  the  complica- 
tions and  sequelae  combine  to  make  it  a  very  fatal  affection  in  children, 
There  are  no  characteristic  post-mortem  appearances.  The  skin  changes 
are  those  associated  with  an  intense  hyperaemia. 

There  is  a  catarrhal  condition  of  the  mucous  membranes,  particularly 
of  the  bronchi.  The  fatal  cases  show  almost  invariably  either  broncho- 
pneumonia, capillary  bronchitis  with  patches  of  collapse,  or  less  frequently 
lobar  pneumonia.  The  bronchial  glands  are  invariably  swollen,  i^leurisy 
is  less  common.  During  convalescence  from  measles  there  is  a  special  lia- 
bility to  tuberculous  invasion,  and  tuberculous  broncho-pneumonia  claims 
a  large  number  of  victims.     The  bronchial  glands  may  also  be  affected. 

The  gastro-intestinal  mucosa  may  be  hyperaemic.  Swelling  of  Peyer's 
glands  is  not  at  all  uncommon  and  may  reach  a  very  intense  grade  in  the 
patches. 

Symptoms. — Incubation. — This  is  about  ten  days,  but  the  limits  are 
variable,  and  it  may  be  as  long  as  twenty  days.  The  disease  las  been  fre- 
quently inoculated.  In  such  cases  the  incubation  period  is  less  than  ten 
(lays. 

Invasion. — The  disease  usually  begins  with  symptoms  of  a  feverish 
cold.  There  are  shiverings  (not  often  a  definite  chill),  marked  coryza, 
sneezing,  running  at  the  nose,  redness  of  the  eyes  and  lids,  with  photo- 
phobia, and  within  twenty-four  hours  cough.  These  early  catarrhal 
symptoms  are  more  marked  in  measles  than  in  any  other  infectious  disease 
of  children.  There  may  be  the  symptoms  so  commonly  associated  with 
an  on-coming  fever — nausea,  vomiting,  and  headache.     The  tongue  is 


^  U^-\ 


78 


SPECIFIC  INFECTIOUS  DISEASES. 


furred.     Examination  of  the  throat  may  show  a  reddish  hyperaemia  or  in 
some  instances  a  distinct  punctiform  rash.     Occasionally  this  spreads  over 

the  whole  mucous  membrane  of 
the  mouth  with  the  exception  of 
the  tongue.  The  temperature  at 
this  stage  is  usually  high,  reach- 
ing from  103°  to  104°,  ascending 
gradually  through  the  second  and 
third  days. 

Eruption.  —  Usually  on  the 
fourth  day,  when  the  fever  and 
general  symptoms  have  reached 
their  height,  the  rash  appears 
upon  the  cheeks  or  forehead  in 
the  form  of  small  red  papules, 
which  increase  in  size  and  spread 
over  the  neck  and  thorax.  When 
the  eruption  becomes  well  devel- 
oped the  face  is  swollen  and  cov- 


104  0° 


1028' 


100* 


98.6' 


96'8' 


Initial  Fever. 


ruptlve 
Erupt  i< 

Chart  X. — Measles  (Strlliiipell), 


Eruptive  Fever, 
ion. 


ered  with  reddish  blotches,  which  often  have  rounded  or  crescentic  out- 
lines. Here  and  there  is  an  intervening  portion  of  unaffected  skin.  At 
this  stage  the  cervical  lymph-glands  may  be  slightly  swollen  and  sore. 
The  papules  can  now  be  felt,  with  the  finger.  Sometimes  they  are  quite 
shotty,  but  do  not  extend  deep  into  the  skin.  On  the  trunk  and  extremi- 
ties the  swelling  of  the  skin  is  not  so  noticeable,  the  color  of  the  rash  not 
so  intense  and  often  less  uniform.  The  mottled  blotchy  character  of  the 
rash  appears  most  clearly  on  the  chest  or  the  abdomen.  The  rash  is  hy- 
peraemic  and  disappears  on  pressure,  but  in  the  more  malignant  cases 
it  may  become  petechial.  The  general  symptoms  do  not  abate  witli 
the  occurrence  of  the  eruption.  They  persist  until  the  end  of  the  fifth 
or  the  sixth  day,  when  in  the  majority  of  the  cases  all  the  symptoms  be- 
come mitigated.  Among  the  peculiarities  of  the  rash  may  be  men- 
tioned the  development  of  numerous  miliary  vesicles  and  the  occur- 
rence of  petechiae,  which  are  seen  occasionally  even  in  cases  of  moderate 
severity. 

Desquamation. — After  persisting  for  two  or  three  days  the  rash  gradu- 
ally fades  and  desquamation  occurs  in  the  form  of  very  fine  branny 
scales,  which  may  be  difficult  to  see  and  are  wholly  unlike  the  coarse  ex- 
foliation in  scarlet  fever. 

Tlie  catarrhal  symptoms  gradually  disappear  and  convalescence  U 
rapidly  established. 

In  epidemics  of  measles  atypical  cases  are  common.  The  rash  may 
.ippear  early,  within  thirty-six  hours  of  the  onset  of  the  symptoms ;  or,  on 
the  other  hand,  it  may  be  delayed  until  the  sixth  day.  As  in  other  exan- 
thems,  when  many  cases  occur  in  a  household,  one  of  the  children  may 


f-;-    ' 


MEASLES. 


79 


liiive  all  the  initial  symptoms  and  "  sicken  for  the  disease,"  as  it  is  said, 
but  no  eruption  appear. 

The  most  serious  variety  of  measles  is  that  in  which  haemorrhages  oc- 
cur— the  morbilli  luBmorrhayici.  In  general  practice  these  cases  are  very 
uncommon.  Occasionally  in  institutions,  particularly  when  the  hygienic 
surroundings  are  bad,  one  or  two  cases  develop  during  an  epidemic.  It 
has  been  frequently  seen  in  camps  and  when  the  disease  is  freshly  im- 
ported into  a  native  population,  as  in  the  Fiji  Islands.  During  the  civil 
wur,  as  sliown  by  Smart's  statistics,  some  cases  occurred. 

In  this  form  the  disease  sets  in  with  much  greater  intensity,  the  rash 
becomes  petechial,  haBmorrhages  occur  from  the  mucous  membranes,  the 
constitutional  depression  is  very  great,  and  death  occurs  early  from  tox- 
ivuiia. 

Complications  and  Sequelae. — These  are  met  with  chiefly  in  the 
respiratory  system.  The  danger  comes  from  the  existing  bronchitis, 
which  is  apt  to  extend  into  the  smaller  tubes  and  lead  to  collapse  and 
broncho-pneumonia.  When  limited  in  extent  this  causes  only  aggrava- 
tion of  the  cough  and  persistence  of  the  fever  (vsymptoms  which  gradually 
abate),  and  convalescence  ^  rapid ;  but  in  debilitated  children,  more  par- 
ticularly in  institutions  anti  imong  the  lower  classes,  this  complication  is 
extremely  grave  and  is  respo,:-!ible  for  the  high  death-rate  from  measles 
in  the  community.  In  some  instances  the  clinical  picture  is  that  of  a 
sulTocative  catarrh,  the  result  of  a  wide-spread  involvement  of  the  smaller 
tubes.  The  description  of  the  condition  will  be  found  under  the  section 
Broncho-pneumonia.  Lobar  pneumonia  is  less  common  and  perhaps  less 
dangerous. 

Laryngitis  is  not  uncommon  :  the  voice  becomes  husky  and  the  cough 
croupy  in  character,  ffidema  of  the  glottis  is  very  rare.  Pseudo-mem- 
branous inflammation  of  tht  pharynx  and  larynx  may  occur  and  prove 
Tatal.  In  debilitated  infants  severe  stomatitis  or  even  cancrum  oris  may 
develop. 

Catarrhal  inflammation  of  the  middle  ear  is  not  very  uncommon,  and 
may  proceed  to  suppuration  and  to  perforation  of  the  drum.  The  con- 
junctival catarrh  rarely  leads  to  further  trouble,  though  occasionally  the 
inllammation  becomes  purulent. 

Intestinal  catarrh  is  common  in  some  epidemics,  and  there  may  be  the 
symptoms  of  acute  colitis. 

Nephritis  is  an  exceedingly  rare  complication. 

Of  the  sequelae  of  measles,  tuberculosis  is  the  most  important — either 
an  involvement  of  the  bronchial  glands,  a  miliary  tuberculosis,  or  a  tuber- 
culous broncho-pneumonia. 

Among  the  rarer  sequels  of  measles  are  paralyses.  Hemiplegia  is 
very  rare,  but  cases  of  paraplegia  have  been  described.     Thomas  Barlow  * 


•  Medico-Chirurgical  Society's  Transactions,  1887. 


80 


SPECIFIC   INFECTIOUS  DISEASES. 


reports  a  fatal  case  in  n^hich  the  symptoms  occurred  early,  the  paraly- 
sis extended  rapidly  and  involved  the  uppc  limbs,  and  death  took  place 
on  the  eleventh  day.  Marked  vascular  changes  were  found  in  the  gray 
matter  of  the  spinal  cord,  and  were  believed  to  depend  on  an  early  dissemi- 
nated myelitis.  Examination  of  the  peripheral  nerves  was  not  made. 
Similar  cases  are  met  with  in  the  literature,  and  they  probably  come  under 
the  division  of  the  post-febrile  polyneuritis,  though  of  course  it  is  not  im- 
possib'''-  that  some  of  them,  such  as  Barlow's  case,  may  be  due  to  a  rapidly 
ascending  myelitis. 

Diagnosis. — From  scarlet  fever,  with  which  it  is  most  likely  to  be 
confounded,  measles  is  distinguished  by  the  longer  initial  stage  with  char- 
acteristic symptoms,  and  the  blotchy  irregular  character  of  the  rash, 
which  is  so  unlike  the  diffuse  uniform  erythema  of  scarlet  fever.  Occa- 
sionally in  measles,  when  the  throat  is  very  sore  and  the  eruption  pretty 
diffuse,  there  may  at  first  be  difficulty  in  determining  which  disease  is 
present,  but  a  few  days  should  suffice  to  make  the  diagnosis  clear.  It  may 
be  extremely  difficult  to  distinguish  from  rotheln.  I  have  more  than 
once  known  practitioners  of  large  experience  unable  to  agree  upon  a 
diagnosis.  The  shorter  prodromal  stage,  the  slighter  fever  in  many  cases, 
are  perhaps  the  most  important  features.  It  is  difficult  to  speak  definitely 
about  the  distinctions  in  the  rash,  though  perhaps  the  more  uniform  dis- 
tribution and  the  absence  of  the  crescentic  arrangement  are  more  constant 
in  rotheln. 

The  conditions  under  wliich  measles  may  be  mistaken  for  small-pox 
have  already  been  described.  Of  drug  eruptions,  that  induced  by  copaiba 
is  very  like  measles,  but  is  readily  distinguished  by  the  absence  of  fever 
and  catarrh. 

Prognosis. — The  mortality  bills  of  large  cities  show  what  a  serious 
disease  measles  is  in  a  community.  Among  the  eruptive  fevers  it  ranks 
third  in  the  death-rate.  The  mortality  from  the  disease  itself  ia  not 
high,  but  the  pulmonary  complications  render  it  one  of  the  most  serious 
of  the  diseases  of  children. 

In  some  epidemics  the  disease  is  of  great  severity.  In  institutions  and 
in  armies  the  death-rate  is  often  high.  The  fever  itself  is  rarely  a  source 
of  danger.  The  extension  of  the  catarrhal  symptoms  to  the  finer  tubes  is 
the  most  serious  indication. 

Treatment. — Confinement  to  bed  in  a  well- ventilated  room  and  a 
milk  diet  are  the  only  nuiasures  necessary  in  cases  of  uncomplicated 
measles.  The  fever  rarely  reaches  a  dangerous  height.  If  it  does  it  may 
be  lowered  by  sponging  or  by  the  tepid  bath  gradually  reduced.  If  the 
rash  does  not  come  out  well,  warm  drinks  and  a  hot  bath  will  hasten  its 
maturation.  The  bowels  should  be  freely  opened.  If  the  cough  is  dis- 
tressing, paregoric  and  a  mixture  of  ipecacuanha  wine  and  squills  should 
be  given.  The  patient  should  be  kept  in  bed  for  a  few  days  after  the 
fever  subsides.     During  desquamation  the  skin  should  be  oiled  daily, 


RUBELLA. 


8t 


,111(1  warm  batlis  given  to  facilitate  the  process.  The  convaloscenco 
from  measles  is  the  most  important  stage  of  the  disease.  Watchfulness 
anil  ciire  may  prevent  serious  pulmonary  complications.  The  frequency 
wiili  which  the  mothers  of  children  with  simple  or  tuberculous  broncho- 
piicumonia  tell  us  that  "the  child  caught  cold  after  measles,"  and  the 
c;oiit(!mplation  of  the  mortality  bills  should  make  us  extremely  careful  in 
our  management  of  this  affection. 


IX.  RUBELLA  (Hdlheln,  Oerman  Measles), 

This  exanthem  has  also  the  names  of  rnbeola  notha,  or  epidemic  rose- 
ola, and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also 
known  as  hybrid  measles  or  hybrid  scarlet  fever.  It  is  now  generally  re- 
jjanlcd,  however,  as  a  separate  and  distinct  affection. 

Etiology. — It  is  propagated  by  contagion  and  spreads  with  great 
rapidity.  It  frequently  attacks  adults,  and  the  occurrence  of  either 
measles  or  scarlet  fever  in  childhood  is  no  protection  against  it.  The 
epidemics  of  it  are  often  very  extensive. 

Symptoms. — These  are  usually  mild,  and  it  is  altogether  a  less  seri- 
ous alfection  than  measles.  Very  exceptionally,  as  in  the  epidemics  studied 
by  Clieadle,  the  symptoms  are  severe. 

The  stage  of  incubation  ranges  from  ten  to  twelve  days. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the 
l)a(k  and  legs,  and  coryza.  There  may  be  very  slight  fever.  In  30  per 
cent  of  Edwards's  cases  the  temperature  did  not  rise  above  100°.  The 
duration  of  this  stage  is  somewhat  variable.  The  rash  usually  appears  on 
tlie  first  day,  some  writers  say  on  the  second,  and  others  again  give  the 
duration  of  the  stage  of  invasion  as  three  days.  Griffith  places  it  at  two 
days.  The  eruption  comes  out  first  on  the  face,  then  on  the  chest,  and 
gradually  extends  so  that  within  twenty-four  hours  it  is  scattered  over  the 
wliole  body.  It  may  be  the  first  symptom  noted  by  the  mother.  The 
eruption  consists  of  a  number  of  round  or  oval,  slightly  raised  spots,  pink- 
isii-red  in  color,  usually  discrete,  but  sometimes  confluent. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  The 
patches  are  less  distinctly  crescentic.  After  persisting  for  two  or  three 
days  (sometimes  longer),  it  gradually  fades  and  there  is  a  slight  fur- 
furaceous  desquamation.  The  rash  persists  as  a  rule  longer  than  in  scar- 
let fever  or  measles,  and  the  skin  is  slightly  stained  after  it.  The  lym- 
pliatic  glands  of  the  neck  are  frequently  swollen,  and,  when  the  eruption 
is  very  intense  and  diffuse,  the  lymph-glands  in  the  other  parts  of  the 
body. 

There  are  no  special  complications.  The  disease  usually  progresses 
favorably;  but  in  rare  instances,  as  in  those  reported  by  Cheadle,  the 
symptoms  are  of  greater  severity.      Albuminuria  may  occur  and  even 


82 


SPECIFIC  INFECTIOUS   DISEASES. 


I 

I 

I 

i 


nephritis.  Pneumonia  and  colitis  liavc  been  present  in  some  epidemics. 
Icterus  lias  been  seen. 

Diagnosis. — The  mildness  of  the  case,  the  slightness  of  the  prodromal 
symptonjs,  the  mildness  or  the  absence  of  the  fever,  the  more  diffuse 
character  of  the  rash,  its  rose-red  color,  and  the  early  enlargement  of  the 
cervical  glands,  are  the  chief  points  of  distinction  between  ruthelu  and 
measles. 

The  treatment  is  that  of  a  simple  febrile  affection.  It  is  well  to  keep 
the  child  in  bed,  though  this  may  bo  difficult,  as  the  patient  rarely  feels 
ill. 


X.  EPIDEMIC  PAROTITIS  (MumpB). 

Definition. — An  infectious  disease,  characterised  by  inflammation  of 
the  parotid  gland.  The  testes  in  males  and  the  ovaries  and  breasts  in 
femjUes  are  sometimes  involved. 

Etiology. — The  nature  of  the  virus  is  unknown.  It  is  probably  a 
micro-organism,  and  a  bacillus  parotidis  has  been  described. 

The  affection  has  all  the  characters  of  an  epidemic  disease.  It  is 
said  to  be  endemic  in  certain  localities,  and  probably  is  so  in  larg(i 
centres  of  population.  At  certain  seasons,  particularly  in  the  spring  ami 
autumn  months,  the  number  of  cases  increases  rapidly.  It  is  met  most 
frequently  in  childhood  and  adolescence.  Very  young  infants  and  adults 
are  seldom  attacked.  '''  '  :s  are  somewhat  more  frequently  affected  than 
females.    In  instituti  hI  schools  the  disease  has  been  known  to  attack 

over  90  per  cent  of  all  ine  children.  It  may  be  curiously  localised  in  a 
city  or  district.  The  disease  is  contagious  and  ispreads  from  patient  to 
patient. 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or 
disease  of  the  abdominal  or  pelvic  organs.  Stephen  Paget*  has  collected 
101  cases  of  this  kind,  the  majority  of  which  were  not  associated  with 
septic  processes. 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks, 
and  there  are  rarely  any  symptoms  during  this  stage.  The  invasion  k 
marked  by  fever,  which  is  usually-slight,  rarely  rising  above  101°,  but  in 
exceptionally  severe  cases  going  up  to  103°  or  104°.  The  child  com- 
plains of  pain  just  below  the  ear  on  one  side.  Here  a  slight  swelling  is 
noticed,  which  increases  gradually,  until,  within  forty-eight  hours,  there  is 
great  enlargement  of  the  neck  and  side  of  the  cheek.  The  swelling  passes 
forward  in  front  of  the  ear,  and  back  beneath  the  sterno-cleido  muscle.  The 
other  side  usually  becomes  affected  within  a  day  or  two.  The  submaxil- 
lary glands  may  also  be  involved.  The  greatest  inconvenience  is  experi- 
enced in  taking  food,  for  the  patient  is  unable  to  open  the  mouth,  and 

*  British  Medical  Journal,  March  19,  1887. 


epidemh;  parotitis. 


88 


even  speech  and  deglutition  become  difficult.  There  may  be  an  increase 
ill  tlie  secretion  of  the  saliva,  but  the  reverse  is  sometimes  the  case.  There 
i.-t  si^ldom  great  pain,  but,  instead,  an  unpleasant  feeling  of  tension  and 
li}j;iitncss.     There  may  be  earache  and  slight  impairment  of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually 
siil)sides  and  the  child  rajjidly  regains  his  strength  aiul  health.  Jielapse 
ntirly  if  ever  occurs. 

Occasionally  the  disease  is  very  severe  and  characterised  by  high 
fever,  delirium,  and  great  prostration.  The  patient  may  even  lai)se  into 
11  typhoid  condition. 

One  of  the  most  remarkable  features  of  the  disease  is  a  tendency  to 
involvement  of  the  testes.  This  most  frequently  occurs  after  the  atfec- 
tioii  of  the  salivary  glands  has  subsided.  The  swelling  may  be  great,  and 
occasionally  effusion  takes  place  into  the  tunica  vaginalis.  The  orchitis 
is  in  some  instances  unilateral,  involving  the  right  testicle.  The  inflam- 
iiiiition  increases  for  three  or  four  days,  and  resolution  takes  place  gradu- 
ally. Occasionally  there  may  be  a  muco-purulent  discharge.  In  severe 
(•iisos  atrophy  may  follow.     Orchitis  is  rarely  seen  before  puberty. 

A  vulvo-vaginitis  sometimes  occurs  in  girls,  and  the  breasts  may  be- 
coiiu'  eidarged  and  teiuler.     Involvement  of  the  ovaries  is  rare. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections 
arc  perhaps  the  most  serious.  As  already  mentioned,  there  may  be  de- 
liriiun  and  high  fever.  In  rare  instances  meningitis  has  been  found. 
Hemiplegia  and  coma  may  also  occur.  A  majority  of  the  fatal  cases  are 
associated  with  meningeal  symptoms.  These,  of  course,  are  very  rare  in 
(comparison  with  the  frequency  of  the  disease ;  yet,  in  the  Index  Catalogue,, 
under  this  caption,  there  are  six  fatal  cases  mentioned.  In  some  epi- 
demics the  cerebral  complications  are  much  more  marked  than  in  others. 
Acute  mania  has  occurred,  and  there  are  instances  on  record  of  insanity 
following  the  disease. 

Arthritis  is  an  occasional  complication.  Albuminuria,  with  convul- 
sions, has  been  described.     Fatal  cases  have  occurred  from  acute  uraemia. 

Suppuration  of  the  gland  is  an  extremely  rare  complication  in  genuine 
idiopathic  mumps.  Gangrene  has  occasionally  occurred.  The  special 
senses  may  be  seriously  involved.  Many  cases  of  deafness  have  been  de- 
s(  ribed  in  connection  with  or  following  mumps.  The  deafness,  unfortu- 
nately, may  be  permanent.  Affections  of  the  eye  are  rare,  but  atrophy  of 
the  optic  nerve  has  been  described. 

The  diagnosis  of  the  disease  is  usually  easy.  The  position  of  the 
swelling  in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on  the 
atfected  side  definitely  fix  the  locality  of  the  swelling.  In  children  in- 
fliunmation  of  the  parotid,  apart  from  ordinary  mumps,  is  ;xcessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  height 
of  tlie  disease.  The  bowels  should  be  freely  opened,  and  the  patient  given 
a  light  hquid  diet.    No  medicine  is  required  unless  the  fever  is  high,  in 


11 


84 


SPECIFIC   INFRCTIOUS  DISKASES. 


which  case  aeonito  nmy  bo  ffivcn.  Cold  compresses  may  bo  phvced  on  the 
ghuui,  but  children,  us  a  rule,  prefer  hot  applications.  A  pad  of  cottoti 
wuddiiif?  covered  with  oiled  silk  is  the  best  application.  Suppuration 
is  ahnost  unknown,  and  need  not  bo  dreaded,  even  thoujjh  the  gland  I)e- 
coino  very  tense.  Should  redness  and  tenderness  develop,  leeches  niav 
bo  used.  With  delirium  and  head  symptoms  tl>o  ico-cap  nuiy  bo  applied. 
In  a  robust  subject,  uidess  the  signs  of  constitutional  depression  are  ex- 
treme, a  fre(!  venesection  may  do  goctd.  For  tho  orchiti.s,  rest,  with  sup- 
port and  ])rotoctiou  of  tho  swollen  gland  witli  cotton-wool,  is  usually 
sutlicicut. 


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XI.  WHOOPING-COUGH. 

Definition. — A  specific  affection  characterised  by  convulsive  cough 
and  a  long-drawn  ins])iration,  during  which  tho  "  whoop"  is  produced. 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases 
appear  in  a  community  from  time  to  time.  It  is  directly  contagious  from 
person  to  person ;  but  dwelling-rooms,  houses,  school-rooms,  and  other 
localities  may  be  infected  by  a  sick  child.  It  is.  however,  in  this  way  less 
infectious  than  other  diseases,  and  is  probably  most  often  taken  by  direct 
contact.  'J'he  nature  of  tlio  virus  is  still  doubtt'ul,  many  organisms  hav- 
ing been  described  in  the  sputum.  The  observations  of  Afanassjew  in 
1887  have  been  the  most  satisfactory.  He  has  cultivated  a  short  bacillus, 
which  grows  with  well-marked  characters,  and,  when  inoculated  into  the 
trachea  of  animals,  produces  a  catarrhal  condition  of  the  mucous  mem- 
brane. Cornil  and  Babes  *  conclude  that  the  organism  has  not  charac- 
teristics sufficiently  pronounced,  or  an  influence  on  animals  sufficiently 
characteristic,  to  enable  us  to  say  that  it  is  specific.  E})idemics  prevail  for 
two  or  three  months,  usually  during  the  winter  and  spring,  and  have  a 
curious  relation  to  other  diseases,  often  preceding  or  following  measles, 
less  frequently  scarlet  fever. 

Children  between  the  first  and  second  dentition  are  commonly  affected. 
Sucklings  are,  however,  not  exempt,  and  I  have  seen  very  severe  attacks 
in  infants  under  six  weeks.  It  is  stated  that  girls  are  more  subject  to  the 
disocase  than  boys.  Adults  and  old  people  are  sometimes  attacked,  and  in 
the  aged  it  may  be  a  very  serious  affection.  Many  persons  possess  immu- 
nity against  the  disease,  and,  though  frequently  exposed,  escape.  Delicate 
anaemic  children  with  nasal  or  bronchial  catarrh  are  more  subject  to  the 
disease  than  others.  According  to  the  United  States  Census  Reports,  the 
disease  is  more  than  twice  as  fatal  in  the  negro  race  than  in  others. 

Morbid  Anatomy. — Whooping-cough  itself  has  no  special  patho- 
logical changes.  In  fatal  cases  pulmonary  complications,  particularly 
broncho-pneumonia,  are  usually  present.     Collapse  and  compensatory  eni- 


Les  Bacteries.  1890. 


■t  '■ 


WIIOOIMNG-COUGH. 


85 


physoma,  vcsiculur  and  iiitorstitial,  are  found,  and  tlie  tracheal  and  bron- 
cliiiil  ^dands  aro  t'idar<(('(l. 

Symptoms. — Catarrlial  and  paroxysmal  Htaj^oH  can  bo  roco;^nizi'»i. 
Thoro  is  a  variublo  period  of  iiu^iibation  of  from  seven  to  ten  days.  In 
tli(!  calufrltnl  xttKje  the  ciiiM  has  the  symptoms  of  an  ordinary  cold, 
wliicli  may  be;^in  with  slij;ht  fever,  rutinin<(  at  the  nose,  injection  of 
tlie  eyes,  and  a  bronchial  cou^jfh,  nsiially  dry  and  sometimes  givin<^  indi- 
cations of  a  spasmodic  character.  The  fever  is  usually  not  hij^h,  and 
slif,dit  attention  is  paid  to  the  symptoms,  which  aro  thought  to  be  those 
of  an  ordinary  cold.  After  lasting  for  a  week  or  ten  days,  instead 
of  subsiding,  the  cough  becomes  worse  and  more  convulsive  in  char- 
acter. 

Tho  jmi'oxi/smal  ,st<(f/e,  marked  by  the  i  haracterifitic  cough,  dates  from 
the  first  appearance  of  the  "  whoop."  The  tit  begins  with  a  series  of  from 
tiftei'U  to  twenty  short  coughs  of  increasing  intensity,  and  then  witl;  - 
(loop  inspiration  the  air  is  drawn  into  the  lungs,  making  the  "  whoop," 
which  may  bo  heard  at  a  distance  and  from  which  tho  disease  takes  'ts 
name.  This  loud  inspiratory  sound  may  sometimes  precede  the  serii-'S  of 
spasmodic  expiratory  ell'orts.  Several  coughing- fits  may  succeed  each  other 
until  a  teiuicious  mucus  is  expctorated.  This  may  be  small  in  amount, 
but  after  a  series  of  coughing-lits  a  considerable  quantity  may  be  expec- 
torated. Not  infreq'u  ntly  it  is  brought  up  by  vomiting  or  by  a  combina- 
tion of  cough  and  regurgitation.  There  may  bo  only  four  or  five  of  these 
attacks  in  the  day,  or  in  severe  cases  they  may  recur  every  half-hour. 
During  the  attack  the  thorax  is  very  strongly  compressed  by  the  powerful 
expiratory  efforts,  and,  as  very  little  air  passes  in  through  the  glottis,  there 
are  signs  of  defective  aeration  of  the  blood ;  the  face  becomes  swollen  and 
congested,  the  veins  are  prominent,  the  eyeballs  protrude,  and  the  con- 
junctivie  become  deeply  engorged.  Suffocation  indeed  seems  imminent, 
when  with  a  deep  crowing  inspiration  air  enters  the  lungs  and  the 
color  is  quickly  restored.  Children  aro  usually  terrified  at  the  onset,  and 
run  at  once  to  the  mother  or  nurse  to  be  supported  during  the  attack. 
Few  diseases  are  more  painful  to  witness.  In  severe  paroxysms  vomiting 
is  frequent  and  the  sphincters  may  be  opened. 

Au  ulcer  under  tho  tongue  is  a  very  common  event,  and  was  thought 
at  one  time  to  be  the  cause  of  the  disease. 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective 
in  the  expiratory  stage, full  and  clear  during  the  deep,  crowing  inspiration; 
but  on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur 
heard,  owing  to  tho  slowness  with  which  the  air  passes  the  narrowed  glot- 
tis.   Bronchial  rales  are  occasionally  heard. 

Among  circumstances  which  precipitate  an  attack  are  emotion,  such 
as  crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowing 
sometimes  seems  sufficient.  In  a  close  dusty  atmosphere  the  coughing- 
fits  are  more  frequent.    After  lasting  for  three  or  four  weeks  the  attacks 


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80  SPECIFIC  INFECTIOUS  DISEASES. 

become  lighter  and  finally  cease.    In  cases  of  ordinary  severity  the  course 
of  the  disease  is  rarely  under  six  weeks. 

The  complications  and  se'^^uelae  of  whooping-cough  are  important. 
1  )uring  the  extensive  venous  congestion  haemorrhages  are  very  apt  to  oc- 
cur in  the  form  of  petechifc,  particularly  about  the  forehead,  ecchymosis  of 
tlie  conjunctiva?,  epistaxis,  and  occasionally  hajmoptysis.  Haemorrhage 
from  the  bowels  is  rare.  During  the  paroxysm  convulsions  may  occur, 
due  perhaps  to  the  extreme  engorgement  of  the  cerebral  cortex.  Very 
rarely  hemiplegia  or  monoplegia  follows.  Sudden  death  has  been  caused 
by  extensive  subdural  haemorrhage.  Whooping-cough  must  be  regarded 
as  a  very  unusual  cause  of  cerebral  palsy  in  children.  It  was  associated 
with  three  cases  of  my  series  of  one  hundred  and  twenty  cases,  but  in 
none  of  them  did  tlie  hemiplegia  come  on  during  the  paroxysm,  as  in  a 
case  reported  by  S.  West. 

Th*  persistent  vomiting  may  induce  marked  anaemia  and  wasting. 
The  i^ulmouary  complications  which  follow  whooping-cough  are  extremely 
serious.  During  the  severe  coughing-spells  interstital  emphysema  may  be 
induced,  more  rarely  j)neumothorax.  I  saw  one  instance  in  which  rupture 
occurred,  evidently  near  the  root  of  the  lung,  and  the  air  passed  along  the 
trachea  and  reaciied  the  subcutaneous  tissues  of  the  neck,  a  condition 
which  has  been  known  to  become  general.  Bi'oncho-pneumonia,  with  its 
accompanying  collapse,  is  the  most  frequent  pulmonary  complication  and 
carries  off  a  large  number  of  children.  It  may  be  simple,  but  in  a  consid- 
erable proportion  of  the  cases  the  process  is  tuberculous.  Pleurisy  is 
sometimes  met  with  and  occasionally  lobar  pneumonia.  Enlargement  of 
the  broncliial  glands  is  very  common  in  whooping-cough  and  has  been 
thought  to  cause  the  disease.  It  may  sometimes  "be  sufficient  to  produce 
dulness  upon  the  manubrium.  The  heart  stands  the  strai'i  of  whooping- 
cough  remarkably  well.  During  the  spasm  the  radial  pulse  is  small,  the 
right  heart  engorged,  and  during  and  after  the  attack  the  cardiac  action  is 
very  much  disturbed.  It  is  difficult  to  determine  whether  serious  damage 
ever  results.  Possibly  some  of  the  cases  of  severe  valvular  disease  in  chil- 
dren who  have  had  neither  rheumatism  nor  scarlet  fever  may  be  attrib- 
uted to  the  terrible  heart  strain  during  a  prolonged  attack  of  whooping- 
cough.  Kenal  complications  are  very  uncommon.  Sugar  is  occasionally 
found  in  the  urine. 

Diagnosis. — So  distinctive  is  the  "  whoop  "  of  the  disease  that  the 
diagnosis  is  very  easy ;  but  occasionally  there  are  doubtful  cases,  partieu- 
larly  during  epidemics,  in  which  a  series  of  expiratory  coughs  occurs  witii- 
out  .any  inspiratory  crow. 

Prognosis. — Taken  with  its  complications,  whooping-cough  must  ho. 
regarded  as  a  very  fatal  affection.  According  to  Dolan  it  ranks  third 
among  the  fatal  diseases  of  children  in  England,  where  the  death-rate 
per  million  from  this  disease  is  five  thousand  annually.  The  younger 
the  infant  the  greater  is  the  probability  of  serious  complications.    The 


INFLUENZA. 


87 


deaths  are  chiefly  among  children  of  the  poor  and  among  delicate  in- 
fants. 

Treatment. — Parents  should  be  wariuHl  of  the  serious  nature  of 
wlKKiping-cough,  the  gravity  of  which  is  scarcely  appreciated  by  the 
public.  Particular  care  sliould  be  taken  that  children  suspected  of  the 
.lisi'iise  are  not  sent  to  the  public  schools  or  exposed  in  any  way  so  tliat 
other  cliildren  can  become  contaminated.  There  is  more  reprehensible 
neglect  in  connection  with  this  than  with  any  other  disease.  The  medi- 
ciiial  treatment  of  whooping-cough  is  most  unsatisfactory.  Like  other 
infectious  disorders  it  runs  its  course  practically  uninfluenced  in  a  majority 
of  cases  by  drugs.  In  the  catarrhal  stage  when  there  is  fever  the  child 
should  be  in  bed  and  a  saline  fever  mixture  administered.  If  tlie  cough  is 
distressing,  ipecacuanha  wine  and  paregoric  may  be  given.  For  the  par- 
oxysmal stage  a  suspiciously  long  list  of  remedies  has  been  recommended, 
twenty-two  in  one  popular  text-book  on  therapeutics.  If  the  disease  is 
due,  as  seems  probable,  to  a  germ  growing  upon  and  irritating  the  bron- 
cliiiil  mucosa,  a  germicidal  plan  of  treatment  seems  highly  rational  and 
persistent  attempts  should  be  made  to  discover  a  suitable  remedy.  Quinine 
placed  upon  the  tongue ;  resorcin  in  one-per-cent  solutions,  swabbed  fre- 
quently on  the  throat ;  two  or  three  grains  of  iodoform  to  an  ounce  of 
starch  powder;  a  spray  of  carbo"o  acid — have  all  beon  warmly  recom- 
mended. J.  Lewis  Smith  advises  the  use  of  the  steam  atomizer  with  a 
solution  of  carbolic  acid,  chloride  of  potassium  and  bromide  of  potassium 
in  glycerin.  Jacobi  regards  belladonna  as  the  most  satisfactory  remedy. 
He  gives  it  in  full  doses,  as  much  as  one  sixth  of  a  grain  of  the  root  or 
the  extract  to  a  child  of  six  or  eight  months  three  times  a  day.  It  should 
be  given  in  suflicient  doses  to  produce  the  cutaneous  flush.  For  the 
nervous  element  in  the  disease  antipyrin  has  been  used  with  apparent 
success. 

After  the  severity  of  the  attack  has  mitigated  and  convalescence  has 
begun,  the  child  should  be  watched  with  the  greatest  care.  It  is  just 
at  this  period  that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The 
cough  sometimes  persists  for  months  and  the  child  remains  weak  and  deli- 
cate. Change  of  air  should  be  tried.  Such  a  patient  should  be  fed  ith 
care,  and  given  tonics  and  cod-liver  oil. 


Xn.  INFLUENZA  {La  Grippe). 

Definition. — An  infectious  disease  characterised  by  great  prostration 
and  often  catarrh  of  the  mucous  membranes,  particularly  the  respiratory 
mid  gastro-intcstinal.  There  is  a  marked  liability  to  serious  complications, 
particularly  pneumonia. 

Epidemics  appear  at  intervals  aiid  spread  with  extraordinary  rapidity, 
so  that  in  a  few  weeks  an  entire  continent  may  bo  involved.    The  dis- 


88 


SPECIFIC  INFECTIOUS  DISEASES. 


ease  has  been  known  for  several  centuries,  and  there  have  been  within 
the  past  fifty  years  several  extensive  outbreaks,  notably  those  of  1833, 
1847-'48,  and  the  recent  outbreak  in  1889-'90.  Many  of  the  epidemics 
have  started  in  llussia,  hence  the  name  liussian  fever.  In  October  of 
1889  it  prevailed  extensively  in  St.  Petersburg.  During  November  and 
December  it  spread  to  Germany,  France,  and  western  Europe,  appearing 
in  London  about  tlie  end  of  December.  Cases  appeared  in  this  country 
about  Cliristmas,  and  the  disease  rapidly  became  epidemic. 

Etiology. — The  conditions  which  favor  its  development  and  rapid 
spread  are  unknown,  and  the  exhau&iive  literature  of  the  past  year  has 
not  brought  us  nearer  a  solution  of  the  problem.  It  appears  to  be  in- 
dependent of  meteorological  conditions.  Wiiile  some  authorities  hold 
that  the  affection  is  due  to  a  miasmatic  material  in  the  atmosphere,  others 
probably  more  correctly  hold  that  it  is  due  to  a  specific  virus  of  the 
most  intense  infectiveness.  Like  other  rapidly  spreading  diseases,  it  is 
conveyed  along  lines  of  travel.  The  bacteriological  examinations  which 
have  been  made  in  large  numbers  of  cases  leave  us  still  in  doubt,  and  the 
varied  character  of  the  germs  found  by  reliable  observers  indicates  that 
the  true  virus  has  not  yet  been  detected.  The  pus  organisms  and  the 
diplococcus  pneumonm  have  been  found  oftenest,  but  these  are  wide- 
spread organisms  and  are  probably  not  associated  in  a  causative  manner 
with  the  disease. 

Morbid  Anatomy. — Uncomplicated  cases  recover.  In  the  delicate 
and  aged  alone  do  we  see  fatal  results,  and  then  only  from  the  intensity 
of  the  fever  or  the  profound  depression.  Injection  and  swelling  of  the 
pharyngeal  and  laryngeal  mucosa,  bronchitis,  and  a  catarrhal  condition  of 
the  stomach  and  intestines  may  be  present. 

The  complications  are  very  varied.  Severe  bronchitis,  lobar  and  lobu- 
lar pneumonia,  and  nephritis  may  exist. 

Symptoma. — In  many  cases  the  attack  closely  resembles  an  ordinary 
catarrh  with  slight  fever,  dryness  and  swelling  of  the  nasal  mucosa,  and 
then  increase  in  the  secretion.  In  the  severer  cases  the  coryza  is  sub- 
sidiary or  absent,  and  the  symptoms  are  those  of  an  infection  of  varying 
grades  of  severity.  A  striking  feature  is  the  severe  nervous  manifestation 
at  the  outset,  the  headache,  pain  in  the  back  and  legs,  and  a  general  sore- 
ness as  if  bruised  or  beaten.  With  the  exception  of  dengue  and  small-pox 
there  is  no  affection  in  which  these  symptoms  are  more  pronounced.  De- 
lirium may  be  marked.  Associated  with  these  is  a  prostration  and  cardiac 
weakness  out  of  proportion  to  the  intensity  of  the  fever,  and  sometimes 
very  alarming.  The  pulse  is  feeble,  small,  and  intermittent.  Death  may 
result  directly  from  heart-f allure,  as  in  cases  mentioned  by  Wilks. 

Serious  nervous  complications  are  marked  delirium  and  meninffifi'^, 
the  latter  usually  in  association  with  pneumonia.  Bristowe  has  reported 
several  cases  of  abscess  of  the  brnin  following  influenza.  Peripheral  neu- 
ritis was  not  very  uncommon  in  the  last  epidemic.     Mental  disorders  are 


INFLUENZA. 


89 


not  infrequent.  Inaptitude  for  mental  exertion,  depression  of  spirits,  even 
insanity,  may  follow  an  attack. 

Affections  of  the  respiratory  organs  are  the  most  serious.  Many  cases 
present  an  intense  bronchitis,  involving  the  large  and  small  tubes  and 
coming  on  with  high  fever,  sometimes  with  delirium.  An  intense  general 
broiicliitis  was  common  during  the  recent  epidemic.  In  cliildren  it  may 
1)0  complicated  with  broncho-pneumonia.  By  far  the  most  serious  and 
fatal  complication  is  pmumoHla,  which  may  follow  the  bronchitis,  or  set 
in  with  well-characterised  symptoms.  Sometimes  the  symptoms  may  at 
first  be  obscure  and  the  pneumonia  atypical.  Thus,  after  an  initial  rigor, 
with  some  dyspncea  and  high  fever,  the  local  signs  may  be  obscure  and  it 
may  not  be  until  the  third  or  fourth  day,  or  even  later,  that  the  physical 
signs  of  a  pneumcinia  are  detected.  The  sputa  may  not  be  rusty  until  the 
fourth  or  fifth  day.  The  crisis  may  be  deferred  or  the  defervescence  may 
be  by  lysis,  A  considerable  proportion  of  the  cases,  however,  run  a  normal 
course.  So  far  as  I  could  see,  there  was  nothing  special  or  peculiar  in  the 
pneumonia ;  all  the  anomalies  which  have  Oeen  mentioned  as  occurring  in 
influenza  are  found  in  any  large  series  of  cases.  Abscess  of  the  lung  may 
follow.  Pleurisy  is  not  an  uncommon  complication,  and  empyema  may 
develop. 

The  gastro-intestinal  symptoms  may  be  marked  ;  thus,  with  the  initial 
fever,  there  may  be  nausea  and  vomiting.  Diarrhoea  is  not  uncommon ; 
indeed,  the  brunt  of  the  catarrhal  process  may  fall  upon  the  gastro-intes- 
tinal mucosa.  .        ; 

Tlie  diagnosis  of  the  disease  offers  no  difficulties  when  it  occurs  in  epi- 
demic form.  Coryza  is  not  always  present,  and  the  symptoms  may  be 
those  of  general  fever  with  great  prostration.  In  other  instances  the  bron- 
chitis may  be  an  important  feature.  The  severe  prostration,  fever,  de- 
lirium, with  the  initial  bronchitis,  and  occasionally  epistaxis,  may  lead  to 
the  diagnosis  of  typhoid  fever.  The  complications  are,  as  a  rule,  readily 
recognised,  though  at  first  the  symptoms  of  the  pneumonia  may  be  scme- 
what  indefinite. 

Treatment. — In  every  case  the  disease  should  be  regarded  as  serious, 
and  the  patient  should  be  confined  to  bed  until  the  fever  has  completely 
ilisapi)eared.  In  this  way  alone  can  serious  complications  be  avoided. 
I'lom  the  outset  the  treatment  should  be  supporting,  and  the  patient 
should  be  carefully  fed  and  well  nursed.  The  bowels  should  be  opened 
by  a  dose  of  calomel  or  a  saline  draught.  At  night  ten  grains  of  Dover's 
powdor  may  be  given.  At  the  onset  a  warm  bath  is  sometimes  grateful  in 
relieving  the  pain  in  the  back  and  limbs,  but  great  care  should  be  taken 
to  have  the  bed  well  warmed,  and  the  patient  should  be  given  after  it  a 
ilrink  of  hot  lemonade.  If  the  fever  is  high  and  there  is  delirium,  small 
closes  of  antipyrin  may  be  given  and  an  ice-cap  applied  to  the  head.  The 
medicinal  antipyretics  should  be  used  witli  caution,  as  j);ofound  prostra- 
tion sometimes  develops  iu  these  cases.     Too  much  stress  should  not  be 


90 


SPECIFIC  INFECTIOUS  DISEASES. 


laid  upon  the  mental  features.  Delirium  may  be  marked  even  with  slight 
fever.  In  the  cases  with  great  cardiac  weakness  stimulants  should  be 
given  freely,  and  during  convalescence  strychnia  in  full  doses. 

The  intense  bronchitis,  pneumonia,  and  other  complications  should 
receive  their  appropriate  treatment.  The  convalescence  requires  careful 
management,  and  it  may  be  weeks  or  months  before  the  patient  is  restored 
to  full  health.  A  good  nutritious  diet,  change  of  air,  and  pleasant  sur- 
roundings are  essential.  The  depression  of  spirits  following  this  disease  is 
one  of  its  most  unpleasant  and  obstinate  features.  * 


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(■ ' 

XIII.  DENGUE. 

Definition. — An  acute  infectious  disease  of  tropical  and  subtropical 
regions,  characterised  by  febrile  paroxysms,  pains  in  the  joints  and  mus- 
cles, and  sometimes  a  cutaneous  rash. 

The  disease  was  first  noted  in  Java  toward  the  close  of  the  last  cent- 
ury, and  it  was  probably  described  by  Kush  in  1780.  During  this  century 
many  epidemics  of  it  have  been  reported,  particularly  in  India,  Africa, 
and  the  southern  United  States.  S.  H.  Dickson  gave  the  most  satisfac- 
tory account  of  the  disease  as  it  appeared  in  Charleston  in  1838.  Since  tliat 
time  there  have  been  three  or  four  wide-spread  epidemics,  confined  chiefly 
to  the  Gulf  States  and  rarely  e:™.tending  beyond  the  32nd  parallel. 

Etiology. — Many  observers  regard  it  as  contagious,  and  Dickson 
mentions  in  the  history  of  his  own  household  that  during  the  epi- 
demic of  1828  all  were  attacked,  whereas  in  the  epidemic  of  1850  he 
and  the  cook  (the  only  .  es  remaining  in  his  household  of  those  who 
composed  it  in  1828')  a'  escaped.  The  question  can  scarcely  yet  be 
considered  settled.  The  • » jease  spreads  from  place  to  place,  and  is  con- 
veyed by  ships  and  along  railroads.  It  is  remarkable  among  epidemics  as 
practically  affecting  all  members  in  a  community  who  have  not  been  pro- 
tected by  a  previous  attack.  Matas,  in  his  excellent  account,*  states  that 
one  attack  does  not  protect  from  subsequent  infection.  It  attacks  all 
races  equally.     The  disease  is  stated  to  attack  animals. 

McLoughlin,  of  Texas,  has  found  in  the  blood  of  patients  a  micro- 
coccus, which  he  regards  as  the  special  agent  and  has  been  able  to 
cultivate.  The  slides  which  he  kindly  sent  me  show  a  streptococcus-like 
organism,  but  it  is  impossible  yet  to  speak  definitely  as  to  the  relations 
which  it  bears  to  the  disease.  If  it  be  true  that  animals  are  subject  to  the 
affection,  the  subject  could  be  conclusively  worked  out  during  the  next 
epidemic.  Some  riters  have  held  that  dengue  is  only  a  modified  form 
of  yellow  fever,  xt  has  in  some  instances  preceded  the  development  of 
this  disease. 

*  Kcating's  Encyclopedia  of  Diseases  of  Children,  vol.  i. 


DENGUE. 


91 


As  the  lisease  is  never  fatal,  no  (^servations  have  been  made  upon  its 
patliological  anatomy. 

Symptoms. — The  period  of  incubation  is  from  tliree  to  five  days, 
during  whivvh  the  patient  feels  well.  The  attack  sets  in  suddenly  with 
hemlache,  chilly  feelings,  and  intense  aching  pains  in  the  joints  and  mus- 
cles. The  fever  rises  gradually  and  may  reach  as  high  as  106°  or  107°. 
Tlio  pulse  is  rapid  and  there  are  the  other  phenomena  associated  with 
acute  fever — loss  of  appetite,  coated  tongue,  slight  nocturnal  delirium,  and 
concentrated  urine.  In  the  initial  stage  there  may  be  an  erythematous 
rash.  In  a  majority  of  the  cases  the  pains  in  the  muscles,  joints  and  bones 
are  of  a  most  aggravated  character,  and  the  patients  speak  of  them  as  of  a 
boring  or  breaking  character,  hence  the  popular  name  "  break-bone  fever." 
Tlie  large  and  small  joints  are  affected,  sometimes  in  succession,  and  they 
become  swollen,  red,  and  painful.  The  pains  shift  about,  and  in  some 
cases  cutaneous  hyperajsthesia  has  been  noted.  In  some  instances  there  is 
a  tendency  to  haemorrhage,  from  either  the  nose,  lungs,  stomach,  or  bow- 
els. Eugene  Foster  speaks  of  having  seen  black  vomit,  similar  to  that  of 
Yellovv'  fever,  and  in  three  instances  alarming  hsemorrhage  from  the  bow- 
els, wliich  in  one  case  persisted  for  three  months  and  caused  death. 

The  fever  gradually  reaches  its  height  by  the  third  or  fourth  day,  and 
the  patient  enters  upon  the  apyretic  period,  which  may  last  from  two  to 
four  days,  and  in  which  he  feels  prostrated  and  stiff.  At  this  time,  in  a 
large  number  of  cases,  an  eruption  is  common  which,  judging  from  the 
description,  has  nothing  distinctive,  being  at  times  macular,  like  measles, 
at  others,  diffuse  and  scarlatiniform,  or  papular,  or  lichen-like.  In  other 
instances  the  rash  has  been  described  as  urticarial,  or  even  vesicular.  A 
second  paroxysm  of  fever  then  occurs,  and  the  pains  return.  Certain 
writers  describe  inflammation  and  hyperaemia  of  the  mucous  membrane 
of  the  nose,  mouth,  and  pharynx.  Enlargement  of  the  lymph-glands 
is  not  uncommon,  and  may  persist  for  weeks  after  the  disappearance 
of  the  fever.  Convalescence  is  often  protracted,  and  there  is  a  degree  of 
mental  and  physical  prostration  out  of  all  proportion  to  the  severity  of 
the  primary  attack.  By  far  the  most  distressing  symptom  is  the  pain, 
whicli  all  who  have  experienced  the  disease  sjieak  of  as  agonising  and  in- 
tolerable, and  more  severe  than  that  experienced  in  any  other  acute  fever. 

Complications  ar  ...re.  Insomnia  and  occasionally  delirium,  resem- 
bling somewhat  the  alcoholic  form,  have  been  observed.  A  relapse  may 
occur  even  as  late  as  two  weeks.  Briefly,  the  course  of  the  disease  may  be 
described  as  consisting  of  a  febrile  paroxysm  of  three  or  four  days;  a  re- 
mission of  variable  duration,  which  may  be  wanting ;  and  a  second  parox- 
ysm of  about  three  days.  The  average  duration  of  a  moderate  attack  is 
from  -even  to  eight  days. 

The  diagnosis  of  the  disease  rarely  offers  any  special  difficulties,  pre- 
vailing as  it  does  in  epidemic  form,  and  attacking  all  classes  indiscrimi- 
nately.   Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatism. 


92 


SPECIFIf    INFECTIOUS  DISEASES. 


Southern  })liysiciaii3  say  tlmt  occasionally  yellow  fever  and  dengue  may 
be  confounded. 

Treatment. — This  is  entirely  symptomatic.  Quinine  is  stated  to  ho 
a  prophylactic,  but  on  insufficient  grounds.  Hydrotherapy  may  be  eiii- 
})loyed  to  reduce  the  fever.  The  salicylates  or  antipyrin  may  bo  tried  for 
the  j)ains,  which  usually,  however,  require  opium.  During  convalescencu 
iodide  of  potassium  is  recommended  for  the  arthritic  i)ains,  and  tonics 
arc  indicated. 


XIV.  CEREBRO-SPINAL  MENINGITIS. 


f 


m- 


Definition. — A  specific  infectious  disease,  occurring  sporadically  and 
in  epidemics,  characterised  by  inflammation  of  the  cerebro-spinal  menin- 
ges and  a  clinical  course  of  great  irregularity. 

The  aifection  is  known  by  the  names  of  malignant  purpuric  fevor, 
petechial  fever,  and  spotted  fever. 

etiology. — Since  its  recognition  in  Geneva  in  the  early  part  of  tliis 
century,  numerous  epidemics  have  been  described  in  Europe  and  in 
America,  the  full  details  of  which  are  to  be  found  in  Stille's  elaborate 
article.*  In  Europe  it  is  remarkable  with  what  frequency  the  disease 
has  occurred  in  garrisons.  In  this  country  the  disease  was  first  seen  in 
Massachusetts  in  180G,  since  which  date  there  have  been  epidemics  in  vari- 
ous localities  at  irregular  intervals. 

During  the  civil  war,  according  to  Smart's  report,  comparatively  few 
deaths  were  caused  by  this  disease. 

Sporadic  cases  occur  from  time  to  time  in  the  larger  cities  and  country 
districts  on  this  continent.  After  the  first  epidemic  in  Montreal  in  18T3 
occasional  cases  occurred.  In  Philadelphia,  since  its  appearance  in  18G3, 
there  have  been  cases  reported  every  year  in  the  mortality  bills.  Without 
autopsy  the  diagnosis  of  many  of  these  cases  is  extremely  doubtful ;  but 
there  can  be  no  question  that  the  disease,  though  rare,  still  lingers.  Judi;- 
ing  from  my  own  experience  in  three  of  the  hospitals  of  that  city,  and 
from  the  fact  that  in  five  years  I  saw  only  three  instances,  I  would  regard 
it  as  very  much  less  frequent  than  the  reports  of  the  Health  Office  would 
seem  to  indicate. 

The  disease  has  broken  out  simultaneously  in  regions  far  distant  irom 
each  other. 

The  epidemics  have  occurred  most  frequently  in  winter  and  spring. 
Neither  soil  nor  locality  has  any  special  influence.  The  concentration  of 
individuals,  as  in  large  barracks,  seems  to  be  specially  favorable. 

Children  are  much  more  susceptible  to  the  disease  than  adults,  though 
the  susceptibility  has  differed  in  different  epidemics.     In  certain  places 

*  System  of  Medicine,  Phihideij.hla,  vcl.  i,  1885. 


CEREBRO-SPINAL  MENINGITIS. 


98 


cliildrcn  alone  have  been  affected ;  in  others  tlie  disease  lias  been  ehiefly 
aiiioiig  adults.     It  attacks  males  and  females  alike. 

('(Ttain  epidemics  have  been  most  prevalent  in  country  districts.  In 
!«;;{  the  disease  prevailed  along  the  valley  of  the  Ottawa,  in  villa<,'es  and 
country  places,  much  more  severely  than  in  the  cities  of  Montreal  and 
Ottiiwa. 

Over-exertion,  prolonged  marching  in  the  heat,  depressing  mental  or 
bodily  surroundings,  and  the  misery  and  squalor  of  the  large  tenement- 
lioiises  in  cities  are  predisposing  causes. 

'Pile  disease  is  not  directly  contagious ;  it  is  probably  not  transmitted 
by  ilothing  or  the  excretions. 

The  nature  of  the  virus  is  as  yet  unknoAvn.  In  the  meningeal  exuda- 
tion there  is  now  found  in  many  cases  the  lance-shaped  coccus,  similar  in 
all  respects  to  the  pneumococcus.  In  other  instances  this  microbe  has 
liocn  associated  with  the  ordinary  pus  organisms.  Cornil  and  13abes  con- 
cliulo  that  cerebro-spinal  meningitis  may  be  caused  by  several  different, 
often  associated,  forms  of  micro-organisms,  of  which  the  lance-shaped 
coccus  of  Pasteur  is  the  most  common. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  charac- 
teristic changes,  for  the  patient  may  die  before  exudation  occurs.  In  well- 
marked  cases  the  meninges  of  the  brain  and  cord  are  inilamed.  The  fol- 
lowing abstract  of  one  of  the  Montreal  cases,  in  which  death  occurred 
about  the  fifth  day,  gives  a  good  idea  of  the  condition  in  this  disease  :  The 
brain  contained  an  excessive  amount  of  blood.  The  dural  sinuses  and  all 
tl\o  veins  and  arteries  were  engorged.  Some  of  the  veins  of  the  pia  were 
as  large  as  goose-quills.  On  the  cortex  there  was  much  lymph  beneath 
the  arachnoid  on  either  side  of  the  longitudinal  fissure — more  on  the  right 
than  on  the  left  hemisphere.  At  the  base  there  was  a  purulent  exudate 
about  the  chiasma  and  inner  parts  of  the  Sylvian  fissure,  but  none  on  the 
pons  or  medulla.  There  was  no  lymph  in  the  course  of  the  middle  cere- 
bral arteries.  The  ventricles  contained  serous  exudate ;  the  walls  were 
not  softened.  The  gray  matter  of  the  brain  was  deejily  congested,  but 
presented  neither  haemorrhages,  spots,  nor  softening.  In  the  si)inal  cord 
the  veins  of  the  pia  were  engorged.  On  the  posterior  surface,  from  the 
cervical  enlargement  to  the  cauda  equina,  was  a  thick  layer  of  grayish- 
yollow,  lympho-purulent  exudation,  which  in  places  produced  irregular 
bulging  of  the  arachnoid  membrane.  There  were  no  changes  in  the  tho- 
racic or  abdominal  viscera.  This  picture  corresponds  closely  with  that 
presented  by  five  other  cases  which  I  have  examined.  In  one  case,  how- 
ever, the  amount  of  exudation  on  the  hemispheres  was  large,  and  the  con- 
volutions were  covered  with  a  thick  creamy  pus.  Foci  of  hsemorrhage 
and  of  encephalitis  occur  in  some  cases.  The  formation  of  abscess  has 
iieeu  occasionally  described.  The  involvement  of  the  ventricles  is  less 
than  in  tuberculous  meningitis.  In  the  cases  which  I  liave  seen  the  exu- 
dation, as  is  usual  iu  the  secondary  meningeal  inflammations,  was  most 


91 


SPECIFIC  INFECTIOUS  DISEASES. 


ii! 


}.  J  I 


abundant  on  the  cortex.  The  exudation  may  extend  along  the  lymph- 
sheatlis  of  the  cranial  nerves,  particularly  the  auditory  and  optic.  In 
long-standing  cases  the  inttainniatory  processes  a})pear  more  chronic. 
There  are  thickening  and  adhesion  of  the  membranes,  areas  of  cortical 
softening  or  of  utrophy,  and,  in  some  instances,  hydrocephalus.  The 
changes  in  the  other  organs  are  those  associated  with  fever.  In  the  ma- 
lignant cases  there  may  be  hiemorrhages  into  the  skin  and  on  the  serous 
membranes,  i'neumonia,  pleurisy,  endocarditis,  dysentery  and  nephritis 
have  been  described.  The  spleen  varies  in  size  according  to  the  period 
of  the  disease  at  which  death  has  occurred.  When  the  fever  has  been 
intense  it  is  enlarged 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many 
different  forms  have  been  described.  These  are  perhaps  best  grouped  into 
three  classes : 

1.  Malignant  Form. — This  fulminant  or  apoplectic  type  occurs  with 
variable  frequency  in  epidemics.  It  may  occur  sporadically.  The  onset 
is  sudden,  usually  with  violent  chills,  headache,  somnolence,  spasms  in  the 
muscles,  greac  depression,  moderate  elevation  of  temperature,  and  feeble 
pulse,  which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric 
rash  develo])s.  In  a  Philadelphia  case  in  1888  a  young  girl,  apparently 
quite  well,  died  within  twenty  hours  of  this  form.  There  are  cases  on 
record  in  which  death  has  occurred  within  a  shorter  time.  Stille  tells  of 
a  child  of  five  years,  in  whom  death  occurred  after  an  illness  of  ten  hours; 
and  refers  to  a  case  reported  by  Gordon,  in  which  the  entire  duration  of 
the  illness  was  only  five  hours. 

2.  Ordinary  Form. — The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  .premonitory  symptoms: 
headache,  pains  in  the  back,  and  loss  of  appetite.  More  commonly,  the 
onset  is  with  headache,  severe  chill,  and  vomiting.  The  temperature  rises 
to  101°  or  102°.  The  pulse  is  full  and  strong.  An  early  and  important 
symptom  is  a  painful  stiffness  of  the  muscles  of  the  neck.  The  headache 
increases,  and  there  are  photophobia  and  great  sensitiveness  to  noises. 
Children  become  very  irritable  and  restless.  In  severe  cases  the  contrac- 
tion of  the  muscles  of  the  neck  sets  in  early,  the  head  is  drawn  back,-  and, 
when  the  muscles  of  the  back  are  also  involved,  there  is  opisthotonos. 
The  pains  in  the  back  and  in  the  limbs  may  be  very  severe.  The  motcr 
symptoms  are  most  characteristic.  Tremor  of  the  muscles  may  be  pres- 
ent, with  tonic  or  clonic  spasms  in  the  arms  or  legs.  Rigidity  of  tlie 
muscles  of  the  back  or  neck  is  very  common,  and  the  patient  lies 
with  the  body  stiff  and  the  head  drawn  so  far  back  that  the  occijnit 
may  be  between  the  shoulder-blades.  Except  in  early  childhood  con- 
vulsions are  not  common.  Strabismus  is  a  frequent  and  important 
symptom.  Spasm  of  the  muscles  of  the  face  may  also  occur.  Cases 
have  been  described  in  which  the  general  rigidity  and  stiffness  was  such 
that  the  body  could  be  moved  like  a  statue.    Paralysis  of  the  trunk  mus- 


CEREBRO-SPINAL  MENINGITIS. 


95 


clos  is  rare,  but  paralysis  of  the  muscles  of  the  eye  and  the  face  is  not  un- 
coinmon. 

Of  sensory  symptoms,  lieadache  is  the  most  dominant  and  persists 
from  the  outset.  It  is  chiefly  in  the  hack  of  the  head,  and  tlie  pain  .-x- 
tcnds  into  the  neck  and  hack.  There  may  bo  great  sensitiveness  along 
the  spine,  and  in  many  oases  there  is  nuirked  hyperaisthcsia. 

'i'he  ])8ycliical  symptoms  are  marked.  Delirium  occurs  at  the  outset, 
oof'iisioiuiily  of  a  furious  and  maniacal  kind.  The  patient  may  display 
niiiiked  erotic  symptoms.  The  delirium  gives  jilace  in  a  few  days  to  stu- 
|)()r,  which,  as  the  effusion  increases,  deepens  to  coma. 

'i'he  temperature  is  irregular  and  va"iable.  Kemissions  occur  fre- 
(jiioiitly,  and  there  is  no  uniform  or  typical  curve  during  the  disease.  In 
some  instances  there  has  been  little  or  no  fever.  In  other  cases  the  tem- 
perature may  reach  105"  or  l(J(j°,  or,  before  death,  108°.  The  pulse  may 
be  very  rapid  in  children ;  in  adults  it  is  at  first  usually  full  and  strong. 
In  some  cases  it  is  remarkably  slow,  and  may  not  be  more  than  fifty  or 
sixty  in  the  minute.  Sighing  respirations  and  Cheyne-Stokes  breathing 
are  met  with  in  some  instances.  Uidess  there  is  pneumonia  the  respira- 
tions are  not  often  increased  in  frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  labia- 
lis  occurs  Avith  even  greater  frequency  than  in  pneumonia  or  in  inter- 
iriitlent  fever.  The  petechial  rash,  which  has  given  the  name  spotted 
fever  to  the  disease,  is  very  variable.  Stille  states  that  of  ninety-eight 
cases  in  the  Philadelphia  Hospital,  no  eruption  was  observed  in  thirty- 
seven.  In  the  Montreal  cases  petechia)  and  purple  spots  were  common. 
They  appear  to  have  been  more  frequent  in  the  epidemics  on  this  conti- 
nent than  in  Europe.  The  petechias  may  be  numerous  and  cover  the 
entire  skin.  An  erythema  or  dusky  mottling  may  be  present.  In  some 
instances  there  have  been  rose-colored  hyperjemic  sj)ots  like  the  typhoid 
rash.  Urticaria  or  erythema  nodosum,  ecthyma,  pemphigus  and  in  rare 
instances  gangrene  of  the  skin  have  been  noted. 

As  already  stated,  vomiting  may  be  a  special  feature  at  the  outset ;  but, 
as  a  rule,  it  gradually  subsides.  In  some  instances,  however,  it  persists 
and  becomes  the  most  serious  and  distressing  of  the  symptoms.  Diarrhoea 
is  not  common.  The  bowels  are  usually  confined.  The  abdomen  is  not 
tender.     In  acute  cases  the  spleen  is  usually  enlarged. 

The  urine  is  sometimes  albuminous  and  the  quantity  may  be  increased. 
Glycosuria  has  been  noted  in  some  instances,  and  in  the  malignant  forms 
hiematuria. 

The  course  of  the  disease  is  extremely  variable.  Hirsch  rightly  states 
that  it  may  range  between  a  few  hours  and  several  months.  More  than 
lialf  of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases, 
after  the  symptoms  have  persisted  for  five  or  six  days,  improvement  is  in- 
dicated by  a  lessening  of  the  spasm,  reduction  of  the  fever,  and  a  return 
of  the  intelligence.    Sudden  fall  in  the  temperature  is  of  bad  omen.    Con- 


-FT 


il 


■  r 

ills 

f 

I 

i.: 

1 

96 


SPECIFIC   INFECTIOUS  DISEASES. 


valescencc  is  extremely  tedious,  and  may  be  interrupted  by  complications 
and  se(pielifi  to  be  noted. 

3.  Anomalous  Forms. 

{(i)  Abort ivv  Tii}w. — 'I'lio  attack  sets  in  with  great  severity,  but  in  ;i 
day  or  two  the  symptoms  subside  and  convalescence  is  rapid.  IStriimpell 
would  distinguish  between  this  abortive  variety,  which  sets  in  with  sucli 
intensity,  and  the  mild  ambuhuit  cases  described  by  certain  writers,  lies 
reports  a  case  in  which  the  meningeal  symptoms  set  in  with  the  greatest 
intensity  and  persisted  for  four  days,  the  temperature  rising  to  4U"9°  ('. 
On  the  lifth  day  the  jjatient  entered  upon  a  rujjid  and  satisfactory  con- 
valescence. In  tiie  mild  cases,  as  distinguished  from  the  abortive,  the  ])ii- 
tients  complain  of  headache,  nausea,  sensations  in  the  back  and  limbs,  and 
stiffness  in  the  neck.  There  is  little  or  no  fever,  and  oidy  moderaU^ 
vomiting.  These  cases  have  been  met  with,  and  could  be  recognised  only 
during  tiie  prevalence  of  an  epidemic. 

{b)  An  infcrmiUcnt  type  has  been  observed  in  many  e])idcmics,  and  is 
recognised  by  von  Ziemssen  and  Stille.  It  is  characterised  by  exacerba- 
tions of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curvo 
of  an  intermittent  or  remittent  character.  The  pyrexia  resembles  that  uC 
pya3niia  rather  than  malaria. 

{(•)  Chronic  Form. — Ileubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognised  by  numy  writers  on  tlio 
subject.  An  attack  may  be  protracted  for  from  two  to  five  or  even  six 
months,  and  may  cause  the  most  intense  marasmus.  Tlie  attack  consists 
of  a  series  of  recurrences  of  the  fever,  ami  may  present  the  most  complex 
symptomatology.  It  is  not  improbable  that  these  protracted  cases  depend 
upon  chronic  hydrocephalus  or  abscesses  of  the  brain.  This  form  differs 
distinctly  from  the  intermittent  type.  A  very  remarkable  instance  of  it 
is  described  by  Worthington,*  in  which  the  disease  lasted  for  fourteen 
weeks. 

Complications. — Pleurisy  and  pericarditis  are  not  uncommon. 

Pneumonia  is  descri!)ed  as  frequent  in  certain  epiilemics.  Immer- 
mann  found,  during  the  Erlangen  epidemic,  many  instances  of  the  com- 
bination of  pneumonia  with  meningitis,  but  it  does  not  seem  possible  to 
determine  whether,  in  such  instances,  pneumonia  is  the  primary  disease 
and  the  meningitis  secondary,  or  vice  versa.  The  frequency  with  which 
inflammation  of  the  meninges  of  the  brain  complicates  pneumonia  has 
already  been  mentioned.  It  is  not  impossible  that  the  i)neumococcus  is 
responsible  for  both  affections.  Arthritis  has  been  the  most  frequent 
complication  in  certain  epidemics.  Many  joints  are  affected  simulta- 
neously, and  there  are  swelling,  pain,  and  exudation,  sometimes  serous, 
sometimes  purulent.  This  was  first  observed  by  James  Jackson,  Sr.,  in 
the  epidemic  which  he  described. 

*  Canada  Medical  and  Surgical  Journal,  vol.  xiv. 


i 


CEREimO-SPINAL  MENINGITIS. 


vr 


Among  the  importimt  scquelaj  are  those  aftecting  tlio  special  sonsos. 
niiiiiliioss  may  result  from  optic  neuritis  with  atrophy.  Keratitis  with 
tilccration  may  develop.  This  may  also  occur  in  the  meningitis  following 
limiimonia.     Iritis  is  less  common. 

Still  more  serious  are  the  ear  symptoms,  particularly  in  children. 
|)t;iliii'ss  very  often  follows  inllammation  of  the  labyrinth;  the  result,  no 
(|(»iibt,  of  the  direct  extension  of  the  inllammation  along  the  auditory  nerve. 
In  cliildren  this  not  infrerpiently  leads  to  deaf-mutism.  Von  Ziemssen 
states  that  in  the  deaf  and  dumb  institutions  of  Hamborgand  Nuremberg, 
in  1ST4,  almost  all  the  pupils  had  become  deaf  from  epidemic  eerebro- 
spiiiul  meningitis. 

Headache  nuiy  persist  for  months  or  years  after  an  attack.  Chronic 
hydrocephalus  develops  in  certain  instances  in  children.  The  symptoms 
of  this  are  "  paroxysms  of  severe  headache,  pains  in  the  neck  and  ex- 
tremities, vomiting,  loss  of  consciousness,  convulsions,  and  involuntary 
discluirgcs  of  fteces  and  urine  "  (von  Ziemssen).  \'on  Ziemssen  regards 
chronic  hydrocephalus  as  by  no  means  a  rai'o  secpiela.  Mental  feebleness 
uiul  aphasia  have  occasionally  been  noted. 

Paralysis  of  individual  cranial  nerves  or  of  the  lower  extremities  )nay 
persist  for  some  time.  In  some  of  these  cases  untpiestioiiably  there  may 
be  peripheral  neuritis,  as  Mills  suggested. 

Diagnosis. — There  are  several  affections  with  which  cerebro-spinal 
meningitis  is  likely  to  be  confounded  : 

{(i)  Tuberculous  MeninyUus. — In  sporadic  cases  it  is  sometimes  impos- 
sible to  determine  the  nature  of  a  case  in  the  absence  of  local  tuberculous 
disease.  Retraction  of  the  neck  and  spasms  of  the  muscles  of  the  arms 
iiiul  legs  are  not  nearly  so  marked  and  prominent  in  tuberculous  menin- 
gitis. Herpes  also  is  rare,  and  the  pulse  is  more  irregular.  There  is  rarely 
l)etechial  eruption.  When  the  disease  is  prevailing  epidemically  this  fac- 
tor is  of  the  greatest  help  in  the  diagnosis. 

[b)  Pneumonia. — The  meningeal  complication  of  this  disease  is  most 
commonly  confined  to  the  cerebrum.  As  the  cortex  is  chiefly  involved, 
tliere  may  be  a  good  deal  of  motor  spasm  and  tremor,  but  rarely  is  there 
retraction  of  the  muscles  of  the  neck  or  opisthotonos.  In  sporadic  cases, 
as  lias  been  said,  it  may  be  quite  impossible  to  decide  whether  the  pneu- 
monia has  complicated  the  meningitis  or  the  meningitis  the  pulmonary 
aiTection.  The  bacteriological  examination  gives  no  clue,  as  the  pueumo- 
coccus  is  found  in  both  situations. 

[r)  With  other  Achte  Infectious  Diseases. — Both  typluis  and  typhoid 
present  symptoms  which  closely  simulate  cerebro-spinal  meningitis.  On 
several  occasions  at  the  Montreal  General  Hospital  cases  have  been  sent 
into  the  ward  with  the  diagnosis  of  cerebro-spinal  fever.  These  eases 
showed  high  fever,  delirium,  retraction  of  the  neck,  spasm,  and  tremor  of 
the  muscles,  and  had  not  the  post-mortem  examination  revealed  typhoid 
lesions  and  only  cerebro-spinal  congestion  the  diagnosis  would  not  have 


98 


SrECIFIC  INFECTIOUS   DISEASES. 


1!  '  ■ ! 


■y-u  ^ 


been  corrected.  I  am  sure  that  many  of  the  caseH  sent  into  the  lioalth  oniccH 
us  ccrobro-spiiial  fever  are  instances  of  tlie  cerebral  form  of  t}j)hoi(l. 

I  have  alrc^niiy  referred  to  tlie  fa(!t  that  tlie  malignant  form  of  snmll- 
jiox  may  he  mistaiien  for  cerebro-spinal  meningitis. 

It  could  K(!arccly  be  possible  to  confound  tetanus  with  this  disease. 

Prognosis.  —  llirsith  states  that  the  mortality  has  ranged  in  various 
epidemics  from  20  to  To  jx'r  cent.  In  children  the  death-rate  is  much 
higher  than  in  adults.  Cases  with  deep  coma,  repeated  convulsions,  and 
high  fever  rarely  recover.  The  outlook  in  the  protracted  cases  is  not 
good,  though  lleubncr  gives  an  instance  of  u  lad  of  seven,  who  was  ill 
from  the  end  of  February  until  the  end  of  June,  with  repeated  recur- 
rences, was  worn  to  a  skeleton,  and  yet  comjjletely  recovered. 

Treatment. — The  high  rate  of  mortality  which  has  existed  in  most 
epidemics  indicates  the  futility  of  the  various  therapeutical  agents  which 
liave  been  recommended.  When  wo  consider  the  nature  of  the  local  dis- 
ease and  the  fact  that,  so  far  as  we  know,  sirni)lo  or  tuberculous  cerebro- 
spinal meningitis  is  invariably  fatal,  we  may  wonder  rather  that  recovery 
follows  in  any  well-developed  case. 

In  strong  robust  patients  the  local  abstraction  of  blood  by  wot  cups 
on  tlio  nape  of  the  neck  relieves  the  pain.  General  bloodletting  is  rarely 
indicated.  Cold  io  the  head  and  spine,  which  was  used  in  the  first  e]»i- 
demics  by  New  England  physicians,  is  of  great  service.  A  bladder  of  ice 
to  the  head,  or  an  ice-cap,  and  the  spinal  ice-bag  may  be  continuously  em- 
ployed. The  latter  is  very  beneficial.  Judging  from  the  beneficial  effects 
of  the  general  bath  in  typhoid  with  pronounced  cerebro-spinal  symptoms, 
hydrotherapy  should  bo  systematically  em})loyed  if  the  temperature  is 
above  102^°.  In  private  practice  the  cold-i)ack  or  sponging  nuiy  bo  sul)- 
stituted.  If  any  counter-irritation  is  thought  necessary,  the  skin  of  the 
back  of  tho  neck  may  be  lightly  touclied  with  the  Paquelin  thermo- 
cautery. Blisters,  which  have  been  used  so  much,  arc  of  doubtful  benefit 
and  should  not  bo  employed.  Of  internal  remedies  opium  may  be  given 
freely,  best  as  morphia  hypodermically.  Stille  recommends  either  a  grain 
of  opium  every  hour  in  severe  cases  or  every  two  hours  in  cases  of  mod- 
erate severity ;  von  Ziemssen  advises  the  hypodermic  of  morjihia,  from 
one  third  to  one  half  grain  in  adults.  Mercury  has  no  special  influenci; 
on  meningeal  infiammation.  Iodide  of  potassium  is  ".'armly  recom- 
mended by  some  writers.  Quinine  in  largo  doses,  ergot,  belladonriii 
and  Calabar  bean  have  had  advocates.  Bromide  of  potassium  may  be 
employed  in  tho  milder  cases,  but  it  is  not  so  useful  as  morphia  to  control 
tho  spiisms. 

The  diet  should  be  nutritious,  consisting  of  milk  and  strong  brotlis 
while  tho  fever  persists.  Many  cases  are  very  difficult  to  feed,  and  Heub- 
ner  recommends  forced  alimentation  with  the  stomach-tube.  These  casis 
seem  to  bear  stimulants  well,  and  whisky  or  brandy  may  bo  given  freely 
when  there  are  signs  of  a  failing  heart. 


DIIMITIIKUIA. 


OU 


XV.    DIPHTHERIA. 


Deflnition. — A  specifio  infoctiouH  disoiisc^,  clmmotorizod  by  a  loc'ul 
illiiiiioiiHuxudiite, usuully  upon  a  mucous  nionihriiiu', iiml  by  coiistitutioiml 
Kyniptoma  of  varying  intensity.  The  presence  of  the  Klebs-Loelller  bacil- 
lus may  be  regarded  as  tlie  etiological  criterion  by  which  true  diphtheria 
iiiiiv  be  distinguished  from  other  forms  of  ])seudo-membranous  intlanuna- 

lioM. 

Historical  Note. — The  disease  was  known  to  Areta-us  and  Cialen. 
Kpidemics  occurred  throughout  tiio  middle  ages.  It  appeared  early 
iiniong  the  settlers  of  Now  England,  and  accounts  are  extant  of  epidemics 
ill  lliis  country  in  the  seventeenth  and  eighteenth  centuries.  Iluxham 
uiid  Fothergill  gave  excellent  descriptions  of  the  disease.  An  admirable 
iKJcount  was  given  by  Samuel  liard,*  of  New  York,  in  1770,  wlioso  essay 
is  one  of  the  most  solid  contributions  made  to  medicine  in  America.  It 
\v;is  reserved  for  I'ierro  liretonneau,  of  Tours,  to  grasp  the  fact  tluit 
an;/iiifi  suffocativa,  '■'■  cynanche  mrt/«^«rf,"  the"  putrid  "and  other  forms  of 
iiiiilignant  sore  throat  were  one  and  the  same  disease,  to  which  he  gave 
tlio  name  "diphtherite." 

Etiolog^y. — The  disease  is  endemic  in  the  larger  centres  of  popula- 
tion, and  becomes  epidemic  at  certain  seasons  of  the  year.  It  is  a  re- 
markable fact  that  while  other  contagious  diseases  have  diminished  within 
tlio  past  decade,  diphtheria,  particularly  in  cities,  has  increased.  It  is  by 
no  means  confined  to  the  poorer  districts,  but  occurs  in  the  houses  of  the 
belter  classes,  particularly  when  the  pluml)ing  is  defective.  The  disease 
is,  however,  not  confined  to  cities.  It  has  prevailed  with  great  severity 
in  c-mntry  districts,  in  which  indeed  the  affection  seems  to  bo  specially 
virulent.  The  relation  between  imperfect  drainage  and  the  diphtheria 
poison  has  not  yet  been  satisfactorily  determined.  Perhaps,  as  Thome 
suggests,  the  fiialty  conditions  produce  sore  throat  of  a  benign  character, 
which,  as  in  scarlet  fever,  affords  a  soil  suitable  for  inoculation  by  the 
diphtheria  germ,  when  present  in  the  air.  Drains,  too,  he  thinks  may 
retain  the  virus  received  through  the  sputa  and  djjecta  of  the  sick.  This 
author  states  that  no  prevalence  of  diphtheria  has  ever  been  definitely 
traced  to  polluted  water. 

Diphtheria  is  a  highly  contagious  disease,  readily  communicated  from 
person  to  person.  The  poison  is  given  off  in  the  pharyngeal  secretion 
and  in  the  saliva,  but  not  in  the  breath.  No  disease  of  temperate  regions 
proves  more  fatal  to  physicians  and  nurses.  There  seems  to  be  particular 
danger  in  the  examination  arid  swabbing  of  the  throat,  for  in  the  gagging, 
coughing,  and  spluttering  efforts  the  patient  may  cough  mucus  and  flakes 
of  membrane  into  the  physician's  face.  The  virus  attaches  itself  to  tho 
I'lothing,  the  bedding,  and  tho  room  in  which  the  patient  has  lived,  and 


*  Transactions  of  the  American  Philosophical  Society,  vol.  i,  Philadelphia,  1770. 


??■::   U 


100 


SPECIFIC  INFECTIOUS  DISEASES. 


if  '■ 


has,  in  many  instances,  displayed  great  tenacity.  The  disease  may  be 
transmitted  by  inoculation.  The  contagion  does  not  seem  to  be  widely 
diffused  in  the  neighborhood  of  the  patient.  At  Lhe  Montreal  Genera! 
Hospital  we  rarely  had  cases  develop  in  the  wards  adjacent  to  tliose  in 
which  there  were  diphtlieria  patients. 

There  is  a  wide-spread  belief  in  the  profession  that  the  disea-^e  may  bo 
communicated  from  animals.  There  is  in  calves  a  contagious  pseudo- 
membranous affection  which  is  said  to  be  communicable  to  man.  Cows 
are  not  known  to  be  affected  spontaneously.  In  thi  epidemics  in  which 
the  contagion  has  been  traced  to  the  milk,  it  is  more  probr.ble  that  the 
virus  has  been  accidentally  mixed  with  it  than  that  the  cows  were  them- 
selves diseased.  Cats  are  subject  to  a  pseudo-membranous  disease,  and 
there  are  many  cases  on  record  in  which  children  appear  to  have  cauglit 
diphtheria  from  them.  On  the  other  hand,  I  know  of  one  case  in  whieli 
a  cat  died  of  angina  and  intense  pseudo-membranous  colitis,  and  the  chil- 
dren wno  nursed  it  did  not  take  the  disease ;  and  of  a  second  case,  in 
which  a  pet  cat  had  coryza,  difficult  breathing,  fever,  and  enlarged  cervi- 
cal glands,  and  here  too  +he  children  were  not  affected.  Tiie  so-called 
diphtheria  of  fowls  is  apparently  not  associated  with  the  same  germ  as  the 
human  diphtheria. 

Of  predisposing  causes  a(/e  is  one  of  the  most  important.  Very  young 
children  are  rarely  attacked,  but  Jacobi  states  that  he  has  seen  <^hree  in- 
stances of  the  disease  in  the  newly  born.  Between  the  third  and  the  iif- 
teenth  year  a  large  majority  of  the  cases  occur.  In  this  period  the  great- 
est number  of  deaths  is  between  the  second  and  the  fifth  years.  Girls  are 
attacked  in  larger  numbers  than  boys,  jn'obably  because  they  are  brouglit 
into  closer  contact  with  the  sick.  Adults  are  frequently  affected.  The 
disease  is  most  prevalent  in  the  cold  autumn  weather. 

Caille  regards  as  special  predisposing  elements  in  children,  enlarged 
tonsils,  chronic  naso-pharyngeal  catarrh,  carious  teeth,  and  an  unhealthy 
condition  of  the  mucous  membrane  of  the  r»iouth  sind  tliroat. 

Epidemics  vary  in  intensity.  While  in  some  the  affection  is  mild  and 
rarely  fatal,  in  others  it  is  characterized  by  wide  extension  of  the  mem- 
brane, and  shows  a  special  tendency  to  attack  the  larynx. 

The  Specific  Germ. — The  bacillus  originally  described  by  Klebs  ami 
nxore  thoroughly  studied  by  Loeffler  appears  to  be  the  specific  virus.  It 
is  found  in  the  pseudo-membranes,  not  in  the  subjacent  mucosa,  or  in  the 
blood,  or  in  the  internal  organs.  It  is  a  non-motile  bacillus,  varying  from 
2*5  to  3  |ii  in  length,  and  from  0-5  to  0-8  /*  in  thickness.  It  appears  as  a 
straight  or  slightly  bent  rod  with  rounded  ends.  Irregular  bizarre  forms, 
such  as  rods  with  one  or  both  ends  swollen,  are,  however,  not  uncommon. 
The  bacillus  stains  in  sections  or  cover-glass  specimens  by  Gram's  method. 
It  is  best  cultivated  on  blood  serum  and  bouillon.  The  colonies  are  large. 
elevated,  grayish-white,  with  an  opaque  centre.  Welch  and  Abbott  also 
state  that  it  grows  well  on  potato ;  but  the  growth  is  invisible  or  indicated 


DIPHTHERIA. 


101 


only  Ly  a  dry  thin  glaze.  It  multiplips  readily  in  milk.  Although  it 
fdiiiis  no  spores,  it  is  a  very  persistent  bacillus,  and  cultures  hav)  been 
iniide  from  membrane  preserved  for  five  months  in  a  dry  cloth.  The 
cultures  inoculated  into  the  trachea  of  animals  produce  a  well-marked 
(li|iht]icritic  exudation  with  development  of  the  bacilli  and  secondary  in- 
volvt'inent  of  the  lymph-glands,  in  which  remarkable  necrotic  areas  occur, 
with  fragmentation  of  the  nuclei  (Flexner).  Brieger  and  Frjinkel  have 
separated  from  the  cultures  a  tox-albumin,  Avhich,  injected  into  animals, 
produces  paralysis,  nephritis,  and  albuminuria.  This  point  tends  strongly 
to  confirm  the  view  that  this  bacillus  is  really  the  infective  agent  in  the 
disease.  It  is  one  of  the  most  virulent  poisons  known,  and  when  in- 
jected in  a  sufficiently  small  though  fatal  dose,  there  may  be  no  synij)- 
toms  for  days,  and  the  animal  may  not  develop  the  paralysis  for  weeks  or 
even  months  after  the  injection.  A  point  of  very  great  interest  is  the 
fact  that  cultures  from  cases  vary  in  virulence,  and  this  is  in  accord  with 
the  remarkable  variation  in  the  intensity  of  different  epidemics  and  differ- 
ent eases.  As  a  rule  there  is  a  correspondence  between  the  virulence  of 
the  bacilli  and  the  gravity  of  the  case. 

Associated  with  the  Klebs-Loeffler  bacillus  are  other  pathogenic  bac- 
teria, which  i)robably  play  an  important  role  in  the  complications  of  the 
disease.  Thus  streptococci  and  staphylococci  are  frequently  present  in 
the  exudate,  and  to  their  invasion  through  the  abraded  mucosa  are  duo 
the  secondary  suppurations  and  inflammations  of  serous  surfaces,  and  to 
the  aspiration  of  the  streptococci  into  the  lungs  the  common  and  fatal 
broncho-pneumonia. 

Diphtheria  may  then  be  said  to  be  caused  by  the  Klebs-Loeffler  bacil- 
lus. The  production  of  a  false  membrane  is  the  local  or  primary  effect ; 
the  constitutional  symptoms  are  d.ie  to  the  absorption  of  the  poison  in 
varying  doses,  while  the  secondary  inllamnuitions  are  associated  with  the 
invasion  of  the  ubiquitous  pus  organisms. 

Pseudo-diphtheritic  Processes. — ^Uany  substances  have  the  power  o'" 
exciting  pseudo-membranous  or  croupous  inflammation,  the  exudate  of 
which  is  not  distinguishable  from  that  of  diphtheria.  Some  of  them  are 
non-niicrobic,  as  steam,  ammonia,  and  cliloriiic ;  others  are  dependent 
upon  micro-organisms,  and  must  bo  distinguished  from  true  diph- 
theria. 

(a)  There  are  cases  of  pseudo-mem])ranous  angina,  associated  Avith 
which  is  a  bacillus  identical,  morphologically  and  in  its  behavior  on  cult- 
ure media,  with  the  Klebs-LoeflV^r  bacillus,  but  which  is  not  pathogenic — 
i.e.,  does  not  p'-  duce  the  tox-albumin,  and  is  harmless  when  inoculated. 
Whether  this  is  a  i  attenuated  form,  as  Koux  and  Yf>rsin  hold,  is  not  yet 
settled.  This  complicates  the  question  of  diagnosis.  A  patient  in  my 
ward  presented  a  thin,  grayish  pseudo-membrane  over  the  tonsils  and 
fauces,  without  fever  and  without  constitutional  disturl)ance.  Xon-patho- 
geiiic  bacilli,  identical  with  those  of  true  diphtheria,  were  found  l)y  Welch 


'i'1 


I  ■ 


102 


SPECIFIC  INFECTIOUS  DISEASES. 


. 


and  Abbott.  We  need  additional  information  upon  the  occurrence  of  thin 
form  and  its  relation  to  the  virulent  bacillus. 

(b)  The  pseudo-membranous  angina  of  the  eruptive  fevers  is  an  affec- 
tion distinct,  etiologically  at  least,  from  true  diphtheria.  In  a  majority 
of  all  these  cases,  particularly  in  scarlet  fever,  the  Klebs-Loeffler  bacillus 
is  absent,  and  this  is  in  accord  with  the  fact  that  scarlatinal  angina  rarely 
communicj'  ^,s  diphtheria,  and  is  still  more  rarely  followed  by  paralysis. 

Streptococci  and  staphylococci  are  present  in  the  membranes  in  these 
cases.  Late  in  the  disease  infection  with  the  bacillus  diphtheria)  may  oc- 
cur, and  it  is  probable  that  under  these  circumstances  alone  is  the  angina 
followed  by  symptoms  of  paralysis. 

Morbid  Anatomy. — A  majority  of  the  cases  die  of  the  faucial  or 
of  the  laryngeal  disease.  The  exudation  may  occur  in  the  mouth  and 
cover  the  inner  surfaces  of  the  cheeks ;  it  may  even  extend  beyond  the 
lips  on  to  the  skin.  This  was  met  once  in  thirty  autopsies  at  the  Mont- 
real General  Hospital.  The  amount  of  exudation  varies  in  different  cases. 
Usually  the  tonsils  and  the  pillars  of  the  fauces  are  swollen  and  covered 
with  the  false  membrane  More  commonly,  in  the  fatal  cases,  the  exuda- 
tion is  very  extensive,  involving  the  uvula,  the  soft  palate,  the  posterior 
nares,  and  the  lateral  and  posterior  walls  of  the  pharynx.  These  parts  are 
covered  with  a  dense  pseudo-membrano,  in  places  firmly  adherent,  in 
others  beginning  to  separate.  In  extreme  cases  the  necrosis  is  advanced 
and  there  is  a  gangrenous  condition  of  the  parts.  The  membrane  is  of  a 
dirty-greenish  or  gray  color,  and  the  tonsils  and  palate  may  be  in  a  state 
of  necrotic  sloughing.  The  erosion  may  be  deep  enough  in  the  tonsils  to 
open  the  carotid  artery,  or  a  false  aneurism  may  be  produced  in  the  deep 
tissues  of  the  neck.  The  nose  may  be  completely  blocked  by  the  false 
membrane,  which  may  also  extend  into  the  conjunctivas  and  through  the 
Eustachian  tubes  into  the  middle  ear.  In  cases  of  laryngeal  diphtheria 
the  exudate  in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it 
is  slight  upon  the  tonsils  and  fauces  and  abundant  upon  the  epiglottis  and 
the  larynx,  which  may  be  completely  occluded  by  false  membrane.  In 
severe  cases  the  exudate  extends  into  the  trachea  and  to  the  bronchi  of 
the  third  or  fourth  dimension.  This  occurred  in  nearly  half  of  my  thirty 
Montreal  autopsies. 

In  all  these  situations  the  membrane  varies  very  much  in  consistency, 
depending  greatly  upon  the  stage  at  which  death  has  occurred.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent ;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  off  with  difficulty 
and  leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there 
is  extensive  necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lym- 
phatic glands  of  the  neck  are  enlarged  and  there  is  a  general  infiltration 
of  the  tissues  with  serum ;  the  salivary  glands,  too,  may  be  swollen.  In 
rare  instances  the  membrane  extends  to  the  gullet  and  stomach. 

Histological  Changes. — We  owe  i.^rgely  to  the  labors  of  Wagner,  Weir 


DIPHTHERIA. 


103 


|rort,  and  more  particularly  to  the  splendid  work  of  Oertel,  our  knowledge 
of  tlie  minute  changes  which  take  place  in  diphtheria.  The  following  is 
a  brief  abstract  of  the  views  of  the  last-named  author  : 

The  diphtheritic  poison  induces  first  a  necrosis  or  death  of  cells  with 
wliich  it  comos  in  contact,  particularly  the  superficial  epithelium  and  the 
leucocytes.  The  deeper  cells  of  the  mucosa  and  of  the  other  parts  reached 
by  the  poison  may  also  be  affected.  The  second  change  is  hyaline  trans- 
formation of  the  dead  cells,  or,  as  Weigert  terms  it,  the  production  of  co- 
agiiliition-necrosis.  The  bacilli  excite  inflammation  with  the  migration  of 
leu(!ocytes,  which  are  destroyed  ty  the  poison  and  undergo  the  hyaline 
change.  The  superficial  epithelial  layers  undergo  a  similar  alteration,  and 
what  we^know  as  the  false  membrane  represents  an  aggregation  of  dead 
cells,  most  of  which  have  undergone  the  transformation  into  hyaline  ma- 
teriiil.  This  is  in  all  probability  a  conservative  process  by  which,  in  a 
measure,  the  poison  is  localized  and  prevented  from  reaching  the  deeper 
structures.  The  laminated  condition  of  the  exudate  is  probably  produced 
by  the  inflammation  of  different  layers.  The  formation  of  these  foci  of 
necrobiosis,  starting  from  the  epithelium  and  proceeding  inward,  is,  ac- 
cording to  Oertel,  the  distinguishing  characteristic  of  diphtheria.  The 
action  of  the  poison  is  by  no  means  confined  to  the  superficial  mucosa 
on  which  the  bacilli  grow.  Although  they  do  not  themselves  penetrate 
deeply,  the  contiguous  bronchial  glands  show  extensive  foci  of  necrosis. 
In  severe  cases  these  necrotic  areas  are  found  in  the  internal  organs,  in  the 
solitary  glands  of  the  intestines,  and  in  the  mesenteric  glands. 

The  blood-vessels  may  themselves  be  much  altered  and  the  capillaries 
may  show  extensive  hyaline  degeneration.  Every  one  of  the  histological 
ohanges  described  by  Oertel  in  human  diphtheria  may  be  paralleled  in  the 
experimental  disease  induced  by  the  Klebs-Loeffler  bacillus,  particularly 
the  necrotic  areas  in  the  deep-seated  organs,  associated  in  the  lymph-glands 
with  a  remarkable  fragmentation  of  the  nuclei. 

The  changes  in  the  other  organs  are  variable.  When  death  has  oc- 
oiirrcd  from  asphyxia  there  is  general  congestion  of  the  viscera. 

(Capillary  bronchitis,  areas  of  collapse,  and  patciies  of  broncho-pneu- 
monia are  almost  constantly  found  in  fatal  cases.  In  very  malignant  cases 
the  blood  may  be  fluid.  Fibrinous  coagula  may  be  found  in  the  heart,  but 
the  wide-spread  idea  that  they  may  cause  sudden  death  is  erroneous. 
Myocardial  changes  are  not  infrequent,  and  in  certain  cases  sudden  death 
is  due  to  heart-failure  in  consequence  of  degeneration  of  the  muscle-fibres. 
Kndocarditis  is  extremely  rare.  It  was  not  present  in  one  of  my  thirty 
imtopsios.  The  serous  membranes  often  show  ecchymoses.  The  kidneys 
liroseiit  parenchymatous  changes,  such  as  are  associated  with  acute  febrile 
affections.  There  may,  however,  be  acute  nephritis.  The  spleen  and  liver 
show  the  usual  febrile  changes.  The  spleen  is,  however,  not  always 
enlarged. 

Symptoms. — The  period  of  incubation  varies.  In  the  cases  of  acci- 
8 


N,...  .> 


104 


SPECIFIC  INFECTIOUS  DISEASES. 


,[    ]'    ' 

lgg 

I'r^;    I    "'     '''M| 

1'   'i.   ;              "    ' 

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U\-^% 

1 

i         1 

1      .;:     , 

■ 

dental  inoculation  the  duration  ia  from  two  to  three  days.  In  cases  in 
which  the  disease  is  contracted  in  the  usual  way  it  is  from  seven  to  twelve 
days.  The  initial  syni{)tonKS  are  those  of  an  ordinary  febrile  attack :  slight 
chilliness,  fever,  and  acliing  pains  in  the  back  and  limbs.  In  mild  cases 
these  symptoms  are  trifling,  and  the  child  may  not  feel  ill  enough  to  go 
to  bed.  Usually  the  temperature  rises  to  103"  or  even  more.  There  may 
be  convulsions  at  the  outset.  In  an  attack  of  ordinary  severity  there  is 
at  first  redness  of  the  fauces,  and  the  child  complains  of  slight  difficulty 
in  swallowing.  The  exudate  first  appears  upon  the  tonsils.  It  may  be 
difficult  to  distinguish  the  patchy  diphtheritic  pellicle  from  the  exudate 
in  the  tonsillar  crypts.  Tlie  swelling  of  the  throat  increases  and  the 
glands  of  the  neck  become  involved.  Usually  by  the  third  day  the  mem- 
brane has  covered  the  tonsils,  and  crept  on  to  the  pillars  of  the  fauces,  and 
even  to  the  uvula,  whicli  is  now  thickened  and  (edematous  and  completely 
fills  the  space  between  the  swollen  tonsils.  The  false  membrane  may  ex- 
tend also  to  the  posterior  wall  of  the  pharynx.  At  first  grayish  white  in 
color,  it  changes  to  a  dirty  gray,  often  a  yellowish  gray.  The  membrane 
is  firmly  adherent,  and  if  removed  leaves  a  bleeding,  somewhat  eroded 
surface.  New  membrane  rapidly  forms  in  place  of  that  removed.  The 
general  condition  of  the  patient,  in  a  case  of  moderate  severity,  is  fairly 
good.  The  temperature  is  not  necessarily  high,  and  in  the  absence  of 
complications  the  range  is  from  103°  to  103*. 

At  this  stage,  say  the  fourth  or  fifth  day  of  the  disease,  the  condition 
of  the  child  is  favorable.  The  pulse  and  temperature  are  not  much  above 
100" ;  the  throat  symptoms  are  not  of  extreme  severity ;  and  the  constitu- 
tional depression  is  not  extreme.  The  symptoms  may  then  abate  and  tlie 
swelling  of  the  neck  diminish.  The  false  membrane  separates,  and  by  tlio 
eighth  or  tenth  day  the  throat  is  clear  and  convalescence  begins. 

Deviations  from  this  favorable  course  result  either  from  extension  of 
the  local  disease  or  from  systemic  infection. 

(1)  Extension. — The  inflammation  may  pcss  into  the  posterior  nares, 
obstructing  the  respiration,  causing  a  very  acr  d  and  foetid  discharge,  and 
usually  a  marked  aggravation  of  the  constitutional  symptoms.  The 
glandular  inflammation  is  usually  more  intense;  due,  as  Jacobi  points 
out,  to  the  greater  richness  of  the  nasal  mucosa  in  lymphatics,  which  thus 
favors  systemic  infection.  Though  usually  secondary,  nasal  diphtheria 
may  be  primary.  It  greatly  increases  the  danger  in  any  case.  From  the 
nose  the  inflammation  may  extend  through  the  tear-ducts  to  the  conjunc- 
tivae  and  into  the  antra.  In  these  cases  the  disease  is  more  apt  to 
involve  the  ears,  through  the  Eustachian  tubes,  causing  otitis  media  and 
perforation  of  the  drum. 

Extension  of  the  inflammation  downward  into  the  larynx  is  by  far 
tiie  most  serious  complication  of  the  disease.  It  is  particularly  dangerous 
in  children,  because  it  produces  what  is  known  as  diphtheritic  croup. 
The  symptoms  are  identical  with  those  of  ordinary  membranous  croup. 


DIPllTIIEKIA. 


105 


111  niiiny  instances  the  pharynx  is  but  sliglitly  involved.  There  may  bo 
only  a  trifling  patch  upon  one  tonsil.  The  first  symptoms  of  laryngeal 
alTcction  are  huskiness  of  the  voice,  a  brazen  cough,  and  stridulous,  noisy 
iiisjiiration  and  expiration.  With  increasing  obstruction  the  respiration 
becomes  greatly  embarrassed,  the  lower  thoracic  zone  and  the  lower  ster- 
luiin  are  drawn  in  with  each  inspiration,  and  the  supra-clavicular  and 
iiiteivoHtal  spaces  are  depressed.  Too  often  there  is  a  gradually  deepening 
cyanosis,  and  the  child  dies  asphyxiated. 

'J'lie  exudation  may  extend  into  the  trachea  and  bronchi,  which  become 
lined  by  a  uniform  sheeting  of  false  membrane.  It  is  not  always  easy  to 
siiy,  during  life,  whether  exudation  has  taken  place  into  these  parts.  In 
the  performance  of  tracheotomy,  when  membrane  is  found  in  the  trachea 
the  outlook  is  generally  bad.  Occasionally  the  tracheal  and  bronchial 
membrane  is  coughed  up  as  a  definite  mould. 

{'i)  Systemic  Infection. — In  mild  cases  of  diphtheria  the  constitutional 
disturbance  is  very  slight.  There  may  even  be  extensive  local  disease 
without  great  constitutional  disturbance.  As  a  rule,  however,  the  general 
symptoms  bear  a  definite  proportion  to  the  severity  of  the  local  disease. 
There  are  rare  instances  in  which  from  the  outset,  even  before  the  pharyn- 
geal symptoms  are  at  all  well-marked,  the  constitutional  prostration  is 
extreme,  the  pulse  frequent  and  small,  the  fever  high,  the  nervous  phe- 
nomena are  pronounced ;  and  the  patient  sinks  in  two  or  three  days,  over- 
whelmed by  the  severity  of  the  poison.  In  some  of  these  cases  the  exuda- 
tion is  chiefly  nasal ;  in  others  the  exudation  is  marked,  but  the  throat 
symptoms  are  by  no  means  extensive.  It  is  specially  to  be  noted  that  the 
temperature  may  not  be  raised  ;  it  may  even  be  subnormal.  The  malig- 
nant diphtheria  of  this  kind  is  fortunately  rare.  The  severe  systemic 
symptoms  appear  more  commonly  at  a  later  date,  when  the  pharyngeal 
symptoms  are  at  their  height.  They  are  invariably  met  when  the  disease 
is  extensive  and  when  there  is  a  sloughing  foetid  condition  in  the  pharynx 
causing  an  offensive  odor  of  the  breath.  The  lymphatic  glands  are  greatly 
enlarged ;  the  pallor  is  extreme,  the  color  of  the  face  an  ashen  gray,  the 
pulse  is  rapid  and  feeble,  and  the  temperature  sinks  below  normal.  In 
the  most  aggravated  form  there  are  gangrenous  processes  in  the  throat. 
If  life;  is  prolonged  there  may  even  be  extensive  sloughing  in  the  tissues  of 
the  neck. 


v.; 


There  are,  of  course,  many  variations  in  the  above  clinical  picture. 
The  cases  may  be  so  mild  as  scarcely  to  be  recognized.  Such  cases,  in- 
deed, are  often  mistaken  for  ordinary  lacunar  tonsillitis.  There  are  also 
certain  anomalous  forms  which  may  be  mentioned ;  cases  which  come  on 
insidiously,  with  a  tonsillitis  of  so  mild  a  grade  that  it  may  be  overlooked, 
and  which  is  followed  by  a  diphtheritic  croup  or  a  severe  broncho-pneu- 
monia. In  rare  instances  the  disease  may  almost  be  termed  chronic,  since 
the  membrane  remains  upon  the  tonsils  and  pharynx  for  weeks. 


106 


SPECIFIC   INFECTIOUS   DISEASES. 


|i(;,*,J-..  r^  ..    T 


There  are  instances  in  which  well-cliaracterized  pseudo-membrano 
occurs  on  the  tonsils  and  fauces  without  much  swelling  and  without 
severe  constitutional  disturbance.  A  young  woman  came  to  my  clinic  at 
the  University  Hospital,  Philadelphia,  whose  tonsils,  soft  palate  and 
uvula  were  covered  with  a  smooth,  firm,  grayish-white  pseudo-membrano. 
There  was  little  or  no  swelling  of  the  parts,  the  membrane  was  clean,  its 
edges  were  well  defined,  and  on  removal  of  the  membrane  the  mucosa 
beneath  bled  freely.  The  exudation  had  all  the  characters  of  false  mem- 
brane. The  patient  had  scarcely  any  constitutional  disturbance.  The 
temperature  was  below  100°,  and  she  had  not  felt  ill  enough  to  go  to  bed. 
After  persisting  foi  eight  or  nine  days  the  membrane  was  gradually  re- 
moved, find  she  recovered  without  any  ill  effects.  The  membrane  may 
appear  first  upon  the  mucous  membrane  of  the  mouth,  or  it  may  attai^k 
the  conjunctiva  or  the  external  auditory  meatus.  Occasionally  the  vulvii, 
{)repuce,  or  anus  is  first  attacked.  In  rare  cases  the  skin  is  involved. 
When  the  disease  is  epidemic,  external  wounds  and  abrasions  are  apt  to 
be  infected.  In  recently  delivered  women  the  disease  may  attack  tlie 
u*;erus  or  vulva. 

Complications  and  Sequelae. — Local  complications,  haemorrhage 
from  the  nose  or  throat,  may  occur  in  the  severe  ulcerative  cases.  Skin 
rasi^es  are  not  infrequent,  particularly  the  diffuse  erythema.  Occasion- 
ally there  is  urticaria  and  in  the  severe  cases  purpura.  The  pulmonary 
complications  are  extremely  important.  Fatal  cases  almost  invariably 
show  capillary  bronchitis  with  broncho-pneumonia  and  large  patches  of 
collapse.  In  very  bad  cases,  with  extensive  sloughing,  the  septic  particles 
may  reach  the  bronchi  and  excite  gangrenous  processes  which  may  load 
to  severe  and  fatal  hemorrhage. 

Renal  complications  are  common.  In  my  experience  albuminuria  is 
present  in  all  severe  cases.  It  may  cause  with  the  usual  tests  only  a  slight 
turbidity  of  the  urine,  the  ordinary  febrile  albuminuria.  In  others  there 
is  a  large  amount  of  albumen,  curdy  in  character.  It  is  only  when  the 
albumen  is  in  considerable  quantity  and  associated  with  epithelial  or 
blood  casts  that  the  condition  indicates  parenchymatous  nephritis  and  is 
alarming.  The  nephritis  may  be  quite  early  in  the  disease.  It  sets  in 
occasionally  with  complete  suppression  of  the  urine.  In  comparison  with 
scarlet  fever  the  renal  changes  lead  less  frequently  to  general  dropsy.  In 
the  large  number  of  cases  of  diphtheria  which  came  under  observation  at 
the  Montreal  General  Hospital,  I  call  to  mind  only  one  or  two  instances 
in  which  the  nephritis  was  associated  with  general  anasarca.  Arthritis  is 
an  occasional  complication  just  as  in  scarlet  fever.  Endocarditis,  peri- 
carditis and  pleurisy  are  very  rare  events. 

Of  the  sequelae  of  diphtheria,  paralysis  is  by  far  the  most  important. 
This  can  be  experimentally  produced  in  animals,  as  already  noted,  by  the 
inoculation  of  the  toxic  albumen  produced  by  the  bacilli.  The  paralysis 
occurs  in  a  variable  proportion  of  the  cases,  ranging  from  10  to  15  and 


'S&LM 


DIPHTHERIA. 


107 


evoii  to  20  per  cent.  It  is  strictly  a  sequel  of  the  disease,  coming  on  usu- 
iilh  in  the  second  or  third  week  of  convalescence.  Occasionally  it  conies 
as  <:ii'ly  as  the  seventh  or  eighth  day  of  the  disease.  It  may  follow  very 
miM  cases;  indeed,  the  local  disease  may  be  so  trifling  that  the  onset  of 
tilt'  paralysis  alone  calls  attention  to  the  true  nature  of  the  trouble. 

'I'he  disease  is  a  toxic  neuritis,  due  to  the  absorption  of  the  poison, 
and,  like  other  forms  of  multiple  neuritis,  has  an  extremely  complex 
symptomatology,  according  to  the  nerves  which  are  affected.  The  paraly- 
sis may  be  local  or  general. 

(►f  the  local  paralyses  the  most  common  is  that  which  affects  the 
palate.  Tliis  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return 
of  Ikjuids  through  the  nose,  causes  a  difficulty  in  swallowing.  This  may 
be  the  only  symptom.  The  velum  is  seen  to  be  relaxed  and  motionless, 
aiul  the  sensation  in  it  is  also  much  impaired.  The  affection  may  extend 
to  the  constrictors  of  the  pharynx,  and  deglutition  become  embarrassed. 
Witliiu  two  or  three  weeks  or  even  a  shorter  time  the  paralysis  disappears. 
In  many  cases  the  affection  of  the  palate  is  only,  part  of  a  general  neuritis. 
Of  other  local  forms  perhaps  the  most  common  are  paralysis  of  the  eye- 
muscles,  intrinsic  and  extrinsic.  There  may  be  strabismus,  ptosis,  and 
loss  of  power  of  accommodation.  The  neuritis  may  be  confined  to  the 
nerves  of  one  limb,  though  more  commonly  the  legs  or  the  arms  are  af- 
fected together.  Very  often  with  the  palatal  paralysis  is  associated  a 
weakness  of  the  legs  without  definite  palsy  but  with  loss  of  the  knee-jerk. 

By  far  the  most  important  local  paralysis  is  met  with  in  connection 
witli  the  heart.  There  may  be  great  retardation,  even  to  thirty  beats  in  the 
minute.  Bradycardia  and  tachycardia  may  alternate  in  the  same  patient. 
Heart-failure  and  fatal  syncope  may  occur  at  the  height  of  the  disease  or 
(luring  convalescence.  If  they  occur  during  the  fever,  the  child,  perhaps 
after  an  exaggeration  of  symptoms,  presents  an  unusual  palloi*.  The 
pulse  becomes  weak  and  rapid,  but  may  fall  to  fifty,  forty,  or  even  lower. 
The  extremities  are  cold,  the  temperature  sinks,  and  death  takes  place, 
with  all  the  features  of  collapse,  within  a  few  hours.  More  frequently  the 
fatal  collapse  comes  during  convalescence,  even  as  late  as  the  sixth  or 
seventh  week  after  apparent  recovery.  The  attack  may  set  in  abruptly, 
perhaps  following  a  sudden  exertion.  More  commonly  there  have  been 
sym])toms  pointing  to  disturbed  cardiac  rhythm,  or  even  fainting-spells.  In 
some  instances  vomiting  has  preceded  the  serious  cardiac  attack.  There 
may  be  no  physical  signs  other  than  slight  increase  in  the  cardiac  dulness 
and  a  gallop-rhythm  indicating  dilatation.  These  symptoms  were  formerly 
ascribed  to  cardiac  thrombosis  or  to  endocarditis.  Possibly  in  some  of 
the  cases  the  result  is  due,  as  pointed  out  by  Mosler  and  Leyden,  to  an  in- 
fectious myocarditis,  but  in  a  majority  of  the  cases  tliC  symptoms  are 
probably  due  to  a  neuritis  of  the  cardiac  nerves. 

The  multiple  form  of  diphtheritic  neuritis  is  not  uncommon.  It  may 
begin  with  the  palatal  affection,  or  with  loss  of  power  of  accommodation 


108 


SPECIFIC   INFECTIOUS   DISEASES. 


and  loss  of  tho  tendon  reflexes.  This  last  is  an  important  sign,  which,  as 
liuzzurd  and  R.  L.  MacDonnell  have  shown,  may  occur  early,  but  is  not 
necessarily  followed  by  other  symptoms  of  neuritis.  There  is  paraplegia, 
which  may  be  complete  or  involve  only  the  extensors  of  tho  feet.  Tlus 
(iiaoase  nuxy  extend  and  involve  the  arms  and  face  and  render  the  patient 
(  -.tirely  helpless.  The  muscles  of  respiration  may  be  spared.  The  chitf 
(lunger  in  these  severer  forms  comes  from  the  involvement  of  the  heart 
and  of  the  muscles  of  respiration ;  but  the  outlook  is  in  many  cases  not 
so  bad  as  the  patient's  condition  would  indicate.  Of  thirteen  cases  col- 
lected by  Cadet  de  Gassicourt  six  died.  Tho  sphincters  may  be  involved, 
though  they  are  often  spared. 

Diagnosis. — Early  in  the  disease  it  may  be  difficult  to  distinguish 
diphtheria  from  follicular  tonsillitis.  In  mild  cases  it  is  sometimes  impos- 
sible. In  diphtheria  the  exudation  forms  a  definite,  uniform  patch,  situ- 
ated on  a  deeply  congested  area  of  mucosa.  In  follicular  tonsillitis,  when 
the  exudate  oozes  and  if  the  material  from  the  crypts  coalesces,  it  may  be 
extremely  difficult  to  make  a  diagnosis.  If  the  process  is  confined  to  tlio 
tonsil^the  nature  of  the  case  may  be  dubious.  If,  however,  it  extends  to 
the  pillars  of  the  fauces  and  if  laryngeal  symptoms  develop,  all  doubts  arc 
removed.  Occasionally  the  true  character  of  the  disease  is  not  manifested 
until  a  paralysis  develops  during  convalescence.  It  is  in  these  cases  that 
the  detection  of  the  Klebs-Loeffler  bacillus  will  be  of  the  greatest  service 
in  making  clear  the  diagnosis.  Cover-glass  preparations  may  be  made 
from  the  membrane.  Cultures  should  be  made  in  the  blood-serum  ami 
bouillon  mixture,  and  inoculations  performed  on  animals.  Unfortunately, 
these  procedures  can  scarcely  be  carried  out  except  in  well-equipped  labora- 
tories, and  a  ready  and  certain  clinical  method,  such  as  we  have  for  the 
tubercle  bacillus,  is  not  yet  available. 

Between  diphtheritic  laryngitis  and  croup  a  majority  of  writers  now 
hold  that  there  is  no  essential  difference ;  but  it  is  more  rational  to  believe 
that  there  is  a  non-specific  pseudo-membranous  laryngitis.  This  is  a 
point,  too,  which  bacteriology  may  be  able  to  clear  up.  In  several  cases 
which  have  been  examined  the  Loeffler  bacillus  has  been  present.  The 
diagnosis  between  the  two  conditions  is  by  no  means  easy.  In  the  diph- 
theritic form,  however,  there  is  almost  invariably  exudation  upon  the  ton- 
sils or  soft  palate.  Between  scarlet  fever  and  diphtheria  there  may  be 
some  confusion     The  question  has  already  been  discussed. 

The  recognition  of  the  diphtheritic  paralysis  offers  no  difficulties. 

Prognosis. — In  hospital  practice  the  disease  is  very  fatal,  owing 
largely  to  the  fact  that  only  the  severer  forms  are  admitted.  In  country 
places  epidemics  may  display  an  appalling  virulence  and  kill  nearly  all 
the  children  attacked.  In  cases  of  ordinary  severity  the  outlook  is  usually 
good.  Death  results  from  involvement  of  the  larynx,  septic  infection, 
sudden  heart-failure,  diphtheritic  paralysis,  occasionally  from  ursemia,  and 
sometimes  from  broncho-pneumonia  developing  in  the  convalescence. 


BlPHTnERIA. 


109 


Treatment. — Prophylaxis. — Cases  of  diphtheria  should  invuriubly 
bo  isolated.  Physicians  sliouid  insist  that  other  chiklren  in  the  family  bo 
kt'iil  from  school  and  from  mingling  with  their  schoolmates.  All  cloth- 
ing and  utensils  wh'ch  have  been  used  by  the  patient  shoii'  1  be  thoroughly 
dii'iiifected.  For  t..  3  purpose  the  clothing  may  be  soaked  for  twenty-four 
hours  and  then  boiled  in  a  two-per-cent  carbolic  solution.  For  disinfecting 
the  room  sulphur  fumigation  may  be  employed,  taking  care  that  the  air  is 
rciidi'red  moist,  or  the  floor  and  walls  should  be  thoroughly  scoured  with 
corrosive-sublimate  solution. 

Caille  has  urged  the  importance  of  a  careful  inspection  of  the  tonsils 
and  mouth  in  children,  special  attention  being  paid  to  the  care  of  the 
tt'L'tli  and  to  the  tonsils,  which,  if  swollen  and  irregular,  should  be  re- 
moved. In  persons  liable  to  exposure  Loeffler  recommends  the  use  of 
antiseptic  mouth-washes,  such  as  sublimate  (1  to  10,000),  chlorine-water 
(I  to  1,100),  or  thymol.  After  recovery  at  least  two  weeks  should  elapse 
bi'forc  the  child  is  permitted  to  mingle  with  others  or  to  return  to  school. 

Recently  it  has  been  announced  that  the  blood-serum  of  animals  ren- 
dered secure  against  the  diphtheritic  bacillus  and  its  products  can  nullify 
tlie  elfects  of  the  poison  of  diphtheria. 

General  Treatment, — The  two  indications  in  the  treatment  of  dij)hthe- 
ria  are  to  prevent  or  limit  the  local  development  of  the  bacilli  and  to  com- 
bat tlie  effects  of  the  toxic  materials  which  they  produce. 

The  usual  measures  should  be  employed  to  insure  thorough  cleanli- 
ness and  ventilation  and  to  diminish  the  danger  of  infection.  The  air 
should  be  kept  moist  with  steam.  Mild  cases  require  but  little  treatment. 
A  fair  quantity  daily  of  liquid  food,  with  ice  to  suck,  and  a  gargle  of  chlo- 
rate of  potash  are  sufficient.  In  more  severe  cases  the  greatest  care  should 
be  taken  to  maintain  the  strength  of  the  patient.  The  food  should  be 
given  at  stated  intervals.  Stimulants  will  be  required  early  and  should  be 
given  freely.  In  very  young  children  Avith  the  pharyngeal  involvement 
swallowing  is  painful,  and  the  giving  of  food  by  the  mother  or  nurse  is  a 
continuous  struggle.     In  such  instances  nutritive  enemata  should  be  used. 

We  are  still  without  a  remedy  capable  of  combating  in  any  way  the 
effects  of  the  poisonous  tox-albumins.  Two  remedies  are  warmly  recom- 
mended—the tincture  of  the  perchloride  of  iron,  which  may  be  given  hourly 
in  four  or  five  drop  doses  to  a  child  of  three,  and  the  corrosive  sublimate, 
of  which  a  child  a  year  old  may  take  as  much  as  half  a  grain  a  day.  Per- 
sonally, I  much  prefer  the  perchloride  of  iron ;  and  I  cannot  say  that  I 
have  seen  from  the  mercury,  given  either  as  the  bichloride  or  as  calomel, 
tlie  specially  good  effects  which  many  writers  describe.  I  have  not  seen 
any  good  follow  the  administration  of  the  sulphides  or  the  benzoates  or 
quinine  in  large  doses.  Peroxide  of  hydrogen  has  been  warmly  recom- 
mended. 

Local  Treatment. — Diphtheria  is  a  local  disease  at  first,  and  by  the 
production  of  poisonous  substances  causes  the  severe  systemic  symptoms. 


.;  1 


»!  -it 


til  4 

:l  "i 


H  % 


( 


no 


SPECIFIC  INFECTIOUS  DISEASES. 


Hence  the  importance  of  local  treatment.  It  ia  not  well  to  attempt  forcibly 
to  remove  the  false  membranes,  though  some  writers  recommend  that  they 
should  be  scraped  off.  As  far  as  possible  thorough  cleanliness  and  disin- 
fection of  the  fauces  should  be  insured  by  repeatedly  spraying,  either  witli 
carbolic  acid,  corrosive  sublimate  (two  grains  to  the  pint),  chlorinc-wator, 
boric  acid,  Condy's  fluid,  salicylic  acid  or  peroxiile  of  hydrogen  (50  per 
cent  solution),  or  local  application  of  sulphur  with  iodoform  is  recom- 
mended. The  tonsils  and  fauces  may  be  thoroughly  swabbed  every  hour 
or  two  with  a  solution  of  carbolic  acid  (iTlxv)  and  perchloride  of  iron 
(  3  ijss.)  in  glycerin  ( 1  j)  and  water  (  5  j).  Agents  which  are  believed  to 
dissolve  the  membrane  are  lactic  acid,  which  may  be  employed  with  lime- 
water  (two  drachma  to  six  ounces)  and  trypsin  (thirty  grains  to  tlio 
ounce). 

Pepsin  has  also  been  used,  and  the  vegetable  pepsin,  which  may  be 
mixed  with  water  and  glycerin. 

Nasal  diphtheria  requires  prompt  and  thorough  disinfection  of  the 
passages.  'J'he  best  solutions  are  those  recommended  by  Jacobi — chloride 
of  sodium,  saturated  boric  acid,  or  one  part  of  bichloride  of  mercury, 
thirty-five  of  chloride  of  sodium,  and  one  thousand  of  water,  or  the  one  per 
cent  solution  of  carbolic  acid.  The  solution  may  be  applied  with  a  syr. 
inge  or  a  spniy.  To  be  effectual  the  injection  must  be  properly  given. 
The  nurse  should  be  instructed  to  pass  the  nozzle  of  tlie  syringe  horizon- 
tj'liy,  not  vertically ;  otherwise  the  fluid  will  return  through  the  same  nos- 
tril. In  refractory  children  there  is  sometimes  great  difficulty  in  givinj; 
these  injections,  in  which  case  suppositories  of  boric  acid  may  be  em- 
ployed, but  they  are  not  efficient  substitutes. 

When  the  larynx  becomes  involved  a  steam  tent  may  be  arranged  upon 
the  bed,  so  that  the  child  may  breathe  an  atmosphere  saturated  with  moist- 
ure. If  the  dyspnoea  becomes  urgent,  an  emetic  of  sulphide  of  zinc  or 
ipecacuanha  may  be  given.  When  the  signs  of  obstruction  are  marked, 
however,  there  should  be  no  delay  in  the  performance  of  intubation  or 
tracheotomy.  The  diphtheritic  paralysis  requires  rest  in  bed,  and  the  avoid- 
ance of  sudden  exertion,  particularly  in  those  cases  in  which  the  heart- 
rhythm  is  disturbed.  In  the  chronic  forms  with  wasting,  massage,  elec- 
tricity and  strychnine  are  invaluable  aids.  If  swallowing  becomes  very 
difficult,  the  patient  must  be  fed  with  the  stomach -tube,  which  is  very 
much  preferable  to  feeding  per  rectum. 


r  1= 

I- 

liilL 


1; 


XVI.   ERYSIPELAS. 

Deflnition. — An  acute,  contagious  disease,  characterized  by  a  special 
inflammation  of  the  skin  caused  by  streptococci. 

Etiology. — Erysipelas  is  a  wide-spread  affection,  endemic  in  most 
communities,  and  at  certain  seasons  epidemic.     We  are  as  yet  ignorant  of 


ERYSIPELAS. 


Ill 


the  atmospheric  or  telluric  influences  which  favor  the  diffusion  of  the 
jioison. 

It  is  particularly  prevalent  in  the  spring  of  the  year.  This  was  very 
notit'cable  in  the  I'hiladelphia  Hospital,  in  which  the  erysipelas  wards 
were  usually  empty  except  in  the  spring  and  autumn  niunths.  The  affec- 
tion prevails  extensively  in  old  ill-ventilated  hospitals  and  institutions  in 
wliich  the  sanitary  conditions  arc  defective.  With  the  improved  sanita- 
tion of  late  years  the  number  of  cases  has  materially  diminished.  It  has 
bi't'ii  observed,  however,  to  break  out  in  new  institutions  under  the  most 
favoriible  hygienic  circumstances.  Erysijjclas  is  both  contagious  and  in- 
ociilablo;  but,  except  under  special  conditions,  the  poison  is  not  very 
virulent  and  does  not  seem  to  act  at  any  great  distance.  It  can  be  con- 
veyed by  a  third  person.  The  poison  certainly  attaches  itself  to  the  fur- 
niture, bedding,  and  walls  of  rooms  in  which  patients  have  been  confined. 

Tlie  disposition  to  the  disease  is  wide  spread,  but  the  susceptibility  is 
speeiidly  marked  in  the  case  of  individuals  with  woun<ls  or  abrasions  of 
any  sort.  Recently  delivered  women  and  persons  who  have  been  the  sub- 
ject of  surgical  operations  are  particularly  prone  to  it.  A  wound,  how- 
ever, is  not  necessary,  and  in  the  so-called  idiopathic  form,  although  it 
may  be  difficult  to  say  that  there  was  not  a  slight  abrasion  about  the  nose 
or  lips,  in  very  many  cases  there  certainly  is  no  observable  external  lesion. 

Chronic  alcoholism,  debility,  and  Bright's  disease  are  predisposing 
agents.  Certain  persons  show  a  special  susceptibility  to  the  disesise,  and 
it  may  recur  in  them  repeatedly.  There  are  instances,  too,  of  a  family 
predisjiosition  to  the  disease. 

The  specific  agent  of  the  disease  appears  to  be  a  streptococcus  which 
has  been  very  thoroughly  studied  by  Koch  and  Fehleisen.  It  was  believed 
at  first  to  have  specific  and  peculiar  morphological  properties,  but  it  is  now 
generally  held  that  it  cannot  be  distinguished  by  any  biological  or  chem- 
ical tests  from  the  streptococcus  pyogenes. 

Morbid  Anatomy. — Erysipelas  is  a  simple  inflammation.  In  its 
uncomplicated  forms  there  is  seen,  post  mortem,  little  else  than  inflamma- 
tory o'dema.  Investigations  have  shown  that  the  cocci  are  found  chiefly 
in  the  lymph-spaces  and  most  abundantly  in  the  zone  of  spreading  inflam- 
mation. In  the  uninvolved  tissue  beyond  the  inflamed  margin  the  mi- 
crococci are  to  be  found  in  the  lymph-vessels,  and  it  is  here,  according  to 
Metsclinikoff  and  others,  that  an  active  warfare  goes  on  between  the  leuco- 
cytes and  the  cocci  (phagocytosis).  In  moi*e  extensive  and  virulent  forms 
of  the  disease  there  is  usually  suppuration.  It  is  stated  that  the  inflam- 
mation may  pass  inward  from  the  scalp  through  the  skull  to  the  meninges. 
This  I  have  never  seen,  but  in  one  case  I  traced  the  extension  from  the 
face  ah)ng  the  fifth  nerve  to  the  meninges,  where  an  acute  meningitis  and 
thrombosis  of  the  lateral  sinus  were  excited. 

The  visceral  complications  of  erysipelas  are  numerous  and  important. 
The  iruijority  of  them  are  of  a  septic  nature.    Infarcts  occur  in  the  lungs, 


I 


112 


SPECIFIC   INFECTIOUS   DISEASES. 


spleen,  and  kidneys,  and  there  may  be  the  general  evideneos  of  pyncniic 
infection. 

vSonie  of  the  worst  cases  of  nuUignant  cndo(tarditis  are  secondary  lo 
erysij)elas;  thus  of  twenty-three  cases  tl»ree  occurred  in  connection  witii 
tiiis  disease.     Septic  pericarditis  and  [)leiiritis  also  occiiir. 

As  just  mentioned,  the  disease  nuiy  in  rare  cases  extend  and  involve; 
the  meiuufjfes.     I'neumonia  is  not  a  very  common  comj)licati()n. 

Acute  n('j)hritis  is  also  met  with.  It  is  often  ingrafted  u])on  an  old 
chronic  trouble. 

Symptoms. — The  following  description  applies  specially  to  erysipeliis 
of  the  fa(!e  and  head,  the  form  of  the  disease  which  the  physician  is  mofit 
commonly  called  u])on  to  treat. 

The  incubalioH  is  variable,  probably  from  tliree  to  seven  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a 
rapid  rise  in  the  temperature  and  all  the  characters  of  an  acute  fevir. 
When  there  is  a  local  abrasion,  the  spot  is  slightly  reddened ;  but  if  it  is 
idiopathic,  there  is  seen  within  a  few  hours  slight  i-edness  over  the  bridge 
of  the  nose  and  on  the  cheeks.  The  swelling  and  tension  of  the  skin 
increase  and  within  twenty-four  liours  the  external  symptoms  are  well 
marked.  The  skin  is  smooth,  tense,  and  anlematous.  It  looks  red,  feels 
hot,  and  the  superficial  layers  of  the  epidermis  may  be  lifted  as  small 
blebs.  The  patient  complains  of  an  unpleasant  feeling  of  tension  in  the 
skin  ;  the  swelling  rapidly  increases  ;  and  during  the  second  day  the  eyes 
are  usually  closed.  The  first-affected  parts  gradually  become  pale  and 
less  swollen  as  the  disease  extends  at  the  periphery.  When  it  reaches  the 
forehead  it  progresses  as  an  advancing  ridge,  perfectly  well  defined  and 
raised ;  and  often,  on  palpation,  hardened  extensions  can  be  felt  beneath 
the  skin  which  is  not  yet  reddened.  Even  in  a  case  of  moderate  severity, 
the  face  is  enormously  swollen,  the  eyes  are  closed,  the  lids  greatly 
cedematous,  the  ears  thickened,  the  scalp  is  swollen,  and  the  patient's 
features  are  quite  unrecognizable.  The  formation  of  blebs  is  common  on 
the  eyelids,  ears,  and  forehead.  The  cervical  lymph-glands  are  swollen, 
but  are  usually  masked  in  the  oedema  of  the  neck,  'the  temperature  keeps 
high  without  marked  remissions  for  four  or  fivo  days  and  then  deferves- 
cence takes  place  by  crisis.  The  general  condition  of  the  patient  varies 
much  with  his  previous  condition  of  health.  Jn  old  and  debilitated  per- 
sons, particularly  in  those  addicted  to  alcohol,  the  constitutional  depression 
from  the  outset  may  be  very  great.  Delirium  is  present,  the  tongue  be- 
comes dry,  the  pulse  feeble,  and  there  is  marked  tendency  to  death  from 
toxaemia.  In  the  majority  of  cases,  however,  even  with  extensive  disease, 
the  constitutional  disturbance,  considering  the  height  of  the  fever  range, 
is  slight.  The  mucous  membrane  of  the  mouth  and  throat  may  be  swollen 
and  reddened.  The  erysipelatous  inflammation  may  extend  to  tlie  larynx, 
but  the  severe  oedema  of  this  part  occasionally  met  with  is  commonly 
due  to  extension  of  the  inflammation  from  without  inward. 


E11YS1I»KT.AS. 


113 


Tlioro  aro  oases  in  which  the  infliimmiition  extends  from  the  fiico  to  the 
iioik,  and  over  the  ciiest,  iind  may  j,'radually  mi;,'rate  or  wander  over  tlie 
irrujitcr  part  of  the  hody  (A*,  mi(irnns). 

Tiio  close  rehition  between  the  erysipelas  coceus  and  the  pus  or;,'anism8 
JH  shown  by  the  frequency  with  which  suppuration  occurs  in  facial  cry- 
sijK'liis.  Small  cutaneous  abscesses  aro  common  about  tlio  cheeks  and 
forehead  and  neck,  and  beneath  the  scalp  larj^o  coUecrtions  of  pus  may  ac- 
(Uiiiuliite.  Suppuration  seems  to  occur  more  frequently  in  some  epidemics 
tliiiu  ill  others,  and  at  the  Philadelphia  Hospital  one  year  nearly  all  the 
cases  in  the  erysipelas  wards  presented  local  abscesses. 

Complications. — Meningitis  is  rare.  Tlio  cases  in  which  death 
ocpurs  with  marked  brain  symptoms  do  not  usually  show,  post  mortem, 
iiii'iiiiigeal  affection.  The  delirium  and  coma  aro  duo  to  the  fever,  or  to 
toxivniia. 

I'liounumia  is  an  occasional  complication.  IJlcerativo  endocarditis 
iind  scpticiemia  are  more  common.  Albuminuria  is  a! most  constant, 
jiiirtii'ularly  in  persons  over  fifty.  True  nephritis  is  occasiomdly  seen. 
Dh  (!osta  has  called  attention  to  curious  irregular  returns  of  the  fever 
wliicli  occur  during  convalescence  without  any  aggravation  of  the  local 
coiulition. 

Tlie  diagnosis  rarely  presents  any  difficulty.  The  mode  of  onset,  the 
rapid  rise  in  fever,  and  tho  characters  of  the  local  disease  aro  quite  dis- 
tinctive. Acuto  necrosis  of  bone  may  sometimes  be  regarded  as  erysipelas, 
a  mistake  which  I  once  saw  made  in  connection  with  the  lower  end  of  tho 
femur. 

Frogntiosis. — Healthy  adults  rarely  die.  In  the  new-born,  when  the 
disease  attacks  the  navel,  it  is  almost  always  fatal.  This  is  probably  an 
acute  septic  infection.  In  alcoholic  subjects  and  in  the  aged  erysipelas  is 
a  serious  affection,  and  death  may  result  either  from  the  intensity  of  the 
fever  or,  more  commonly,  from  toxaemia.  Tho  wandering  or  ambulatory 
erysipelas,  which  has  a  more  protracted  course,  may  cause  death  from 
exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in 
hospitals.  A  practitioner  in  attendance  ujion  a  case  of  erysi])eLis  .should 
not  attend  cases  of  confinement. 

The  disease  is  self-limited  and  a  large  majority  of  tho  cases  get  well 
without  any  internal  medication.  I  can  speak  definitely  on  this  point, 
having,  at  the  Philadelphia  Hospital,  treated  many  cases  in  this  way.  The 
diet  slionld  be  nutritious  and  light.  Stimulants  are  not  required  except 
in  tlie  old  and  feeble.  For  the  restlessness,  delirium,  and  insomnia,  chloral 
or  the  bromides  may  be  given;  or,  if  these  fail,  opium.  When  fever  is 
high  the  patient  may  be  bathed  or  sponged,  or,  in  private  practice,  if  there 
is  an  objection  to  this,  antipyrin  or  antifebrin  may  bo  given. 

Of  internal  remedies  believed  to  influence  the  disease,  the  tincture  of 
the  perchlorido  of  iron  has  been  highly  recommended.     At  the  Montreal 


t    i 


114 


SPECIFIC  INFECTIOUS  DISEASES. 


General  Hospital  this  wiis  the  routine  treatment,  and  doses  of  half  a 
drachm  to  a  drachm  were  given  every  three  or  four  hours.  I  am  hy  no 
means  convinced  that  it  has  any  special  action ;  nor,  so  far  as  I  know,  luvs 
any  medicine,  given  internally,  a  definite  control  over  the  course  of  the 
disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin 
of  the  spreading  areas  lias  been  much  practised.  Two  per  cent  solutions 
of  carbolic  acid,  the  corrosive  sub] 'mate  and  the  biniodide  of  mercury 
have  been  much  used.  The  injection  should  be  made  not  into  but  just 
a  little  beyond  the  border  of  the  inflamed  patch.  F.  P.  Henry  has  treated 
a  large  number  of  cases  at  the  I'hiladelphia  Hospital  with  die  latter  drug, 
and  this  mode  of  practice  is  certainly  most  rational. 

Of  local  applications,  ichthyol  is  at  present  much  used.  The  inflamed 
region  may  be  covered  with  salicylate  of  starch.  Perhaps  as  good  an  ai)pli- 
catiou  as  any  is  cold  water,  which  was  highly  recommended  by  Hippocrates. 


XVII.  SEPTICEMIA  AND  PYyEMIA. 

1.  SEPTICEMIA. 

Definition. — A  general  febrile  infection,  without  foci  of  supi)uriir 
tion,  which  results  from  the  absorption  of  toxic  materials  produced  bv 
bacteria.  The  organisms  producing  septicaemia  are,  as  a  rule,  those  of 
suppuration — namely,  the  forms  of  streptococci  and  staphylococci. 

Clinical  Forms.* — (a)  Fermentation  Fever. — This  is  also  known  as  tliu 
resorption  fever,  aseptic  fever,  or  after  fever,  and  is  the  simplest  of  all  wound 
complications.  It  is  the  febrile  process  which  is  produced  after  transfusion 
or  the  injection  of  pepsin  into  tlie  blood.  The  term  fermentation  fever 
was  employed  by  Bergman,  as  he  held  that  it  was  caused  by  the  absorption 
of  the  fibrin  ferments.  This  fever  may  follow  an  injury  or  operation,  jiar- 
ticularly  if  tliere  has  been  necrosis  of  the  superficial  tissues  by  the  .solu- 
tions used  in  the  dressing.  It  may  also  follow  the  extravasation  of  blood, 
particularly  when  under  pressure  or  tension. 

The  fever,  which  appears  a  few  hours  after  the  injury  or  operation,  is 
not  preceded  by  a  chill.  It  usually  reaches  its  height  rapidly,  sometimes 
rising  to  103°  or  104°.  The  constitutional  disturbance  is  not  great,  jind 
it  subsides  spontaneously  in  from  one  to  three  days.  This  form  is  ranked 
as  a  septicemia,  since  the  ferment  acts  in  a  manner  similar  to  the  toxins 
produced  by  micro-organisms.  It  is  not  yet  certain  that  bacteria  do  not 
play  an  important  part  in  its  production. 

(ft)  Saprmmia. — This  is  a  septic  intoxication  caused  by  the  ptoniiiitiex 
produced  in  wounds  by  the  putrefactive  bacteria.  There  are  various  fornif! 
of  these  organisms ;  some  are  bacilli,  others  belong  to  the  proteus  group. 

*  I  follow  here  the  division  in  Senn's  Principles  of  Surgery. 


SEPTICEMIA  AND   PY.EMIA. 


115 


In  their  growth,  chemical  poisons  (toxins)  are  produced,  and  under  the 
term  saprajmia  is  included  the  group  of  symptoms  caused  by  the  absorp- 
tion of  these  toxins  from  any  local  focus  of  putrefaction. 

'Die  symptoms  vary  with  the  dose  absorbed.  Twei\ty-four  hours,  or 
later,  after  the  injury  or  operation  a  chill  initiates  the  constitutional  dis- 
tiirbiuice ;  the  fever  rises  rapidly,  reaching  103°  or  104°  ;  the  pulse  is  quick, 
iiml  there  may,  in  severe  cases,  be  great  prostration.  Nervous  symptoms 
are  common — headache,  restlessness,  and  delirium.  Tije  tongue  is  dry, 
often  glazed,  and  there  may  at  first  be  gastric  irritation.  The  clinical 
picture  is  that  of  a  severe  infection.  Three  conditions  must  be  present  in 
this  form  of  sepsis — dead  tissue,  infection  of  this  dead  tissue  with  putre- 
factive bacteria,  and  a  sufficient  time  to  have  enabled  the  putrefactive 
!)acteria  to  produce  a  toxic  quantity  of  ptomaines  (Senn).  The  necrotic 
tissue  may  be  the  blood-clot  in  a  wound,  the  tissues  in  the  interior  of  the 
uterus  after  parturition,  or  tissues  bruised  and  rendered  necrotic  by  injury 
or  by  the  action  of  cold,  heat,  or  chemical  substances. 

The  outlook  in  saprjemia  depends  much  upon  the  dose  of  the  poison 
wliicli  has  been  absorbed  and  the  possibility  of  removing  and  cleansing 
the  infected  focus. 

(r)  Progressive  Septicmmia. — In  this  the  septic  intoxication  is  not  the 
result  of  the  bacteria  of  putrefaction,  but  organisms  enter  the  blood  from 
some  local  septic  focus.  "  The  intoxication  in  this  form  of  sepsis  is  not 
only  caused  by  ptomaines  which  are  produced  at  the  primary  seat  of  in- 
fection, but  jjtomaines  are  also  produced  in  the  blood  by  the  microbes 
which  it  contains "  (Senn).  The  pus  microbes  are  the  most  frequent 
(inuse  of  this  form  of  septicaemia,  and  reach  the  blood  either  through  the 
wall  of  the  blood-vessels  or  through  the  lymph-channels. 

The  clinical  features  of  this  form  are  well  seen  in  the  cases  of  puerpe- 
ral septicaemia  or  in  dissection  wounds,  in  which  the  course  of  the  infec- 
tion may  be  traced  along  the  lymi)hatics.  The  symptoms  usually  set  in 
within  twenty-four  hours,  and  rarely  later  than  the  third  or  fourth  day. 
There  is  a  chili  or  chilliness,  with  moderate  fever  at  first,  which  gradually 
rises  and  is  marked  by  daily  remissions  and  even  intermissions.  The  pulse 
is  small  and  compressible,  and  may  reach  120  or  higher.  Gastro-intesti- 
nal  disturbances  are  common,  the  tongue  is  red  at  the  margin,  and  the 
dorsum  is  dry  and  dark.  There  may  be  early  delirium  or  marked  mental 
prostration  and  apathy.  As  the  disease  progresses  there  may  be  pallor  of 
the  face  or  a  yellowish  tint.     Capillary  haemorrhages  are  not  uncommon. 

The  outlook  is  always  serious.  In  severe  cases  death  may  occur  within 
twenty-four  hours,  and  in  fatal  cases  life  is  rarely  prolonged  for  more  than 
seven  or  eight  days.  On  post-mortem  examination  there  may  be  no  focal 
lesions  in  the  viscera,  and  the  seat  of  infection  may  present  only  slight 
changes.  The  spleeii  is  enlarged  and  soft,  the  blood  may  be  extremely 
'lurk  in  color,  and  haemorrhages  are  common,  particularly  on  the  serous 
surfaces.     Neither  thrombi  nor  emboli  are  found. 


'?    n 


116 


SPECIFIC  INFECTIOUS  DISEASES. 


2.    PYJ5MIA. 


Deflnition. — A  general  disease,  characterized  by  recurring  chills  and 
intermittent  fever  and  the  formation  of  abscesses  in  various  parts,  all  (if 
which  result  from  the  contamination  of  the  blood  by  products  arisiii;,' 
from  a  focus  contaminated  by  the  bacteria  of  suppuration. 

Etiology. — As  a  rule,  the  disease  follows  extension  of  suppuration 
about  a  wound  or  the  collection  of  pus  in  some  part.  It  was  thought  at 
first  that  the  pus  itself  was  taken  up  by  the  blood.  Virchow  showed  tlie 
important  part  played  by  thrombosis  and  embolism.  The  works  of  Lis- 
ter, Klebs,  Pasteur,  Koch,  and  others  have  demonstrated  the  important 
role  of  micro-organisms  in  the  disease.  The  pus  microbes  are  the  strepto- 
coccus pyoge}ies  and  forms  of  staphylococci.  The  streptococcus  is  must 
frequently  found  in  the  pus  at  the  primary  seat  and  in  the  metastatic 
abscesses. 

The  process  which  takes  place  is  as  follows :  In  a  suppurating  wohikI, 
for  example,  the  pus  organisms  induce  coagulation-necrosis  in  the  smaller 
vessels  with  the  production  of  thrombi  and  purulent  phlebitis.  The  en- 
trance of  pus  organisms  in  small  numbers  into  the  blood  does  not  neces- 
sarily produce  pyemia.  Commonly  the  transmission  to  various  parts 
from  the  local  focus  takes  place  by  the  fragments  of  thrombi  which  pass 
as  emboli  to  different  parts,  where  if  the  conditions  are  favorable  the  pus 
organisms  excite  suppuration.  A  thrombus  which  is  not  septic  or  con- 
taminated, when  dislodged  and  impacted  in  a  distant  vessel,  produces  only 
a  simple  infarction;  but,  coming  from  an  infected  source  and  containiii<r 
pus  microbes,  an  independent  centre  of  infection  is  established  wherever 
the  embolus  may  lodge.  These  independent  suppurative  centres  in  pyaf- 
mia,  known  as  embolic  or  metastatic  abscesses,  have  the  following  distri- 
bution : 

(a)  In  external  wounds,  in  osteo-myelitis,  and  in  acute  phlegmon  of 
the  skin,  the  embolic  particles  very  frequently  excite  suppuration  in  the 
lungs,  producing  the  well-known  wedge-shaped  pyaemic  infarcts ;  but  in 
some  cases  the  infected  particles  pass  through  the  lungs,  and  there  are  foci 

>'  inflammation  in  the  heart  and  kidneys. 

(b)  Suppurative  foci  in  the  territory  of  the  portal  system,  particularly 
in  the  intestines,  produce  metastatic  abscesses  in  the  liver  with  or  without 
suppurative  pyle-phlebitis. 

(c)  An  itoresting  form  of  medical  pyaemia  is  produced  by  malignant 
endocarditis — the  arterial  pyaemia  of  VVilks — in  which,  as  a  result  of  in- 
flammation of  the  endocardium  (either  secondary  to  suppurative  disease 
elsewhere,  or  following  the  infection  of  pneumonia  or  of  certain  general 
diseases),  showers  of  infected  thrombi  are  conveyed  from  the  vegetations 
in  the  left  heart  and  produce  multiple  abscesses  in  the  spleen,  kidneys, 
intestines,  brain,  and  even  in  the  skin. 

{d)  There  are  cases  of  so-called  idiopathic  pymmia  in  which  the  ini- 


SEPTICEMIA  AND  PYJ^MIA. 


117 


marv  focus  of  the  disease  is  not  apparent,  but  in  which  there  are  multiple 
abscesses  in  various  parts  of  the  body. 

Symptoms. — In  a  case  of  wound  infection,  prior  to  the  onset  of  the 
characteristic  symptoms,  there  may  be  signs  of  local  trouble,  and,  if  a 
iliscluirging  wound,  the  pus  may  change  in  character.  The  onset  of  the 
disease  is  marked  by  a  severe  rigor,  during  which  the  temperature  rises  to 
103°  or  104°  and  is  followed  by  a  profuse  sweat.  These  chills  are  repeated 
at  intervals,  either  daily  or  every  other  day.  In  the  intervals  there  may 
be  slight  pyrexia.  The  constitutional  dibtiirbunce  is  marked  and  there 
are  loss  of  appetite,  nausea,  and  vomiting,  and,  as  the  disease  progresses, 
rapid  loss  of  flesh.  Transient  erythema  is  not  uncommon.  Local  symp- 
toms usually  develop.  If  the  lungs  become  involved  there  are  dyspnoea 
and  cough.  The  physical  signs  may  be  slight.  Involvement  of  the  pleura 
and  pericardium  is  common.  The  tint  of  the  skin  is  changed ;  at  first 
pale  and  white,  it  subsequently  becomes  bile-tinged.  The  spleen  is  en- 
larged, and  there  may  be  intense  pain  in  the  side,  pointing  to  perisplenitis 
from  embolism.  Usually  in  the  rapid  cases  a  typhoid  state  is  gradually 
devolcpefi,  ''ud  the  patient  dies  comatose. 

I'l    he  Aid  cases  the  disease  may  be  prolonged  for  months ;  the 

chills  1  cui  at  long  intervals,  the  temperature  is  irregular,  and  the  condi- 
tion of  the  patient  varies  from  month  to  month.  The  course  is  usually 
slow  and  progressively  downward. 

Diagnosis. — Pyaemia  is  a  disease  frequently  overlooked  and  often 
mistaken  for  other  affections. 

Cases  following  a  wound,  an  operation,  or  parturition  are  readily  rec- 
ognized. On  the  other  hand,  the  following  conditions  may  be  over- 
looked : 

OKtco-myelitis. — Here  the  lesion  may  be  limited,  the  constitutional 
symptoms  severe,  and  the  course  of  the  disease  very  rapid.  I  recall  two 
instances  in  Avhich  the  actual  cause  of  the  trouble  was  discovered  only  at 
the  post-mortem. 

So,  too,  acute  st  .i:c  if  'ection  may  follow  gonorrhcea  or  a  prostatic 
ukcfiss. 

Cases  are  somei,;Er.o3  -if Mounded  with  ///p7io/rf /ever,  particularly  the 
more  chronic  instances,  k  vhich  there  are  diarrhea,  great  prostration, 
delirium,  and  irregular  fever.    The  spleen,  too,  may  be  enlarged. 

In  some  of  '''e  instances  of  ulcerative  eiuiocarditis  the  diagnosis  is 
very  difficult,  particularly  in  wha  is  known  as  the  typhoid  type  of  this 
disease,  in  contradistinction  to  the  septic.  In  acute  miliary  tuberculosis 
the  symptoms  occasionally  resemble  those  of  septicsemia,  more  commonly 
liioso  of  typhoid  fever. 

'T\\G post-febri'-  arthritides,  such  as  occur  after  scarlet  fever  and  gon- 
orrhcea, are  reali  a"  lances  of  mild  septic  infection.  The  joints  may 
sometimes  proceed  x  appuration  and  pyaemia  develop.  So,  also,  in  tuber- 
cnlosis  of  the  kidneys  and  calculous  pyelitis  recurring  rigors  and  sweats 


in 


' 


"TfW 

■1 

'  i  ■  ':' 

i 

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II 

ji 

Iff  i 


118 


SPECIFIC  INFECTIOUS  DISEASES. 


due  to  septic  infection  are  common  In  this  latitude  septic  and  pygemic 
processes  are  too  often  confounded  with  malaria.  In  early  tuberculosis, 
or  even  when  signs  of  excavation  are  present  in  the  lungs,  and  in  cases  of 
suppuration  in  various  parts,  particularly  empyema  and  abscess  of  the 
liver,  the  diagnosis  of  malaria  is  made.  The  practitioner  may  take  it  as  a 
safe  rule,  to  which  he  will  find  very  few  exceptions,  thai  an  intermitlvnt 
fever  which  resists  quinine  is  not  malaria. 

Other  conditions  associated  with  chills  which  may  be  mistaken  for 
I)yaemia  are  profound  anaemia,  certain  cases  of  Hodgkin's  disease,  the 
hepatic  intermittent  fever  associated  with  the  lodgment  of  gall-stone  at 
the  orifice  of  the  common  duct,  rare  cases  of  essential  fever  in  nervous 
women,  and  the  intermittent  fever  sometimes  seen  in  rapidly  developing 
cancer. 

On  two  or  three  occasions  I  have  met  with  intermittent  pyrexia  per- 
sisting for  weeks,  in  which  it  seemed  to  be  impossible  to  give  any  explana- 
tion of  the  phenomena — cases  n  whioh  tuberculosis,  malaria,  or  septicae- 
mia could  be  almost  positively  t.'.  u 

Treatment. — The  trfatment  .  septicaemia  and  pyaemia  is  largely  a 
surgical  problem.  The  cases  which  come  under  the  notice  of  the  physi- 
cian usually  have  visceral  abscesses  or  ulcerative  endocarditis,  conditions 
which  are  irremediable.  We  have  no  remedy  which  controls  the  fever. 
Quinine  and  the  new  antipyretics  may  be  tried,  but  they  are  of  little  serv- 
ice. Quinine  is  probably  better  than  antipyrin  and  antifebrin,  which 
lower  the  temperature  for  a  time,  but  when  a  careful  two-hourly  twenty- 
four-hour  chart  is  taken,  it  is  often  found  that  the  depression  under  the 
influence  of  the  drug  is  made  up  at  some  other  period  of  the  day ;  a  morn- 
ing may  be  substituted  for  an  afternoon  fever. 

The  brilliant  and  remarkable  results  which  follow  complete  evacuation 
of  the  pus  with  thorough  drainage  give  the  indication  for  the  only  suc- 
cessful treatment  of  this  condition. 

Unfortunately  in  too  many  cases  which  the  physician  is  called  upon 
to  treat,  the  region  of  suppuration  is  not  accessible,  and  we  have  to  be  con- 
tent with  the  employment  of  general  measures  for  the  support  of  the 
patient's  strength. 


XVIII.  CHOLERA   ASIATICA. 


Definition. — A  specific,  infections  disease,  caused  by  the  comma 
bacillus  of  Koch,  and  characterized  clinically  by  violent  i)urging  und 
rapid  collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  ii 
remote  i)eriod,  but  only  within  the  present  century  has  it  made  inroads  into 
Europe  and  America.  An  extensive  epidemic  occurred  in  1832,  in  which 
year  it  was  brought  in  immigrant  ships  from  Great  Britain  to  Quebec.   It 


CHOLERA  ASIATICA. 


119 


travelled  along  the  lines  of  traffic  up  the  Great  Lakes ;  and  finally  reached 
as  far  west  as  the  military  posts  of  the  upper  Mississippi.  In  the  same 
year  it  entered  the  United  States  by  way  of  New  York.  There  were  re- 
currences of  the  disease  in  1835-'36.  In  1848  it  entered  the  country 
through  New  Orleans,  and  spread  widely  up  the  Mississippi  Valley  and 
across  the  continent  to  California.  In  1849  it  again  appeared.  In  1854 
it  was  introduced  by  immigrant  ships  into  New  York  and  prevailed  widely 
throughout  the  country.  In  1866  and  in  1867  there  were  less  serious  epi- 
demics. In  1873  it  again  appeared  in  the  United  States,  but  did  not  pre- 
vail widely.  In  1884  there  was  an  outbreak  in  Europe.  Although  occa- 
sional cases  have  been  brought  by  ship  to  the  quarantine  stations  in  this 
country,  the  disease  has  not  gained  a  foothold  here  since  1873. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  specific 
organism  of  this  disease.  Subsequent  observations  have  confirmed  his 
statement  that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in 
tlie  true  cholera,  and  in  no  other  disease.  It  has  the  form  of  a  slightly 
lent  rod,  which  is  thicker,  but  not  more  than  about  half  the  length  of  the 
tubercle  bacillus,  and  sometimes  occurs  in  an  S-form.  It  is  not  a  true 
bacillus,  but  really  a  spirochaite.  The  organism  grows  upon  a  great 
variety  of  media  and  displays  distinctive  and  characteristic  appearances. 
Tlie  bacilli  are  found  in  the  intestine,  in  the  stools  from  the  earliest  period 
of  the  disease,  and  very  abundantly  in  the  characteristic  rice-water  evacu- 
ations, in  which  they  may  be  seen  as  an  almost  pure  culture.  They  very 
rarely  occur  in  the  vomit.  Post  mortem,  they  are  found  in  enormous 
numbers  in  the  intestine.  In  acutely  fatal  cases  they  do  not  seem  to  in- 
vade tlie  intestinal  wall,  but  in  cases  with  a  more  protracted  course  they 
are  found  in  the  follicles  and  even  in  the  deeper  tissues. 

Modes  of  Infection. 

{a)  Contagion. — It  appears  probable  that  cholera  is  not  highly  con- 
tagious in  the  same  sense  as  small-pox  and  scarlet  fever,  but  in  this  respect 
is  very  similar  to  typhoid  fever.  Physicians,  nurses,  and  others  in  close 
contact  with  the  patients  are  not  often  affected.  On  the  other  hand,  such 
persons  as  washer  women,  who  are  brought  into  very  close  contact  with 
the  cholera  stools  and  the  linen  of  the  cholera  patients,  are  particularly 
prone  to  the  disease. 

{b)  Infection. — The  leading  authorities  now  agree  that  the  disease  is 
propagated  chiefly  by  the  contamination  of  water  used  for  drinking,  wash- 
ing, and  cooking.  It  is  quite  possible  that  articles  of  food  may  be  con- 
taminated, particularly  vegetables,  such  as  lettuces  and  cresses  and  others, 
which  have  been  washed  in  infected  water ;  but  this  is  probably  a  minor 
(lunger  in  comparison  with  impure  drinking-water.  The  bacilli,  under 
suitable  circumstances — that  is,  when  much  impurity  is  present — may  de- 
velop to  some  extent  in  the  water ;  Koch,  as  is  well  known,  found  the 
bacilli  in  a  tank  in  India,  from  which  the  inhabitants  were  supplied  with 
water  for  drinking  and  washing.  Strongly  in  favor  of  this  view  is  the  fact 
9 


120 


SPECIFIC  INFECTIOUS  DISEASES. 


|!''V 


If  I 


that  the  virulence  of  an  epidemic!  in  any  region  is  generally  in  direct  pro- 
portion to  the  imperfection  of  the  water-supply.  On  the  other  hand,  with 
improvements  and  perfection  in  the  water-works  of  a  place,  the  epidemics 
are  reduced  in  intensity,  and  the  place  may  even  obtain  immunity  against 
the  disease.  Not  only  in  India  has  the  demonstration  of  the  connection 
between  drinking-water  and  cholera  infection  been  amply  furnished,  but 
in  England  there  have  been  many  valuable  illustrations.  One  of  the  most 
notable  of  these  was  the  celebrated  Broad  Street  pump,  in  London,  which 
in  1854  was  connected  with  a  severe  epidemic.  Milk  also  may  possibly  in 
some  instances  convey  the  poison. 

Pettenkofer,  on  the  other  hand,  denies  the  truth  of  tins  drinking- 
water  theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the 
greatest  importance ;  particularly  a  certain  porosity,  combined  with  moist- 
ure and  contamination  with  organic  matter,  such  as  sewage.  According 
to  him,  the  condition  most  favorable  for  the  development  of  the  virus  is 
found  when  the  subsoil  water  is  lowest.  As  Stille  remarks :  "  It  is  more 
descriptive  of  the  fact  to  say  that  so  far  as  cholera  has  in  any  way  to  do 
with  the  condition  of  the  soil,  it  is  most  apt  to  be  severe  and  prevalent 
when  very  dry  weather  follows  a  very  wet  period.  Such  instances  are 
most  favorable  to  putrefactive  fermentation  and  the  dissemination  of  its 
products,  which  thus  reach  wells  of  drinking-water  and  oven  rivers,  espe- 
cially when  sewers  empty  into  the  water." 

Pettenkofer  holds  that  germs  develop  in  the  subsoil  moisture  during 
the  warm  months,  and  that  they  rise  into  the  atmosphere  as  a  miasm. 

The  disease  is  always  spread  along  the  lines  of  human  travel.  In 
India  it  has,  in  many  notable  cases,  been  widely  spread  by  pilgrims.  It 
is  carried  also  by  caravans  and  in  ships.  It  is  not  conveyed  through  the 
atmosphere. 

Places  situated  at  the  sea-level  are  more  prone  to  the  disease  than 
those  situated  inland.  In  high  altitudes  the  disease  does  not  prevail  so 
extensively.  A  high  temperature  favors  the  development  of  the  disease, 
but  in  Europe  and  America  the  epidemics  have  been  chiefly  in  the  late 
summer  and  in  the  autumn. 

The  disease  attacks  persons  of  all  ages.  It  is  particularly  prone  to 
attack  the  intemperate  and  those  debilitated  by  want  of  food  and  bad  sur- 
roundings. Depressing  emotions,  such  as  fear,  undoubtedly  have  a 
marked  influence.  It  is  doubtful  whether  an  attack  furnishes  immunity 
against  a  second  one. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  changes 
in  cholera ;  but  a  post-mortem  diagnosis  of  the  nature  of  the  disease 
could  be  made  by  any  competent  bacteriologist,  as  the  micro-organisms 
are  specific  and  distinctive.  The  body  has  the  appearances  associated 
with  profound  collapse.  There  is  often  marked  post-mortem  elevation  of 
temperature.  The  rigor  mortis  sets  in  early  and  may  produce  displace- 
ment of  the  limbs.     The  lower  jaw  has  been  seen  to  move  and  the  eyes  to 


CnOLERA  ASIATICA. 


121 


rotiito.  VariolU'  movements  of  the  arms  and  legs  are  also  seen.  The 
1)1(10(1  is  thick  and  dark,  and  there  is  a  remarkable  diminution  in  the 
iiiiioniit  of  water  and  salts.  The  peritonaeum  is  sticky,  and  the  coils  of 
intestines  arc  congested  and  look  thin  and  shrunken.  There  is  nothing 
gpt'cial  in  the  appearance  of  the  stomach.  The  small  intestine  usually 
roiitainsa  turbid  serum,  similar  in  appearance  to  that  which  was  passed  in 
tlic  stools.  The  mucosa  is,  as  a  rule,  pale  and  swollen  and  often  congested 
about  the  Peyer's  patches.  Post  mortem  the  epithelial  lining  is  some- 
ti?nes  (lonuded,  but  this  is  probably  not  a  change  which  takes  place  dur- 
ing life.  In  the  stools,  however,  large  numbers  of  columnar  epithelial 
cells  have  been  described  by  many  observers.  The  bacilli  are  found  in 
the  contents  of  the  intestine  and  in  the  mucous  membrane.  The  spleen 
is  usually  small.  The  liver  and  kidneys  may  show  cloudy  swelling.  The 
heart  is  flabby;  the  right  chambers  are  distended  with  blood  and  the  left 
cliainbers  are  usually  empty.  The  lungs  are  collapsed,  and  congested  at 
the  bases.  » 

The  above  appearances  are  those  met  with  in  cases  which  prove  rapidly 
fatal.  When  the  patient  survives  and  death  occurs  during  reaction,  there 
may  be  more  definite  inflammatory  appearances  in  the  intestines  and  more 
definite  changes  in  the  kidneys  and  liver. 

Symptoms. — A  period  of  incubation  of  uncertain  length,  probably 
not  more  than  from  two  to  five  days,  precedes  the  development  of  the 
symptoms. 

Three  stages  may  be  recognized  in  the  attack  :  the  preliminary  diar- 
rhea, the  collapse  stage,  and  the  i)eriod  of  reaction. 

(a)  The  preliminary  diarrhoea  may  set  in  abruptly  without  any 
previous  indications.  More  commonly  there  are,  for  one  or  two  days, 
colicky  pains  in  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vom- 
iting, with  headache  and  depression  of  spirits.     There  may  be  no  fever. 

{h)  Collapse  Stage. — The  diarrhoea  increases,  or,  without  any  of  the 
preliminary  symptoms,  sets  in  with  the  greatest  intensity ;  and  profuse 
li(|uitl  evacuations  succeed  each  other  rapidly.  There  are  in  some  instances 
griping  pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaus- 
tion and  collapse.  The  thirst  becomes  extreme,  the  tongue  is  white ; 
cramits  of  great  severity  occur  in  the  legs  and  feet.  Within  a  few  hours 
vomiting  sets  in  and  becomes  incessant.  The  patient  rapidly  sinks  into  a 
eonilition  of  collapse,  the  features  are  shrunken,  the  skin  of  an  ashy  gray 
line,  the  eyeballs  sink  in  the  sockets,  the  nose  is  pinched,  the  cheeks  are 
hollow,  the  voice  becomes  husky,  the  extremities  are  cyanosed,  and  the 
skin  is  shrivelled,  wrinkled,  and  covered  with  a  clammy  perspiration.  The 
temperature  sinks.  In  the  axilla  or  in  the  mouth  it  may  be  from  five  to 
ten  degrees  below  normal,  but  in  the  rectum  and  in  the  internal  parts  it 
iiiiiy  be  103°  or  104°.  The  pulse  becomes  extremely  feeble  and  flickering, 
and  the  ])atient  gradually  passes  into  a  condition  of  coma,  though  con- 
sciousness is  often  retained  until  near  the  end. 


1  '■ 
11 

1 

1 

122 


SPECIFIC   INFECTIOUS  DISEASES. 


Tho  faeces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  hut 
soon  they  become  grayish  white  and  look  like  turbid  whey  or  rice-wator; 
whence  the  term  "  rice-water  stools."  There  are  found  in  it  numerous 
small  flakes  of  mucus  and  granular  matter,  and  at  times  blood.  Tlio 
reaction  is  usually  alkaline.  The  fluid  contains  albumen  and  the  cliiof 
mineral  ingredient  is  chloride  of  sodium.  Microscopically,  mucus  and 
epithelial  cells  and  innumerable  bacteria  are  seen,  tho  majority  of  tlio 
latter  being  the  comma  bacilli. 

The  condition  of  the  patient  is  brgely  the  result  of  the  concentration 
of  the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  There  i.) 
almost  complete  arrest  of  secretion,  particularly  of  the  saliva  and  the 
urine.  On  tho  other  hand,  the  sweat-glands  increase  in  activity,  and  in 
nursing  women  it  has  been  stated  that  the  lacteal  flow  is  unaffected. 
This  stage  may  not  last  more  than  two  or  three  hours,  but  more  com- 
monly lasts  from  twelve  to  twenty-four.  There  are  instances  in  which 
the  patient  dies  before  purging  begins — the  so-called  cholera  sicca. 

(c)  Reaction  Stage. — When  the  patient  survives  the  collapse,  the 
cyanosis  gradually  disappears,  the  warmth  returns  to  the  skin,  which  may 
have  for  a  time  a  mottled  color  or  present  a  definite  erythematous  rash. 
The  heart's  action  becomes  stronger,  the  urine  increases  in  quantity,  tho 
irritability  of  the  stomach  disappears,  the  stools  are  at  longer  intervals, 
and  there  is  no  abdominal  pain.  In  the  reaction  the  temperature  may 
not  rise  above  normal.  Not  infrequently  this  favorable  reaction  is  inter- 
rupted by  a  recurrence  of  severe  diarrhoea  and  the  patient  is  carried  ol!  in 
a  relapse.  Other  cases  pass  into  the  condition  of  what  has  been  called 
cholera-typhoid,  a  state  in  which  tho  patient  is  delirious,  tho  pulse  rapid 
and  feeble,  and  the  tongue  dry.  Death  finally  occurs  with  coma.  These 
symptoms  have  been  attributed  to  uraemia. 

During  epidemics  attacks  are  found  of  all  grades  of  severity.  There 
are  cases  of  diarrhoea  with  griping  pains,  liquid,  copious  stools,  vomiting, 
and  cramps,  with  slight  collapse.  The  term  cholerine  has  been  applied  to 
these  cases.  They  resemble  the  milder  cases  of  cholera  nostras.  At  the 
opposite  end  of  tho  series  there  are  the  instances  of  cholera  sicca,  in  which 
death  may  occur  in  a  few  hours  after  tho  attack,  without  diarrhcea.  There 
are  cases  also  in  which  the  patients  are  overwhelmed  with  the  poison  and 
die  comatose,  without  the  preliminary  stage  of  collapse. 

Complications  and  Sequelee. — The  typhoid  condition  has  al- 
ready been  referred  to.  The  consecutive  nephritis  rarely  induces  dropsy. 
Diphtheritic  colitis  has  been  described.  There  is  a  special  tendency  to 
diphtheritic  inflammation  of  the  mucous  membranes,  particularly  of  tho 
throat  and  genitals.  Pneumonia  and  pleurisy  may  develop,  and  destruc- 
tive abscesses  may  occur  in  different  parts.  Suppurative  parotitis  is  not 
very  uncommon.  In  rare  instances  local  gangrene  may  develop.  A 
troublesome  symptom  of  convalescence  may  be  cramps  in  the  muscles  of  j 
the  arms  and  legs. 


CHOLERA    ASIATICA. 


123 


Diagnosis. — The  only  affection  with  which  Asiatic  cholera  could  be 
confcpiiiuk'd  is  the  cholera  nostras,  the  severe  choleraic  diarrhoea  which 
occurs  during  the  summer  months  in  temperute  climates.  The  clinical 
picture  of  the  two  affections  is  identical.  The  extreme  collapse,  vomiting, 
iiud  rice-water  stools,  the  cramps,  the  cyanosed  appearance,  are  all  seen  in 
tlie  worst  forms  of  cholera  nostras.  In  enfeebled  persons  death  may 
occur  within  twelve  hours.  It  is  of  course  extremely  important  to  be 
able  to  diagnose  between  the  two  affections.  This  can  only  be  done  by 
one  thoroughly  versed  in  bacteriological  methods,  and  conversant  with  the 
(livcrsifiod  flora  of  the  intestines.  The  comma  bacillus  is  present  in  the 
dejections  of  a  great  majority  of  the  cases  and  can  be  seen  on  cover-glass 
preiJiirutions.  Though  the  eye  of  the  expert  may  bo  able  to  differentiate 
between  the  bacillus  of  true  cholera  and  that  which  occurs  in  cholera 
nostras,  cultures  should  be  made,  from  which  alone  positive  results  can  be 
obtained. 

Attacks  very  similar  to  Asiatic  cholera  are*produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi ;  but  a  difficulty  in  diag- 
nosis could  scarcely  arise. 

'Hw  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
eindeniics  from  30  to  80  per  cent.  Intemperance,  debility,  and  old  ago 
are  unfavorable  conditions.  Tlie  more  rapidly  the  collapse  sets  in,  the 
greater  is  the  danger.  Cases  with  marked  cyanosis  and  very  low  tempera- 
ture rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation 
of  the  sick  and  thorough  disinfection  have  effectually  prevented  the  dis- 
ease entering  England  or  the  United  States  since  1873.  On  several  occa- 
sions since  that  date,  cholera  has  been  brought  to  various  ports  in  Amer- 
ica, but  has  been  checked  at  quarantine.  During  epidemics  the  greatest 
care  sliould  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the 
patients.  When  an  epidemic  prevails,  persons  should  be  Avarncd  not  to 
drink  water  unless  previously  boiled.  Errors  in  diet  should  be  avoided. 
As  the  disease  is  not  more  contagious  than  typhoid  fever,  the  chance  of  a 
person  passing  safely  through  ar.  epidemic  depends  very  much  upon  how 
far  lie  is  able  to  carry  out  thoroighly  prophylactic  measures.  Digestive 
disturbances  are  to  be  treated  promptly,  and  particularly  the  diarrhoea, 
which  so  often  is  a  preliminary  symptom.  For  this  opium  and  acetate  of 
lead  and  large  doses  of  bismuth  should  be  given. 

Attempts  have  been  made  to  procure  a  protective  virus.  During  the 
last  epidemic  in  Europe,  Ferran,  in  Spain,  made  a  large  number  of  inocu- 
lations which  were  claimed  to  be  protective;  but  the  French  commission 
reported  adversely  against  these  claims.  Shakespeare*  seemed  to  have 
been  more  favorably  impressed.     Both  Gamaleia  and  Lowenthal  have  ren- 


*  Hcfiort  on  Cholera  in  Europe  and  India. 
Commi>sioner.    Washington,  1891. 


By  E.  L'.  Shakespeare,  United  States 


124 


SPECIFIC    INFECTIOUS   DISEASES. 


(lored  animals  immune  against  the  cholera  virus,  but  it  is  not  probable 
that  the  method  which  they  employ  would  bo  available  for  man. 

Medicinal  Treatment.— During  the  initial  stage,  when  the  diar- 
rhu'a  is  not  excessive  but  the  abdominal  pain  is  marked,  opium  is  the  most 
oflicient  remedy,  and  it  should  be  given  hypodermically  as  morj)hia.  It 
is  advisable  to  give  at  once  a  full  dose,  which  may  be  repeated  on  the 
return  of  the  pain.  It  is  best  not  to  attempt  to  give  remedies  by  the 
mouth,  as  they  disturb  the  stomach.  Ice  should  be  given,  and  brandy  or 
hot  coffee.  In  the  collapse  stage,  writers  speak  strongly  against  the  use 
of  opium.  Undoubtedly  it  must  be  given  with  caution,  but,  judging  from 
its  effects  in  cholera  nostras,  I  should  say  that  collapse  per  se  was  not  a 
contra-indication.  For  the  intense  thirst  the  patient  may  be  given  ice- 
water,  of  which  he  should  bo  allowed  to  drink  freely.  The  vomiting  is 
very  difficult  to  chock.  In  severe  cases  creosote,  hydrocyanic  acid,  and 
other  remedies  seem  quite  ineffectual. 

Salol  has  been  warmly  recommended  as  capable  of  preventing  the  de- 
velopment of  the  bacilli  in  the  intestine. 

External  applications  of  heat  should  be  made  and  a  hot  bath  may  be 
tried.  AVarm  applications  to  the  abdomen  are  very  grateful.  Hypodermic 
injections  of  ether  will  be  found  serviceable. 

Judging  from  the  success  w.iich  has  followed  the  copious  encmata  in 
cholera  infantum.,  this  practice  should  be  tried.  Two  or  three  pints  of 
water  should  be  allowed  to  flow  slowly  into  the  re:tum.  If  the  hips  are 
elevated  it  may  be  retained  for  soinc  tiine,  but  is  u.?ually  rapidly  ejected. 
The  water  may  be  given  either  cold  or  warm  ;  probably  the  latter  would 
bo  better.  During  th  last  epidemic  in  Italy,  Cantani  used  this  method, 
which  he  calls  enterochjsis,  with  great  success.  In. each  injection  he  gave 
tannic  acid  and,  generally,  laudanum. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concen- 
trated, and  absorption  takes  place  rapidly  from  the  lymph-spaces.  This 
it  is  which  gives  the  shrunken  puckered  appearance  to  the  features  and 
skin  of  a  patient  in  the  collapse  stage.  To  meet  this,  intravenous  injec- 
tions have  been  practised.  My  preceptor,  Bovell,  first  practised  the  intra- 
venous injections  of  milk  in  Toronto,  in  the  epidemic  of  1854.  Less  risky 
and  equally  efficacious  is  the  subcutaneous  injection  of  a  saline  solution. 
For  this  common  salt  should  be  used  in  the  proportion  of  about  four 
grammes  to  the  litre.  With  rubber  tubing,  a  canula  from  an  aspirator, 
or  even  with  a  hypodermic  needle,  the  warm  solution  may  be  allowed  to 
run  by  pressure  beneath  the  skin.  It  is  rapidly  absorbed,  and  the  process 
may  be  continued  until  the  pulse  shows  some  sign  of  improvement.  This 
is  really  a  valuable  method,  thoroughly  physiological,  and  should  be  tried 
in  all  severe  cases. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the 
diet  and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


YELLOW   FEVER. 


125 


XIX.  YELLOW   FEVER. 


Definition. — An  acuto  fobrilo  disease  of  tropical  and  subtropical 
coiintrios,  characterized  by  jaundico  and  ha'morrliagcs,  and  due  to  the 
action  of  ;i  specific  virus,  the  nature  of  which  is  yet  unknown. 

Etiology. — 'I'he  disease  prevails  endemically  in  the  West  Indies  and 
in  eortiiin  sections  of  the  Spanish  Main.  From  these  regions  it  occasionally 
extends  and,  under  suitable  conditions,  prevails  epidemically  in  the  Southern 
States.  Now  and  then  it  is  brought  to  the  largo  seaports  of  the  Atlantic 
coast.  Formerly  it  occurred  extensively  in  the  United  States.  In  the 
latter  part  of  the  last  century  and  the  beginning  of  this,  frightful  epi- 
(k'niics  prevailed  in  Philadelphia  and  other  Northern  cities.  The  epidemic 
of  1793,  so  graphically  described  by  Matthew  Carey,  was  the  most  serious 
that  has  ever  prevailed  in  any  city  of  the  Middle  States.  The  mortality, 
as  given  by  Carey,  during  the  months  of  August,  Sejitember,  October,  and 
November,  was  4,041,  of  whom  3,435  died  in  the  months  of  September  and 
October.  The  popidation  of  the  city  at  the  time  was  only  40,000.  Epidem- 
ics occurred  in  the  United  States  in  1707,  1708,  1709,  and  in  1803,  when 
the  disease  prevailed  slightly  in  Boston  and  extensively  in  IJaltimore.  In 
1803  and  1805  it  again  appeared  ;  then  for  many  years  the  outbreaks  were 
slight  and  localized.  In  1853  the  disease  raged  throughout  the  Southern 
Stiitos.  In  New  Orleans  alone  there  was  a  mortality  of  nearly  eight  thou- 
sand. In  1807  and  1873  there  were  moderately  severe  epidemics.  In 
1878  the  last  extensive  epidemic  occurred,  chiefly  in  Louisiana,  Alabama, 
and  Mississippi.  The  total  mortality  was  nearly  sixteen  thousand.  In 
Europe  it  has  occasionally  gained  a  foothold,  but  thc:o  have  been  no 
wide-spread  epidemics  except  in  the  Spanish  ports.  The  disease  exists  on 
the  west  coast  of  Africa.  It  is  sometimes  carried  to  ports  in  Great  Britain 
and  Franco,  but  it  has  never  extended  into  those  countries.  The  histoiy 
of  the  disease  and  its  general  symptomatology  are  exliaustively  treated  in 
the  classical  work  of  Rene  La  Koche. 

Guiteras  recognizes  three  areas  of  infection  :  (1)  The  focal  zone  in 
which  the  disease  is  never  absent,  including  Havana,  Vera  Cruz,  Kio,  and 
other  Spanish-American  porta.  (2)  Perifocal  zone  or  regions  of  periodic 
epidemics,  including  the  ports  of  the  tropical  Atlantic  in  America  and 
Africa.  (3)  The  zone  of  accidental  epidemics,  between  the  parallels  of 
45°  north  and  35°  south  latitude. 

The  epidemics  are  invariably  due  to  the  introduction  of  the  poison 
either  by  patients  affected  with  the  disease  or  through  infected  articles. 
Unquestionably  the  poison  may  be  conveyed  by  fomites.  Individuals  of 
all  ages  and  races  are  attacked.  The  negro  is  much  less  susceptible  than 
the  white,  but  he  does  not  enjoy  an  immunity.  Residents  in  southern 
countries,  in  which  the  disease  is  prevalent,  are  not  so  susceptible  as  stran- 
gers and  temporary  residents.  Males  are  more  frequently  affected  and  the 
mortality  is  greater  among  them,  owing  probably  to  greater  exposure. 


190 


SPECIFIC   INFECTIOUS  DISEASES. 


Very  young  (;l)ildron  usuuUy  escuijo ;  but  in  tho  epidemics  of  lari,'(i 
cities  tlio  niiinbor  uiuJer  five  attacked  is  large,  since  they  constitute  u  con- 
siderablo  ])r()portion  of  the  population  unprotected  by  jjrovious  attiu  k. 
(juiteras  states  that  tlie  "foci  of  cndeniicity  of  yellow  fever  are  essentially 
maintained  by  tho  Creole  infant  population."  Immiinity  is  ac»piiied  i)y 
passing  through  an  attack  or  by  prolonged  residence  in  a  locality  in  which 
it  is  endemic.  Tho  statement  so  often  made  that  tho  Creoles  aro  exempt 
from  yellow  fever  has  b<!en  abundantly  disproved.  They  certainly  aro  not 
so  susceptible,  but  in  severe  epidemics  they  die  in  numbers.  Tho  evidence 
in  favor  of  inherited  immunity  is  not  conclusive. 

t'onditiom  favor imj  the  JJevelopment  of  /'Jpidmnics.—YcWow  fever  is 
a  disease  of  the  sea-coast,  and  rarely  prevails  in  regions  with  an  eleva- 
tion above  one  thousand  feet.  Its  ravages  are  most  serious  in  cities,  par- 
ticularly when  tho  sanitary  conditions  are  unfavorable.  It  is  always  most 
severe  in  tho  badly  drained,  unhealthy  portions  of  a  city,  where  tho  pojju- 
lation  is  crowded  together  in  ill-ventilated,  badly  drained  houses.  The 
disease  prevails  during  the  hot  f^eason.  In  Havana  the  death-rate  is  great- 
est during  the  months  of  June,  July,  and  August.  Tho  epidemics  in  tlic 
United  States  have  always  been  in  the  summer  and  autumn  months. 

The  specific  germ  of  the  disease  lias  not  yet  been  discovered.  Stern- 
berg, in  liis  last  report  to  the  United  States  Government,  concludes  that 
the  specific  cause  of  yellow  fever  has  not  yet  been  demonstrated.  With 
this  statement Cornil  and  Babes*  agree, and  they  do  not  accept  the  organ- 
isms described  by  Freiro,  Carmona,  and  Gibior. 

Morbid  Anatomy.— The  skin  is  more  or  less  jaundiced.  Cutano- 
ous  haemorrhages  may  bo  present.  No  specific  or  distinctive  internal 
lesions  have  been  found.  The  blood-serum  contains  hajmoglobin,  owino; 
to  destruction  of  the  red  cells,  just  as  in  pernicious  malaria.  Tho  heart 
sometimes,  not  invariably,  shows  fatty  change ;  the  stomach  presents  more 
or  less  hyperaemia  of  the  mucosa  vith  catarrhal  swelling.  It  contains  the 
material  which,  ejected  during  life,  is  known  as  the  black  vomit.  Tlio 
essential  ingredient  in  tliis  is  transformed  blood-pigment.  In  tho  two 
specimens  which  I  have  had  an  opportunity  of  examining  it  differed  in  no 
respect  from  tho  material  found  in  other  affections  associated  with  haema- 
temcsis.  There  is  no  proof  that  this  black  material  depends  upon  the 
growth  of  a  micro-organism.  The  liver  is  usually  of  a  pale  yellow  or 
brownisli-yellow  color,  and  the  cells  are  in  various  stages  of  fatty  degen- 
eration. From  the  date  of  Louis's  observations  at  Gibraltar  in  1828,  the 
appearances  of  this  organ  have  been  very  carefully  studied,  and  some  have 
thought  the  changes  in  it  to  be  characteristic.  Councilman  has  described 
remarkable  appearances  in  the  liver-cells  which  he  believes  are  distinctive 
and  peculiar.  Fatty  degeneration  and  regions  of  necrosis  are  present  in 
all  cases.     The  kidneys  often  show  traces  of  diffuse  nephritis.     The  epi- 


*  Les  Bact4ries,  1800. 


YKLLOW   KKVKIl. 


127 


tholium  of  tho  convoluted  tubules  is  Hwollon  and  very  jfrannliir;  thoro 
miiv  iil'^'i  bo  iieorotio  changes.  In  botli  liver  and  kidneys  bacteria  of  vari- 
ous sorts  havo  been  deseribed. 

SymptomSi — Tlio  incubation  is  usually  three  or  four  days,  but  it 
niiiv  l)t!  less  than  twenty-four  hours  and  ])rolonged  to  seven  days,  'J'ho 
oiisi't  is  sudden ;  as  a  rule,  without  preliminary  symptoms.  An  initial 
cliill  is  common,  and  with  it  are  usually  associated  headache  and  pains  in 
tho  buck  and  limbs.  Tho  fever  rises  rapidly  and  the  skin  feels  very  hot 
and  dry.  Tho  face  is  flushed  ;  tho  tongue  furred,  but  moist ;  tho  throat 
sore.  Nausea  and  vomiting  are  ])rescnt,  and  become  more  intense  on 
tho  sncond  or  third  day.  The  bowels  are  usually  constipated.  The 
uriiu!  is  reduced  in  amount  and  nuiy  bo  albuminous  from  the  outset. 
The  pulse,  at  Ihst,  has  tho  usual  febrile  characters,  but  qiiickly  becomes 
fci'l)le  and,  as  the  jaundice  develops,  may  become  slow.  This  stago  of 
invasion,  or  tho  febrile  .sfat/r,  lasts  from  a  few  hours  to  two  or  three 
(lavs.  It  is  succeeded  by  a  remission,  or,  as  it  has  sometimes  been  called, 
the  stni/e  of  calm,  during  wliich  tho  temporaturo  falls  and  the  sever- 
ity of  the  symptoms  abates.  In  favorable  cases  the  fever  now  subsides 
and  convalescence  sets  in.  In  such  cases  jaundice  may  not  develop. 
In  the  third  stage,  or  that  of  the  febrile  reaeiian,  tho  temperature  rises 
again  and  the  symptoms  become  aggravated.  The  jaundice  develops 
rapidly,  tho  vomiting  increases,  and,  in  a  considerable  proportion  of  tiio 
ciisos,  bh  vomit  occurs.  This  consists  of  blood  ami  gastric  mucus 
altered  acid  juices  of  the  stomach.     'J'hougli  usually  regarded  as 

distinctive  and  characteristic  of  the  disease,  material  identical  with  it  is 
brought  np  under  other  febrile  conditions  in  which  vomiting  of  blood 
occurs.  Altered  blood-corpuscles,  epithelial  cells,  portions  of  food,  and 
various  fungi  are  found  in  tho  fluid.  The  vomiting  may  bo  accompanied 
by  great  abdominal  pain.  The  stools  are  often  tarry  from  the  presence  of 
altered  blood.  In  mild  cases  the  vomiting  ceases  during  the  first  stage  of 
the  disease.  Black  vomit  is  not  necessarily  a  fatal  symptom,  though  it  is 
present  only  in  the  reverer  cases  of  the  disease.  Jaundice  occurs  in  a 
limited  number  of  the  cases  which  recover,  and  is  present  in  almost  all  the 
fatal  cases.  From  the  character  of  tho  disease  it  is  probably  ha^matoge- 
nons  in  its  origin.  Bleeding  may  occur  from  the  kidneys  or  from  the  gums, 
and  luemorrhages  into  tho  skin  are  not  uncommon.  As  would  be  expected 
in  a  fever  of  this  nature,  the  urine  is  albuminous;  the  amount  varying  a 
good  deal  with  the  intensity  of  che  fever,  and  with  the  grade  of  jaundice. 
Febrile  icterus,  from  whatever  cause,  is  almost  invariably  associated  with 
albuminuria  and  tube-casts,  and  the  evidences  of  a  diffuse  nephritis. 

Kelajises  occasionally  occur.  Among  the  varieties  of  the  disease  it  is 
important  to  recognize  the  mild  cases.  These  are  characterized  by  slight 
fever,  continuing  for  one  or  two  days,  and  succeeded  by  a  rapid  convales- 
cence. Such  cases  would  not  be  recognized  as  yellow  fever  in  the  absence 
of  a  prevailing  epidemic.     Cases  of  greater  severity  have  high  fever  and 


128 


SPECIFIC  INFECTIOUS  DISEASES. 


Iti 


l;-;! 


i 

It- 


I'. 


m  r 


9-1'! 


I  1 

\    ] 

h  i 


the  features  of  the  disease  are  well  marked — vomiting,  prostration,  and 
ha3morrhagcs.  And  lastly  there  are  malignant  cases  in  which  the  pafjnt 
is  overwhelmed  by  the  intensity  of  the  fever,  and  death  takes  place  in  two 
or  three  days. 

In  severe  cases  convalescence  may  be  complicated  by  the  occurrence  of 
parotitis,  abscesses  in  various  parts  of  the  body,  and  diarrha>a.  An  attack 
confers  an  immunity  which  persists,  as  a  rule,  through  life. 

Diagnosis. — Mild  cases,  and  even  severe  cases  in  the  early  period  of 
an  epidemic,  are  very  difficult  to  recognize.  The  disease  simulates  closely, 
and  may  be  mistaken  for  ordinary  malarial  remittent  fever.  It  is  not  un- 
common for  physicians,  in  regions  in  which  yellow  fever  is  occasionally 
epidemic,  to  call  the  milucr  o  ises  malarial  fever,  reserving  the  name  ot 
yellow  fever  for  the  severer  forms  with  jaundice  and  black  vomit.  The 
only  disease  with  which  these  cases  could  be  confounded  is  malaria  in 
its  remittent  and  pernicious  forms.  But  yellow  fever  can  now  be  defi- 
nitely and  at  once  separated  by  the  examination  of  tlie  blood.  Twice 
in  Philadelphia  I  was  sent  for  to  determine  whether  a  patient,  freshly 
arrived  in  the  city  from  the  South,  had  yellow  fever  or  pernicious  mala- 
ria; and  I  was  able  in  both  instances,  by  finding  Lavaran's  organisms  in 
the  blood,  to  pronounce  definitely  upon  the  nature  of  the  disease.  TJie 
clinical  picture  in  certain,  cases  of  malarial  remittent  and  yellow  fever 
may  be  almost  identical.  The  presence  of  albumen  in  the  urine,  upon 
which  some  writers  lay  such  stress  as  a  distinguishing  feature  in  yellow 
fever,  is  far  too  common  a  symptom  in  all  forms  of  malaria  to  bo  wortii 
much  as  a  guide.  Guiteras  states  that  there  may  be  difficulty  for  a  time 
in  recognizing  the  difference  between  mild  cases  of  thermic  fever  and 
yellow  fever. 

Frogrosis. — In  its  graver  forms,  yellow  fever  is  one  of  the  most 
fatal  of  ep  .emic  diseases.  The  mortality  has  ranged,  in  various  epidem- 
ics, from  15  to  85  per  cent.  In  heavy  drinkers  and  those  who  have  been 
exposed  to  hardships  the  death-rate  is  much  higher  than  among  the  bet- 
ter classes.  In  the  epidemic  of  1878,  in  New  Orleans,  while  the  mortality 
in  hospitals  was  over  50  per  cent  of  the  white  and  21  per  cent  of  the  col- 
ored patients,  in  i)rivato  practice  the  mortality  was  not  more  than  10  per 
cent  among  the  white  patients.  Favorable  symptoms  are  a  low  grade  of 
fever,  slight  jaundice,  absence  of  haemorrhages,  and  a  free  secretion  of 
urine.  If  the  temperature  rises  above  103°  or  104°  during  the  first  two 
days,  the  outlook  is  serious.  Black  vomit  is  not  an  invariably  fatal  symp- 
tom. Cases  with  suppression  of  urine,  delirium,  coma,  and  convulsions 
rarely  recover. 

Prophylaxis. — The  measures  to  be  taken  are — 

(a)  "Exclusion  of  the  exotic  germ  of  the  disease  by  the  sanitary  super- 
vision, at  the  port  of  departure,  of  ships  sail' hg  from  infected  ports,  and 
thorough  disinfection  at  the  port  of  arrival,  when  there  is  evidence  or  rea- 
sonable suspicion  that  they  are  infected ;  {b)  isolation  of  the  sick  on  ship- 


YELLOW  FEVER. 


129 


boanl,  at  quarantine  stations,  and,  so  far  as  practicable,  in  recently  infected 
i)liu'('> ;  {i')  disinfection  of  excreta,  and  of  the  clothing  and  bedding  used 
by  tlu'  sick,  and  of  localities  into  which  cases  have  been  introduced,  or 
wliich  have  become  infected  in  any  way;  ((/)  depopulation  of  infected 
pljitjes — i.  e.,  the  removal  of  all  susceptible  persons  whose  presence  is  not 
ncci'ssiiry  for  the  care  of  the  sick  "  (Sternberg).  During  an  epidemic, 
individiii.ils  who  must  remain  in  the  locality  should  avoid  the  regions  in 
wliicli  tlie  disease  prevails  most ;  they  should  live  lomperately,  avoiding  all 
excesses,  and  should  be  careful  not  to  get  overheated,  either  in  the  sun  or 
bv  exercise.  It  is  very  doubtful  whether  the  preventive  inoculations  in- 
troduced by  Freire  in  Brazil  and  Carmona  in  Mexico  are  of  any  value. 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment 
probiil)ly  give  the  best  results.  Bleeding  has  long  since  been  abandoned. 
How  naich  patients  will  stand  in  this  disease  is  illustrated  by  Rush's  prac- 
tice, which  was  of  the  most  heroic  character,  lie  says :  "  From  a  newly 
arrived  Englishman  I  took  144  ounces,  at  twelve  bleedings,  in  six  days ; 
four  were  in  twenty-four  hours.  I  gave  within  the  course  of  the  same  six 
days  nearly  150  grains  of  calomel,  with  the  usual  proportions  of  jalap  and 
gamboge  "  *  With  the  courage  of  his  convictions  this  modern  Saugrado 
liimself  submitted  to  two  bleedings  in  one  day,  and  had  his  infant  of  six 
weeks  old  bled  twice.  Neither  emetics  nor  purgatives  are  now  employed. 
Of  special  remedies  quinine  is  warmly  recommended,  and,  when  haimor- 
rhage  sets  in,  the  perchloride  of  iron.  Digitalis,  aconite,  and  jaborandi 
have  been  employed.  Stern',  org  advises  the  following  mixture :  Bicar- 
bonate of  soda,  150  grains;  ichloride  of  mercury,  ^  grain;  pure  water, 
1  quart.  Three  tablespoonfuls  to  be  given  every  hour.  This  is  given  on 
the  view  that  the  specific  agent  is  in  the  intestine,  and  that  its  growth  may 
possibly  be  restrained  by  this  antacid  and  antiseptic  mixture.  The  fever 
is  best  treated  by  hydrotherapy.  There  are  several  reports  of  the  good 
effects  of  cold  baths,  sponging,  and  the  application  of  ice-cold  water  to 
the  head  and  the  extremities  in  this  disease.  Vomiting  is  a  very  difficult 
symptom  to  control.  Morphia  hypodermically  and  ice  in  small  quantities 
are  probably  the  best  remedies.  Medicines  given  by  the  mouth  for  this 
purpose  are  said  to  be  rarely  efficacious. 

We  liave  no  reliable  medicine  which  can  be  depended  upon  to  check 
the  haemorrhages.  Ergot  and  acetate  of  lead  and  opium  are  recommended. 
The  urismic  symptoms  are  best  treated  by  the  hot  bath.  Stimulants  should 
be  given  freely  during  tb  j  second  stage,  when  the  heart's  action  becomea 
feeble  and  there  is  a  ter  iency  to  collapse.  The  patient  should  be  carefully 
led;  but  when  the  voniting  is  incessant  it  is  best  not  to  irritate  the  stom- 
ach, but  to  give  nutri*  .ve  enemata  until  the  gastric  irritation  is  allayed. 


Manuscript  letter  to  Redman  Coxe. 


130 


SPECIFIC  INFECTIOUS  DISEASES. 


XX.    DYSENTERY. 


i-:\^  I 


iiij  I 


Definition. — Under  this  clinical  term  several  different  forms  of  in- 
testinal flux  are  described,  which  are  characterized  by  frequent  stools,  and 
in  the  acute  stage  are  accompanied  by  tormina  and  tenesmus.  Anatomi- 
cally there  are  inflammation  and  usually  ulceration  of  the  large  bowel. 

Etiology. — Dysentery  is  one  of  the  four  great  epidemic  diseases  of 
the  world.  In  the  tropics  it  destroys  more  lives  than  cholera,  and  it  lias 
been  more  fatal  to  armies  than  powder  and  shot. 

While  especially  severe  in  the  tropics,  sporadic  cases  constantly  occur 
in  more  temperate  climates,  and  under  favoring  circumstances  epidemics 
are  found  even  in  the  more  northern  countries,  such  as  Canada  and  Nor- 
way. It  has  become  less  frequent  of  late  years,  owing  to  improved  sani- 
tary conditions.  The  statistics  of  the  Montreal  General  llospitaJ,  for  the 
twenty  years  ending  May  1,  1889,  show  a  remarkable  decrease  in  the  dis- 
ease. In  the  decade  ending  May,  1879,  150  cases  were  admitted ;  whereas 
in  the  last  ten  years  there  have  been  only  31  cases  admitted.  There  lias 
been  a  similar  decrease  at  the  Pennsylvania  IIos})ital. 

In  the  Southern  cities  of  this  country  dysentery  is  more  prevalent;  even 
when  not  epidemic,  sporadic  cases  are  common.  In  Baltimore  it  prevails 
every  summer,  and  has  on  several  occasions  been  epidemic. 

Epidemics  of  dysentery  have  occurred  in  the  United  States  for  more 
than  a  century,  and  Woodward  has  collected  tho  dato  which  show  the 
various  outbreaks.  Perhaps  the  most  serious  was  thai  which  prevailed  in 
various  localities  from  1847  to  185G.  During  the  war  of  secession  the  dis- 
ease existed  to  an  alarming  extent  in  both  armies.  According  to  Wood- 
ward's report,*  there  were  in  the  Federal  service  in  all  259,071  cases  of 
acute  and  28,451  cases  of  chronic  dysentery.  Probably  a  considerable  pro- 
portion of  the  183,580  cases  of  chroni'  diarrhoea  should  also  come  in  this 
category.  The  decennial  census  reports  since  1850  show  a  progressive  de- 
crease in  the  total  number  of  deaths  from  this  disease.  It  prevails  most 
extensively  in  the  summer  and  autumn.  Sudden  changes  of  temperature 
appear  more  harmful  than  variations  in  moisture.  The  efliuvia  from  de- 
composing animal  m.iLter  have  been  thought  by  some  to  predispose  to  or 
even  to  cause  the  disease.  That  dysenteric  affections  are  more  frequent 
in  malarial  localities  has  long  been  known,  and  is  probably  connected  with 
external  conditions  favoring  their  development.  With  reference  to  the 
influence  of  drinking-water,  Woodward  is  doubtless  correct  in  stating  tliat 
the  effects  of  dissolved  mineral  matters  have  been  greatly  exaggerated. 
On  the  other  hand,  from  the  days  of  the  old  Creek  physicians,  it  has  been 
held  that  the  impurities  in  the  stagnant  water  of  marshy  districts  ami 


*  Medical  and  Surgical  Flistory  of  the  War  of  the  Ilcbollion,  Medical,  vol.  ii;  the 
most  exhaustive  treatise  extant  on  intestinal  fluxes — an  enduring  monument  to  the  in- 
dustry and  ability  of  the  author. 


ill 


ii" 


m 


DYSENTERY. 


131 


ponds  may  give  rise  to  diarrhopa  and  dysentery.  Hero,  however,  it  is  prob- 
ablv  not  the  vegetable  impurities  which  are  directly  causative,  but  the  or- 
giiiiic  matter  renders  the  water  a  more  favorable  medium  for  the  develop- 
ment of  organisms  which  may  cause  disease. 

Dyspeptic  conditions,  particularly  those  caused  by  the  ingestion  of  bad 
food  and  unripe  fruit,  seem  to  predispose  to  the  disease.  Groat  stress  has 
been  laid  by  German  authorities  on  the  importance  of  constipation  as  a 
causal  factor  in  dysentery. 

Dysentery  occurs  at  all  ages.  There  is  no  race  immunity.  The  con- 
tar'iousness  of  the  disease  is  doubtful.  The  experience  of  the  civil  war 
is  decidedly  against  it,  but  the  possibility,  as  with  typhoid  fever,  must  bo 
acknowledged. 

Clinical  Forins.— («)  Acute  Catarrhal  Dysentery.— This  may  occur 
sponidically  or  endemically,  and  is  the  variety  most  frequently  found  in 
temperate  climates. 

Morbid  Anatomy. — The  lesions  are  confined  to  the  large  bowel,  and 
sometimes  the  ileum  also  is  involved.  The  mucous  membrane  is  injected, 
swollen,  and  often  covered  with  tenacious  blood-stained  mucus.  The 
most  strilcing  feature  is  the  eidargement  of  the  solitary  follicles,  which 
stand  out  jirominently  from  the  mucous  membrane.  In  very  acute 
ionns,  as  in  children,  the  picture  is  that  of  an  acute  follicular  colitis.  In 
more  protracted  cases  the  follicles  suppurate  or  are  capped  with  an  area 
of  necrotic  tissue.  In  other  instances  the  slouglis  have  separated  and  the 
entire  colon  presents  numerous  ulcers,  most  of  which  have  developed  from 
the  follicles,  and  others  have  resulted  from  necrosis  and  sloughing  of  the 
intervening  tissue. 

Sijwploms. — There  may  be  preliminary  dyspepsia  or  slight  pains  in  the 
abdomen.     Chills  are  rare.     Diiirrha}a  is  the  most  constant  initial        ip- 
tom,  and  at  first  is  not  painful.     Usually  within  thirty-six  hours  the  cii;ir- 
acteristic  features  of  the  disease  develop — abdominal  pain  of  a  colicky, 
griping  character,  frequent  stools,  which  are  j)assed  with  straining  and 
tenesmus;  the  constitutional  disturbance  is  variable,  and  in  mild  cases 
may  be  slight.     The  temperature  range  is  not  high,  but  at  the  outset  the 
fever  may  rise  to  102''  or  103°.     The  tongue  is  furred  and  moist,  and  as 
the  disease  progresses  becomes  red  and  glazed.     Nausea  and  vomiting  may 
be  present,  but  as  a  rule  the  patient  retains  nourishment.     The  constant 
desire  to  -;o  to  stool  and  the  straining  or  tenesmus  are  the  most  distressing 
symptoms.    The  abdomen  may  be  fiat  and  hard.    The  thirst  is  often  exces- 
sive.  The  stools  in  this  variety  of  dysentery  have  the  following  characters  : 
DuriiiiT  the  first  twenty-four  or  forty-eight  hours  they  consist  of  more  or 
less  clear  mucus  and  blood  mixed  with  small  faecal  scybala.    After  this  they 
become  purely  gelatinous  and  bloody,  and  are  small  and  frequent,  from 
iifteen  to  two  hundred  in  twenty-four  hours,  actiording  to  the  severity  of 
the  case.    About  the  end  of  the  first  week  the  mucus  becomes  opaque,  the 
proportion  of  blood  diminishes,  and  grayish  or  brownish  shreddy  material 


132 


SPECIFIC  INFECTIOUS   DISEASES. 


y 


appears  in  tlio  stools,  which  become  gnidiuiUy  reduced  in  frequency. 
Some  of  the  stools  at  this  time  may  bo  wholly  composed  of  a  greenish  ])iil- 
taceous  material  and  mucus.  As  the  disease  subsides,  f;pcal  matter  again 
appears  in  the  stools,  increasing  in  amount  until  fully  formed  faeces  are 
passed,  containing  no  mucus  or  blood.  Mitn'oscopical  examination  of  the 
glairy  bloody  stools  shows  red  blood-corpuscles,  few  or  many  leucocytes, 
and  constantly  large,  swollen,  round  or  oval  ej)ithelioid  cells,  containing 
fat-drops  aiul  vacuoles.  Hacteria  are  scarce ;  occasionally  the  cercovwnas 
intestinaUfi  is  seen  in  large  numbers. 

Course  of  the  Diseatte. — The  milder  cases  run  a  course,  as  Flint  has 
shown,  of  about  eight  days;  severer  ones  rarely  terminate  within  four 
weeks.  Recovery  may  bo  imjierfect,  and  the  affection  occasionally  be- 
comes chronic.  In  this  form  the  complications  are  not  numerous;  peri- 
tonitis jind  liver  ab.scess  are  extremely  rare.  Except  in  young  children,  a 
majority  of  the  cases  terminate  favorably. 

{b)  Tropical  Dysentery— Amoebic  Dysentery. — This  form  of  intestinal 
flux  is  characterized  by  irregular  diarrluea  aiul  the  constant  presence  in  tlie 
stools  of  the  amo'ba  roli  (Losch),  (HiKvkt  (/i/seiiteriw  (Councilman  and  La- 
fleur).  It  is  this  variety  which  i)revails  extensively  in  the  tropical  and  sub- 
tropical regions,  ami  which  }. roves  so  fatal  in  epidemic  form.  The  amaba 
is  a  unicellular,  ])rotoplasmic,  motile  organism,  from  ten  to  twenty  micro- 
millimetres  in  diameter,  consisting  of  a  clear  outer  zone,  ectosarc,  and  a 
granular  inner  zone,  endosarc,  containing  a  nucleus  and  one  or  more 
vacuoles.  It  was  first  described  by  [iambi  in  1859,  and  subsequently  by 
Losch,  who  considerc  '  it  the  cause  of  the  disease.  In  the  endemic  dysen- 
tery of  Egypt,  Kartulis,  in  188.'},  found  these  anuebae  constantly  in  the 
stools,  in  the  intc-iines,  aiul  in  the  liver  abscesst^s.  lie  was  afterward 
enabled  to  cultivate  them  in  straw  infusion,  ami  to  produce  the  disease 
artificially  in  cats  and  dogs.  In  1890  I  reported  a  case  of  dj'sentery  with 
abscess  of  the  liver  originating  in  Panama,  in  which  the  amrebaj  were 
fouiul  in  the  stools  and  in  the  ]>us  from  the  abscess ;  and  lately  Council- 
man and  Lafleur*  have  described  the  clinical  features  and  anatomical 
lesions  in  a  series  of  cases  of  this  f<n'm  of  dysentery  in  my  wards.  Dock, 
in  Calveston,  has  demonstrated  their  presence  in  a  number  of  cases,  and 
Musser  has  found  them  in  Philadelphia.  The  disease  is  very  common  in 
tropical  and  subtro])ical  countries.  It  is,  however,  found  more  or  less 
widely  distributed  throughout  Europe  and  North  America.  The  source;- 
of  infection  are  not  known,  but  it  seems  probable  that  one  of  them  is 
drinking-water. 

Morbid  Anatomy. — The  lesions  arc  found  in  the  large  intestine,  some- 
times in-  the  lower  portion  of  the  ileum.  Abscess  of  the  liver  is  a  common 
sequence.     Perforation  into  the  right  lung  is  not  infrequent. 

Intestines. — The  lesions  consist  of  ulceration,  produced,  by  preceding 

•  Johns  Hopkins  Hospital  Reports,  vol.  ii. 


DYSENTERY. 


133 


infiltration,  general  or  local,  of  tlio  submucoaa,  the  gononil  infiltration 
bi'iii"'  duo  to  au  a3domatou3  condition,  the  local  to  multiplication  of  the 
fixoil  cells  of  the  tissue.  In  the  earliest  stage  these  local  infiltrations 
iipiH'ar  as  hemis])herical  elevations  above  the  general  level  of  the  mucosa. 
The  mucous  membrane  over  these  soon  becomes  necrotic  and  is  cast  off, 
exposing  the  infdtrated  submucous  tissue  as  a  grayish-yellow  gelatinous 
mass,  which  at  first  forms  the  lloor  of  the  ulcer,  but  is  subsequently  cast 
ol!  as  a  slough. 

The  individual  xilcers  are  round,  oval,  or  irregular,  with  infiltrated, 
undernuned  edges.  The  visible  aperture  is  often  small  compared  to  the 
loss  of  tissue  beneath  it,  the  ulcers  undermining  the  mucosa,  coalescing, 
and  forming  sinuous  tracts  bridged  over  by  apparently  nornuil  mucous 
munibranc.  According  to  the  stage  at  which  the  lesions  are  observed,  the 
floor  of  the  ulcer  may  bo  formed  by  the  submucous,  the  muscular,  or  the 
serous  coat  of  the  intestine.  The  ulceration  may  aifect  the  whole  or  some 
portion  only  of  the  large  intestine,  particularly  the  caecum,  the  hepatic 
and  sigmoid  flexures,  and  the  rectum.  In  severe  cases  the  whole  of  tho 
intestine  is  much  thickened  and  riddled  with  ulcers,  with  only  here  and 
there  islands  of  intact  mucous  membrane. 

Tho  disease  advances  by  progressive  infiltration  of  the  connective-tissue 
layers  of  the  intestine,  which  ])roduccs  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  slough- 
ing en  masse  of  the  mucosa  or  of  tho  muscularis,  and  the  same  process  ia 
observed,  but  not  so  consi)icuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  diphtheritic  inflammation  complicates  the 
original  lesions. 

Healing  takes  place  by  the  gradual  formation  of  fibrous  tissue  in  the 
floor  and  at  the  edges  of  tho  ulcers,  which  may  ultimately  result  in  partial 
and  irregular  strictures  of  the  bowel. 

Microscopical  examination  shows  a  notable  absence  of  tho  products  of 
purulent  inflammation.  In  the  infiltrated  tissues  polynuclear  leucocytes 
are  seldom  found,  and  never  constitute  purulent  collections.  On  the 
otlier  hiuul,  there  is  proliferation  of  tho  fixed  connective-tissue  cells. 
Ama'biw  are  found  more  or  less  abundantly  in  the  tissues  at  the  base  of 
and  around  the  ulcers,  in  tho  lymphatic  spaces,  and  occasionally  in  the 
blood-vessels. 

The  lesions  in  the  liver  are  of  two  kinds :  firstly,  local  necroses  of  the 
parenchyma,  scattered  throughout  tho  liver  and  possibly  due  to  the  action 
of  chemieal  })roducts  of  the  amu'biu ;  and,  secondly,  abscesses.  These  may 
be  single  or  multiide.  When  single  they  are  generally  in  the  right  lobe, 
either  toward  the  convex  surface  near  its  diaphragmatic  attachment,  or  on 
tlie  coiiciivo  surface  in  proximity  to  the  bowel.  Multiple  abscesses  are 
sniuU  and  generally  superficial.  In  an  early  stage  the  abscesses  are  grayish- 
yellow,  with  sharply  defined  contours,  and  contain  a  spongy  necrotic  ma- 
li!iialj  with  more  or  less  fluid  in  its  interstices.     The  larger  abscesses  have 


1-      ! 
'.i'   J. 


IP    ' 

:| !  ■ 
If ' 


134 


SPECIFIC  INFECTIOUS  DlSEASEa 


ragged  necrotic  wulls,  and  contain  a  more  or  less  viscid,  greenish-yellow 
or  reddish-yellow  purulent  material  mixed  with  blood  and  shreds  of  liver- 
tissue.  The  older  abscesses  have  fibrous  walls  of  a  dense,  almost  carti- 
h»ginous  toughness.  A  section  of  the  abscess  wall  shows  an  inner  necrotic 
zone,  a  middle  zone  in  which  there  is  great  proliferation  of  the  connective- 
tissue  cells  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  hypcra3mia.  There  is  the  same  absence  of  purulent  inflam- 
mation as  in  the  intestine,  except  in  those  cases  in  which  a  secondary  in- 
fection with  pyogenic  organisms  has  taken  place.  1'ho  material  from  the 
abscess  cavity  shows  chiefly  fatty  and  granular  detritus,  few  cellular  ele- 
ments, and  more  or  less  numerous  amccba?.  Ama-bte  are  also  found  in  the 
abscess  walls,  chiefly  in  the  inner  necrotic  zone.  Cultures  are  usually 
sterile.  Lesions  in  the  lungs  are  seen  when  an  abscess  of  tlie  liver — as  so 
frequently  happens — points  toward  the  diaphragm  and  extends  by  conti- 
nuity through  it  into  the  lower  lobe  of  the  right  lung.  The  gross  and 
microscopical  appearances  are  similar  to  those  of  the  liver. 

Sytnptoms. — The  onset  may  be  sudden,  as  in  catarrhal  dysentery,  or 
gradual,  beginning  as  a  trifling  and  perhaps  transient  diarrhu?a.  In  severe 
gangrenous  cases  the  abru2>t  onset  is  more  common.  The  subsequent 
course  is  a  very  irregular  diarrho'a,  marked  by  exacerbations  and  inter- 
missions, and  progressive  loss  of  strength  and  flesh.  There  is  moderate 
fever  as  a  rule,  but  many  cases  arc  afebrile  throughout  the  greater  part  of 
their  course.  Abdominal  pain  and  tenesmus  are  frequently  present  at  the 
onset,  especially  in  severe  cases,  but  may  be  entirely  absent,  and  vomiting 
and  nausea  are  only  occasionally  observed.  The  stools  vary  very  much  in 
frequency  and  appearance  in  different  cases  and  at  different  periods  in  the 
game  cases.  They  may  be  vei-y  frequent,  blood y^  and  mucoid  at  the  out- 
set, as  in  catarrhal  dysentery;  but  their  main  chai'acteristic,  when  the 
disease  is  well  established,  is  fluidity.  From  six  to  twelve  yellowish-gray 
liquid  stools,  containing  mucus  and  occasionally  blood  in  varying  pro])or- 
tions,  are  passed  daily  for  weeks.  Actively  moving  amoobaB  arc  found  in 
these  stools,  more  abundantly  during  exacerbations  of  the  diarrhoea,  and 
disappear  gradually  as  the  stools  become  formed. 

Abscess  of  the  liver,  and  especially  of  the  liver  and  lung,  is  a  frequent 
and  formidable  complication.  In  India  it  occurs  once  in  every  four  or 
five  cases. 

The  duration  of  the  disease  in  uncomplicated  cases  varies  from  six  to 
twelve  weeks.  Recovery  is  tedious,  owing  to  anaemia  and  muscular  weak- 
ness, often  delayed  by  relapses,  and  there  is  in  all  cases  a  constant  tend- 
ency to  chronicity.  The  mortality  is  much  higher  than  in  catarrhal 
dysentery.  A  fatal  issue  is  due  either  to  the  initial  gravity  of  the  intes- 
tinal lesions,  to  exhaustion  in  prolonged  cases,  or  to  involvement  of  the 
liver. 

{<:)  Diphtheritic  Dysentery. — A  form  of  colitis  or  cntcro-colitis  in 
which  areas  of  necrosis  occur  iu  the  mucous  membranes,  which  on  sepa- 


DYSENTERY. 


1S5 


■J5' 

Ipvopor- 

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ea,  and 

rcqucnt 
[four  01 

six  to 
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It  toiul- 

lltlUTlull 

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ot  tlw 

llilis  in 
In  sepa- 


ration leave  ulcers.     This  occurs :  {n)  As  a  primary  disease  coming  on 
iiciitoly  and  sometimes  proving  fatal.     In  its  milder  grades  the  tops  of 
till'  folds  of  the  colon  are  capped  with  a  thin,  yellow  exudate.     In  se- 
Mi-cr  forms  the  colon  is  enormously  enlarged,  the  walls  are  thickened, 
.siilT,  and  infiltrated,  and  the  mucosa,  from  the  ileo-ciecal  valve  to  the 
iccluni,  represented  by  a  tough,  yellowish  material,  in  which  on  sec  don 
no  trace  of   the  glandular  elements  can  be  seen.      It  is  an  extensive 
lu'cro.sis  of  the  mucosa.     There  are  cases  in  which  this  necrosis  is  su- 
iicrticial,  involving  only  the  upper  layers  of  the  mucous  membrane ;  but 
ill  the  most  advanced  forms  it  may  be,  as  in  the  descrii)tion  by  Koki- 
tansky,  "  a  black,  rotten,  friable,  charred  mass."     The  areas  of  necrosis 
iiiav  be  more  localized,  and  large  sloughs  are  formed  which  may  be  a 
half  to  three  fourths  of  an  inch  in  thickness  and  extend  to  the  serosa. 
Tliero  are  instances  in  which  this  condition  is  confined  to  the  lower  por- 
tion of  the  largo  bowel.     A  sailor  from  the  Mediterranean  was  admitted 
to  the  Montreal  General  Hospital  under  my  care  with  symptoms  resem- 
\)\\\vz  typhoid  fever.    The  autopsy  showed  enormous  sloughs  in  the  rectum 
and  in  tiie  sigmoid  flexure,  but  scarcely  any  disease  in  the  transverse  or 
iiscciuling  colon.    In  cases  which  last  for  many  weeks  the  sloughs  separate 
and  may  be  thrown  off,  sometimes  in  large  tubular  jneccs. 

[I))  Scro)i(l(iry  Diphtheritic  Dysentery. — This  occurs  as  a  terminal 
event  ill  many  acute  and  chronic  diseases.  It  is  not  infrequent  in  chronic 
licart  att'eetions,  in  Bright's  disease,  and  in  cachectic  states  generally.  l\\ 
.•iciite  diseases  it  is,  as  pointed  out  by  Bristowe,  most  frequently  associated 
with  pneumonia.  Anatomically  there  may  be  only  a  thin,  superficial  infil- 
tration of  the  upper  layer  of  the  mucosa  in  localized  regions,  particularly 
alon;;  tlie  ridges  and  folds  of  the  colon,  often  extonding  into  the  ileum. 
in  severer  forms  the  entire  mucosa  may  be  involved  and  necrotic,  some- 
times having  a  rough,  granular  appearance.  In  the  secondary  colitis  of 
jmeunionia  the  exudation  may  be  pseudo-membranous  and  form  a  firm, 
thin,  while  i)ellicle  which  seems  to  lie  upon,  not  within,  the  mucous  mem- 
lirane. 

SiimplDins. — The  clinical  features  of  diphtheritic  dysentery  are  very 
varied,  in  the  acute  primary  cases  the  patient  from  the  outset  is  often 
extremely  ill,  with  high  fever,  great  prostration,  pain  in  the  abdomen,  and 
fii>(|iR'nt  (liseliarges.  Delirium  may  be  early  aiul  the  clinical  features  may 
closely  reseinl)le  severe  typhoid.  I  have,  on  more  than  ore  o(>casion, 
known  this  mistake  to  bo  made.  The  abdomen  is  distended  and  often 
tender.  Tlio  discharges  are  frequent  and  diarrheal  in  character,  and 
tenesmus  may  not  be  a  striking  symptom.  Blood  and  mucus  may  be 
fouiul  early,  l)iit  are  not  such  constant  features  as  in  the  follicular  disease. 
'I'liis  iiriniary  form  is  very  fatal,  but  the  sloughs  may  separate  and  the 
leoiuliiion  hrt'ome  chronic.  In  the  secondary  form  there  may  have  been 
110  syniptoms  to  attract  attention  to  the  large  bowel.  In  a  majority  of  the 
[cuiies  the  patient  has  a  diarrha>a — three,  four,  or  more  niovoments  in  the 

10 


:'■    V 


%.  . 


186 


SPECIFIC   INFECTIOUS  DISEASES. 


I     1 


day,  wliicli  uro  often  profuse  and  weakening.  A  little  blood  and  mucus 
may  be  ])a.stied  at  lirst,  but  they  are  not  specially  characteristic  elemonts 
in  the  stools. 

In  all  forms  of  dysentery  death  nsnally  results  from  asthenia.  The 
pidse  becomes  weaker  and  more  rapid,  the  tongue  dry,  the  face  ])inclip(l, 
the  skin  eoul  and  covered  with  sweat,  and  the  patient  falls  into  a  drowsv, 
torpid  condition.  Consciousness  may  be  retained  until  the  last,  but  in 
the  protracted  oases  there  is  a  low  delirium  deepening  into  collapse. 

(d)  Chronic  Dysentery. — This  usually  succeeds  an  acute  attack,  thoii^'h 
the  ama'bic  form  may  bo  subacute  from  the  outset  and  not  present  an  acute 
period.  Anatomical  changes  in  the  large  intestine  in  chronic  dysentery 
arc  variable,  'inhere  may  be  no  ulceration,  and  the  entire  mucosa  presents 
a  rough,  iircgidar  puckered  ajipearance,  in  places  slate-gray  or  blackish  in 
color.  The  submucosa  is  thickened  and  the  muscular  coats  are  hyper- 
trophiod.  There  nuiy  be  cystic  degeneration  of  the  glandular  elements, 
as  is  beautifully  ligured  in  Woodward's  volume. 

Ulcers  are  usually  present,  often  extensive  and  deeply  pigmentol,  in 
places  perhaps  liealing.  Tlie  submucous  and  muscular  coats  are  thiclv- 
ened  and  the  calibre  of  the  bowel  may  be  reduced.  Stricture,  however,  is 
very  rare. 

Tlie  fiymplfims  of  chronic  dysentery  are  by  no  means  definite,  and  it  lis 
not  always  i)ossible  to  sej)arate  the  cases  from  those  of  chronic  diarrluia. 
Many  of  the  characteristic  symptoms  of  the  acute  disease  are  aljsent. 
Tenesmus  and  severe  griping  pains  rarely  occur  except  in  acute  exacerba- 
tions.    The  character  of  the  stools  varies  very  much.     Blood  and  necrotic 
shreddy  tissue  are  not  often  found.     Mucus  is  passed  in  variable  amounts, 
On  a  mixed  diet  the  fasces  are  thin,  often  frothy;  ami  contain  particles 
of  food.     The  motions  vary  from  four  or  five  to  twelve  or  more  in  the 
twenty-four  hours.     IMiere  are  cases  in  which  marked  constipation  iiller- 
nates  with  attacks  of  diarrhoea,  and  scybala  may  be  passed  with  inueli 
nnicus.     In  many  cases  the  faeces  have  a  semi-fluid  consistency,  and  a  yel- 
lowish or  brown  color  depending  on  the  amount  of  bile.     Fragments  of 
undigested  food  may  be  found,  and  the  discharges  have  the  character  of 
what  is  termed  a  lienteric  diarrho'a.     Indeed,  variations  in  the  bile  ami 
in  the  food  give  at  once  corresponding  variations  in  the  character  of  tliC' 
stools.     In  chronic  dy.sentery  recurrences  are  common  in  which  blood  ami 
mucus  again  appear  in  the  stools,  accompanied  perhaps  by  pus.     I'latii- 
lence  is  i  i  some  cases  distressing,  and  there  is  always  more  or  less  ten- 
derness along  the  course  of  the  colon.     The  appetite  is  capricious,  the 
digestion  disordered,  and  unless  the  patient  is  on  a  strictly  regulatcil  ditt 
the  number  of  stools  is  greatly  increased.    The  tongue  is  not  often  fiineil; 
it  is  more  commonly  n»d,  glazed,  and  b(?efy,  and  becomes  dry  and  crackci 
toward  the  end  in  i)rotracted  cases.     There  is  always  aiuvmia  and  tlit 
emaciation  may  bo  extreme;  with  the  exception  of  gastric  cancer,  we 
rarely  see  such  ghastly  faces  as  in  patients  with  prolonged  dysentery- 


DYSENTERY. 


137 


Tlic  romi)liciitions  are  those  already  referred  to  in  the  acute  form.  Tlie 
"renter  debility  renders  the  patient  more  liable  to  the  intercurrent  af- 
feciiuii.s,  such  as  i)neumonia  and  tuberculosis.  Ulceration  of  the  cornea 
was  frequently  noted  during  the  civil  war. 

Complications  and  Sequelee. — A  local  peritonitis  may  arise  by 
exteiK-^iiiii,  or  a  dilfuse  inllammatiou  may  follow  perforation,  which  is 
usually  fatal.  When  this  occurs  about  the  ca'cal  region,  perityphlitis  re- 
sults; when  low  down  in  the  rectum,  periproctitis.  In  one  hundred  and 
eight  autoi)sies  collected  by  Woodward  perforation  occurred  in  eleven.  Jiy 
far  tlie  nujst  serious  complication  is  abscess  of  the  liver,  which  occurs  fre- 
quently in  the  tropics  and  is  not  very  uncommon  in  this  country.  It  was 
not,  however,  a  frequent  complication  in  dysentery  during  the  civil  war. 
In  this  latitude  it  is  certainly  not  uncommon,  as  wo  have  had  five  cases, 
witliiii  two  years,  in  the  Johns  Hopkins  Hospital.  It  usually  comes  on 
insidiously.  The  symptoms  will  be  discussed  in  connection  with  hepatic 
iibscess. 

It  is  stated  that  malaria  is  a  complication,  but  with  one  exception  the 
cases  which  I  have  seen  with  intermittent  pyrexia  were  invariably  associ- 
ated with  suppuration.  In  extensive  epidemics,  however.  Woodward  states 
that  eases  of  ordinary  dysentery  occur  associated  with  <ill  the  phenomena 
of  nuiluria.  With  reference  to  typhoid  fever,  as  a  complication,  this  au- 
thor mentions  that  the  combination  was  exceedingly  frequent  during  the 
eivil  war,  and  characteristic  lesions  of  both  diseases  coexisted.  In  civil 
praitiee  it  must  be  extremely  rare 

Sydeidiam  noted  that  dysentery  was  sometimes  associated  with  rheu- 
iniitie  pains,  and  in  certain  epidemics  joint  swellings  have  been  especially 
inevalent.  They  are  probably  not  of  the  nature  of  true  rheumatism,  but 
are  ratlier  analogous  to  gonorrlural  arthritis.  In  severe,  protracted  cases 
tliere  iiuiy  be  pleurisy,  pericarditis,  endocarditis,  and  occasionally  pya^mic 
manifestations,  among  which  may  be  mentioned  pylephlebitis.  Chronic 
Hri;:lit\s  disease  is  also  an  occasional  sequel.  In  protracted  cases  there 
may  be  an  anaemic  oedema.  An  interesting  sequel  of  dysentery  is  paraly- 
sis. Woodward  reports  eight  cases.  Weir  ]\Iitchell  mentions  it  as  not 
uncorniiiou,  occurring  chiefly  in  the  form  of  parajdegia.  As  in  other  acutc^ 
fevers,  this  is  due  to  a  neuritis.*  Intestinal  stricture  is  a  rare  sequence — 
so  rare  that  no  case  was  reported  at  the  Surgeon-Cieneral's  oflice  during 
the  war.  Among  the  sequelae  of  chronic  dysentery,  in  persons  who  have 
neovered  a  certain  measure  of  health,  may  be  mentioned  persistent  dys- 
pqisia  and  irritability  of  the  bowels. 

Diagnosis. — Tlie  recognition  of  the  acute  follicular  form  is  easy ; 
till'  fn^iuency  of  the  passages,  the  jjresence  of  blood  and  mucus,  atul  the 
tiiiesmns  forming  a  very  characteristic  picture.  Local  affections  of  the 
rectum,  particularly  syphilis  and  epithelioma,  may  produce  tenesmus  with 


*  Pugibet,  Revue  de  MeUeeinc,  February,  1888. 


I ', 


» 


138 


SPECIFIC   INFECTIOUS  DISEASES. 


II  .    .1, 


the  passapfe  of  mucoid  and  bloody  stools.  Tlio  acute  diphtheritic  form, 
coming  on  with  great  intensity  and  with  severe  constitutional  disturl)- 
ances,  is  not  infrecjuently  mistaken  for  typhoid  fever,  to  which  indeed  in 
many  cases  the  resemblance  is  extremely  close.  The  liigher  grade  of 
fever,  the  more  pronounced  intestinal  symptoms,  the  presence,  particuliiilv 
in  the  early  stage,  of  a  small  amount  of  blood  in  the  stools,  the  absence  of 
enlargement  of  the  spleen  and  the  rose  rash  should  lead  to  a  correct  diiij;- 
tiosis.  In  the  ama;bic  form  the  diagnosis  can  readily  bo  made  by  ex- 
amination of  the  stools.  A  characteristic  feature  of  these  cases  is  their 
irregular,  chronic  course.  A  patient  may  be  about  and  in  fairly  good 
condition,  with  well-formed  stools  and  very  slight  intestinal  disturbance, 
in  wliose  faices  the  amujbaj  may  still  be  discovered,  and  in  whom  the 
disease  is  at  any  time  likely  to  recur  with  intensity.  In  some  cases,  com- 
{)licated  by  abscess  of  the  liver  and  lung  discharging  through  a  bronchus, 
the  diagnosis  may  rest  on  the  detection  of  amojbte  in  the  sputa,  when  tliey 
cannot  be  found  in  the  stools  owing  to  the  latency  of  the  intestinal  dis- 
turbance.    Three  such  cases  occurred  in  my  wards  in  1890.* 

Treatment. — Flint  has  shown  that  sporadic  dysentery  is,  in  its 
slighter  grades  at  least,  a  self-limited  disease,  which  runs  its  course  in 
eight  or  nine  days.  Reading  a  report  of  his  cases,  one  is  struck,  however, 
with  their  comparative  mildness. 

The  enormous  s"rface  involved,  amounting  to  many  square  feet,  the  con- 
stant presence  of  irritating  particles  of  food,  and  the  impossibility  of  get- 
ting absolute  rest,  are  conditions  which  render  the  treatment  of  dysentery 
peculiarly  difficult.  Moreover,  in  the  severer  cases,  when  necrosis  of  the 
muco.^a  has  occurred,  ulceration  necessarily  follows,  and  cannot  in  any  way 
be  obviated.  When  a  case  is  seen  early,  particularly- if  there  has  been  con- 
stipation, a  saline  purge  should  be  given.  The  free  watery  evacuations 
produced  by  a  dose  of  salts  cleanse  the  large  bowel  with  the  least  possible 
irritation,  and  if  necessary,  in  the  course  of  the  disease,  particularly  if 
scybala  are  present,  tlie  dose  may  be  repeated.  Purgatives  arc,  as  a  rule, 
objectionable,  and  the  profession  has  largely  given  up  their  use.  Of  medi- 
cines given  by  the  mouth  which  are  supposed  to  have  a  direct  effect  upon 
the  disease,  ipecacuanha  still  maintains  its  reputation  in  the  tropics.  It 
did  not,  however,  prove  satisfactory  during  the  civil  war;  nor  can  I  say 
that  in  cases  of  sporadic  dysentery  I  have  ever  seen  the  marked  ctTect 
described  by  the  Anglo-Indian  surgeons.  The  usual  method  of  adminis- 
tration is  to  give  a  preliminary  dose  of  opium,  in  the  form  of  laudaniini  nr 
morphia,  and  half  an  hour  after  from  twenty  to  sixty  grains  of  ipecacuanha. 
If  rejected  by  vomiting,  the  dose  is  repeated  in  a  few  hours. 

Minute  doses  of  corrosive  sublimate,  one  hundredth  of  a  grain  every 
two  hours,  are  warmly  recommended  by  Ringer.  Large  doses  of  bismutli, 
half  a  drachm  to  a  drachm  every  two  hours,  so  that  the  patient  may  take 

*  For  details  see  monograph  of  Councilman  and  Lafleur. 


DYSENTEIIV. 


139 


from  twelve  to  fifteen  draohms  in  a  day,  have  in  many  cases  had  a  l)t'no- 
fu'ial  tlTt'ct.  To  do  good  it  nnist  be  given  in  large  doses,  as  recommended 
bv  Moiiiicri't,  who  gave  as  high  as  seventy  grammes  a  day.  It  certainly  is 
more  useful  in  the  chronic  than  the  acute  cases.  It  is  best  given  alone. 
Oi)iiiin  is  an  invaluable  remedy  for  the  relief  of  the  pain  and  to  quiet  the 
ppiistaliiis.  It  should  be  given  as  morphia,  hypodermically,  according  to 
the  needs  of  the  case. 

'I'lie  treatment  of  dysentery  by  topical  applications  is  by  far  the  most 
mtioiml  ])]an.     A  serious  obstacle,  however,  in  the  acute  cases,  is  the  ex- 
treme irritability  of  the  rectum  and  the  tenesmus  which  follows  any 
iitteiii|it  to  irrigate  the  colon.     A  preliminary  cocaine  suppository  or  the 
inject  ion  of  a  small  quantity  of  tlu;  four-per-cent  solution  will  sometimes 
relieve  tliis,  and  then  with  a  long  tube  the  solution  can  be  allowed  to  How 
in  slowly.    The  patient  should  be  in  the  dorsal  position  with  a  pillow 
luuler  the  hips,  so  as  to  get  the  etTect  of  gravitation.     Water  at  the  tem- 
|it'rature  of  100°  is  very  soothing,  but  the  irritability  of  the  bowel  is  such 
tlial  large  quantities  can  rarely  be  retained  for  any  time.    When  the  acute 
symptoms  subside,  the  injections  are  better  borne.     Various  astringents 
may  bo  used — alum,  acetate  of  lead,  sulphate  of  zinc  and  copper,  and 
nitrate  of  silver.    Of  these  remedies  the  nitrate  of  silver  is  the  best, 
tlioiigli  I  think  not  in  very  acute  cases.     In  the  chronic  form  it  is  per- 
haps the  most  satisfactory  method  of  treatment  which  we  have.     It  is 
useless  to  give  it  in  the  small  injections  of  two  or  three  ounces  with  one 
to  two  grains  of  the  salt  to  the  ounce.     It  must  be  a  large  irrigating  in- 
jection, which  will  reach  all  parts  of  the  colon.     This  plan  was  introduced 
l)y  llaro,  of  Edinburgh,  and  is  highly  recommended  by  Stephen  Alac- 
Kenzie  and  H.  C.  Wood.     The  solution  must  be  fairly  strong,  twenty 
to  tliirty  grains  to  the  pint,  and  if  possible  from  three  to  six  pints  of 
fluiil  must  be  injected.     To  begin  with  it  is  well  to  use  not  more  than  a 
diaelim  to  the  two  pints  or  two  and  a  half  pints,  and  to  let  the  warm  fluid 
run  ill  slowly  through  a  tube  passed  far  into  the  bowel.     It  is  at  times 
intensely  painful  and  is  rejected  at  once.     In  the  cases  of  amo'bic  dysen- 
tery we  have  been  using  at  the  Johns  Hopkins  Hospital  with  great  bcjiefit 
warm  injections  of  quinine  in  strength  of  1  to  .5,000,  1  to  2,500,  and  1  to 
IJiOO.    The  amoebae  are  rapidly  destroyed  by  it.     These  large  injections 
are  not  without  a  certain  degree  of  danger.     IJrayton   liall  reports  the 
case  of  a  child  in  whom  general  peritonitis  followed  the  injections.     I 
iuive  never  seen  any  ill  effects,  even  with  the  very  large  amounts.     When 
tliore  is  not  much  tenesmus,  a  small  injection  of  thin  starch  with  half  a 
liraclim  to  a  drachm  of  laudanum  gives  great  relief,  but  for  the  tormina 
iiuil  tenesmus,  the  two   most  distressing  symptoms,  a  hypodermic  of 
iiiorpliiii  is   the   only  satisfactory  remedy.      Local  applications  to  the 
abdomen,  in  the  form  of  light  poultices  or  turpentine  stupes,  are  very 
grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  broths, 


140 


SPEriFIC   INFECTIOUS   DISMASES. 


and  (luriiij?  coiiviiU'Sctiiice  tho  ^n-atcst  euro  mnHt  bo  taken  to  provitlo  onlv 
tli(!  most  (li^t'stiblo  urticli'H  of  food.  In  chronic  (lysfntcrv,  diet  is  |M'rlia|Prt 
tilt'  most  imjxjrtant  element  ia  tlio  treatment,  'i'lu!  number  of  stools  caii 
fref|uently  bo  reduced  from  ten  or  twelve  in  the  day  to  two  or  three,  hv 
j)lacinif  the  patient  in  bed  and  reslrictin;^  the  dii't.  Many  cases  do  well 
on  milk  alone,  but  tho  stools  should  be  carefully  watched  and  th(!  aniouiii 
limited  to  that  which  can  bo  digested.  If  curds  appear,  or  if  much  (tilv 
nuitter  is  aeon  on  microscopical  examination,  it  is  best  to  reduce  tho 
amount  of  milk  aiul  to  Hup()lenu'nt  it  with  beef-juice  or,  better  still,  v<:<^- 
albunu-n  The  large  doses  of  bismuth  Hccm  specially  suitable  in  the 
(thronic  cases,  und  the  injections  of  nitrate  of  silver,  in  the  way  already 
mentioned,  should  always  be  given  a  trial. 


XXI.   MALARIAL   FEVER. 

Deflnition. — An  infectious  disease  characterized  by  :  (n)  paroxysms  of 
intermittent  fever  of  (juotidian,  tertian,  or  (piartan  type;  (/>)  a  continiicil 
fever  with  marked  remissions;  (r)  certain  pernicdous,  rapidly  fatal  forms; 
and  {(I)  u  chronic  cachexia,  with  ana'mia  and  an  eidarged  s])leen. 

With  the  disease  are  invariably  associated  the  luematozoa  described  l»y 
Laveran. 

Etiology.— (1)  Geographical  Distribution.— In  Kurope,  soutliorn  Rus- 
sia aiuI  certain  parts  of  Italy  are  now  the  chief  seats  of  the  disease.  It 
is  not  widely  prevalent  in  CJernumy,  France,  or  England,  and  the  foci  of 
epidemics  are  becoming  yearly  more  restricted.  In  America  it  is  now 
rare  on  the  Atlantic  coast  above  tlie  latitude  of  Phihiilelphia.  From  New 
England,  wliero  it  once  prevailed  extensively,  it  has  gradually  disappeared, 
but  there  has  of  late  years  been  a  slight  return  in  some  places.  In  tho  city 
of  >»ew  York  genuine  nudaria  is  rare  except  as  an  imported  disease.  In 
Philadelphia  and  along  the  valleys  of  the  Delaware  ami  Schuylkill  h'ivtis, 
formerly  hot-beds  of  malaria,  tie  disease  has  become  much  restricted. 
Except  in  the  low-lying  southern  portions  of  the  city  it  rarely  devel- 
ops, and  tho  majority  of  cases  admitted  into  hospital  are  of  the  poorer 
class,  who  have  returned  from  picking  cranberries  and  peaches  in  Dela- 
ware and  New  Jersey,  In  Ualtimore  a  few  cases  develoj)  in  the  autiiinn, 
but  a  majority  of  the  patients  seeking  relief  are  from  the  outlying  dis- 
tricts and  one  or  two  of  the  inlets  of  Chesapeake  Bay.  Though  prevalent 
in  certain  regions  on  this  bay,  the  disease  is  yearly  becoming  less  wide- 
spread and  less  severe.  In  the  Southern  States  there  are  on  the  seaboard 
nuiny  isolated  regions  in  which  malaria  prevails ;  but  here,  too,  there  has 
everywhere  been  a  marked  diminution  in  the  prevalence  and  intensity  of 
the  disease.  W.  W.  Johnston  states  that  in  the  Gulf  district  there  are 
places  in  which  the  disease  is  increasing.  The  ])ercentage  of  cases  admit- 
ted to  the  Marine  Hospital  Service  in  1876  was  184,  and  23-4  in  1887. 


MALARIAL  FKVKR. 


Ul 


Hilt  tlii.^  nmy  bo  duo  to  tho  (lovclopnipnt  of  tlio  sliippiiig  triido  and  t<»  tlm 
ifri'iii«r  luiinbcr  of  «iiilora  who  nirry  tlio  infectiou  from  llio  West  Indiuu 
iKjits,  and  tlioHO  of  M(ixi(!o  and  t'l'iilrul  Aincricii. 

Ill  tlio  interior  of  liOiiihiiiiia,  Missirisippi,  Arkatisafl,  niid  Tcxa.'i  nialaria 
is  ciKliiiiic,  and  tiio  Hovcre  types  aro  not  int'iv(|iu'iit.  At  irregular  jieriuiU 
('liiiliiiiicrf  of  tho  ;no8t  njiViTC!  forind  oecnr. 

Ill  tlie  Western  ;uid  iNorthwostern  Statoii  malaria  18  almost  unknown. 
It  is  rare  on  the  I'aeifli  toast.  In  the  rei,Mon  of  the  (Jreat  Lakes  malaria 
prevails  only  in  tho  Late  Krie  ami  Lake  St.  Clair  re;^Moiis.  It  has  ])rae- 
ticallv  disappeared  from  f.ake  Ontario,  whereas  in  tho  upper  Ilinii  and 
hake  Superior  basins  it  is  uJikuowii.  The  St.  Lawrence  IJiver  rejjion  re- 
iiiairis  free  from  the  disease.  In  .Montre.il  a  patient  with  malaria  is  invari- 
ably (|iiestioned  as  to  liis  latest  residence. 

(•.')  Telluric  Conditions. — The  importatico  of  the  state  of  the  soil  in  tho 
ctiiildiry  of  malaria  is  iiniver.sally  roeogni/ed.  It  is  sikmi  ))articiilarly  i^i 
low,  marshy  regions  which  liavo  an  ubumhint  vegetable  growth.  Estu- 
aries, l)a(lly  drained,  o,v-lying  districts,  the  course  of  old  river-beds, traet.s 
(»f  land  which  are  rich  in  vegetable  matter,  and  particularly  districts  such 
as  the  Roman  Campagna,  wliicli  liave  been  allowwl  U>  fall  out  of  cultiva- 
tion, aro  favorite  localities  for  the  development  of  the  malarial  poison. 
These  conditions  are  most  frequently  found,  of  course,  in  tropical  and 
sulitn>|iical  regions,  but  Tiothing  can  be  truer  than  the  fact  that  reeking 
niaislies  ot  tlio  most  jiestilent  a|ipearanco  may  be  entirely  devoid  of  tlio 
|iois(in,  and  the  disapi)earaiico  of  the  disease  from  a  locality  is  not  neces- 
sarily associated  with  any  material  improvement  in  the  condition  of  tho 
niarsiies  or  of  the  sutJ.  Thus,  in  New  England  and  in  jiarts  of  western 
Caiiaila.  in  which  malaria  formerly  was  very  jirevaleiit,  the  increased  salu- 
brity is  usually  attrilmled  to  the  clearing  of  the  forests  and  the  better 
drainage  of  the  ground  ;  but  these  improvements  alono  can  scarcely  ex- 
plain the  disappearance,  since  in  many  districts  there  are  marshy  tracts 
and  low-lying  lands  in  every  respect  like  those  in  Mliich,  even  at  the  same 
lalitiule,  the  disease  still  jirevails.  ('ompare,  for  examjde,  a  swampy  tract 
im  tlie  northern  shore  of  Lake  Erie  and  a  similar  tract  on  the  southern 
shore  (if  Lake  Ontario;  tho  ilora  and  fauna  of  the  two  districts  are  prac- 
tirally  identical,  but  in  tho  former  the  conditions  under  which  the  mala- 
rial virus  develops  still  exist,  whereas  in  the  latter  they  have  gradually 
ilisaiipeured.  In  .short,  it  is  impossible  to  ascertain  from  the  nature  of 
tiie  soil  and  climate  in  any  given  place  whether  it  is  malarial  or  not.  In 
iho  absence  of  accurate  knowledge  as  to  the  habitat  of  the  ha'inatozoa,  tho 
•iiily  means  of  deciding  this  point  is  by  noticing  tho  effect  of  residence  in 
siiiji  a  place  on  tho  human  subject,  preferably  one  of  tho  Caucasian  race. 

(■')  Season. — Even  in  the  tropics,  where  malaria  constantly  prevails, 
there  are  minimal  and  maximal  periods;  the  former  corresponding  to  tho 
summer  and  winter,  tho  latter  to  the  spring  and  autumn  months.  In 
temperate  regions,  like  the  central  Atlantic  States,  there  are  only  a  few 


I  Mi 


/ 

1            ^1*''        !■       ■  J 

^■it 

■  i.?-^ 

*'  ''-l^' 

'  'OA 

'  3    , 


142 


SPECIFIC   INFECTIOUS  DISEASFJS. 


cases  in  tho  spring,  usually  in  the  month  of  May,  and  a  large  number  of 
vases  in  September  and  October,  and  sometimes  in  November.  In  the 
tropics,  too,  tho  cases  are  most  numerous  in  the  autumn  months. 

(■i)  Meteorological  Conditions. — («)  Ilmt.—A  tolerably  high  tempera- 
ture is  one  of  tho  essential  conditions  for  the  development  of  the  virus. 
It  is  more  prevalent  after  prolonged  hot  summers. 

{b)  Mtiisturt'. — In  tho  tropics  tlie  malarial  fevers  are  most  prevalent  in 
tho  rainy  seasons.  In  the  temperate  climates  tho  relation  between  tlic 
rainfall  and  nuilaria  is  not  so  clear,  and  cases  are  more  nu:nerous  after  a 
dry  summer;  but  if  either  heat  or  moisture  is  excessive,  tho  development, 
of  the  virus  is  checked  for  a  time. 

(r)  Wimh. — Many  facts  are  on  record  which  seem  to  iiulicato  that  tlio 
poison  nuiy  lie  carried  to  some  distance  by  winds.  The  planting  of  trees 
has  been  held  to  interfere  with  the  transmission  by  prevailing  winds. 
I'ossibly,  however,  the  quickly  growing  trees,  such  as  the  Encahjpfns  yhihu- 
lus,  have  acted  more  beneficially  by  drying  the  soil. 

(o)  Specific  Gravity. — That  the  distribution  of  the  poison  of  malariii 
is  influenced  by  gravity  has  long  been  conceded.  Persons  dwelling  in  the 
upper  stories,  or  in  buildings  elevated  some  distance  above  the  ground, 
are  exempt  in  a  marked  degree. 

The  Specific  Germ. — As  llirsch  correctly  remarks,  tho  late  J.  K.  Mitch- 
ell "  Avas  the  first  to  approach  in  a  scientific  spirit  the  nature  of  infec- 
tive disease  aiul  particularly  in  malarial  fever."  Many  attempts  were 
made  to  discover  a  constant  and  characteristic  organism.  Klebs  and 
Tommasi-Crudeli  in  18T'J  announced  the  discovery  of  a  bacillus  vialarhr, 
but  their  observations  have  not  been  confirmed.  In  1880  Laveran,  u 
French  ariTiy  surgeon,  now  jjrofessor  at  tho  Medical  School  at  VjiI  dp 
CIrace,  announced  the  discovery  of  a  parasite  in  the  blood  of  patients  iit- 
tacked  by  malarial  fever.  During  the  next  three  years  he  published  nine 
additional  cominunications,  but  for  a  tir.ic  tiieso  observations  attracted 
little  attention.  The  Italian  observers  Marchiafava,  C'olli,  and  (iolgi 
corrol)()rated  Laveran's  statements.  Councilman  carefully  studied  the 
question  in  this  country,  and  Laveran's  statements  were  confirmed  by  my- 
self in  I'hiladelphia,  by  Walter  James  in  New  Y'ork,  and  more  recently 
by  Dock  in  Galveston.  In  Iiulia,  Vandyke  Carter  has  published  an  ehib- 
orate  nioiuigr-vph  on  the  parasites.  In  France,  Germany,  and  F^ngland, 
owing  in  great  })art  to  tho  absence  of  cases  of  malaria,  the  value  of  Lave- 
ran's observations  has  been  overlooked,  but  recently  tho  confirmatl'^n  iiiiH 
been  published  from  many  of  tho  Gernuin  clinics.  So  ftvr  as  I  knc  w,  'M 
a  single  observer,  who  has  had  the  necessary  training  and  the  material  •  t 
his  command,  has  failed  to  .lemonstrato  the  existence  of  these  parasites. 

Tho  bodies  which  have  been  found  invariably  associated  with  all  h)xw\> 
of  malarial  fevers,  belong  to  tho  i)rotozoa  and  to  a  group  of  organisms 
known  as  the  /unmai.zoa,,  the  precise  affinities  of  which  have  not  yet  liecn 
definitely  determined.    In  some  respects  they  closely  resemble  the  monads, 


MALARIAL  FEVER. 


143 


in  oiliors  the  sporozoa.  Parasites  of  the  red  blood-corpnsclcs  have  been 
met  with  abundantly  in  tlio  blood  of  fish,  turtles,  and  nuvny  species  of 
birds.  One  of  the  best  and  most  readily  studied  examples  is  the  Drepn- 
nidinm  rananuit,  a  common  parasite  in  the  red  blood-corpuscles  of  the 
fi'(»g.*  In  the  blood  of  patients  with  malarial  fevers  tlie  followinij  forms 
niiiy  be  seen:  (1)  an  unpigmented  hyaline  body  within  the  rod  blood-cor- 
pnscli's  which  displays  active  movements;  (2)  a  pigmented  ama'boid  body 
witliin  the  red  blood-corpuscles,  which,  under  certain  circumstances,  may 
ineiTiiso  in  size  and  form  (;{)  a  segmenting  body,  in  which  the  proto- 
pliusiii  divides  into  a  variable  number  of  delinite  small  si)heres  ;  (4)  cres- 
oeiiti(i  bodies,  the  so-called  crescents,  which  develop  within  the  blood-cor- 
puscles and  form  characteristic  and  distinctive  structures;  (A)  tlagellato 
organisms,  which  may  be  seen  to  develop  from  the  intercellular  pigment- 
ed forms,  or  from  ovoid  bodies  which  are  altered  crescents  ;  ((J)  free  llugella. 
To  the  ama'boid  from  within  the  red  blood-corpuscles  Marohiafava  and 
C'elli  gave  the  name  Plasmodium  vialnrice.  The  following  statements  may 
be  made  with  reference  to  these  bodies  : 

The  highest  living  authorities  on  protozoa,  such  as  Riitschli,  of  Heidel- 
berg, acknov  ledge  that  they  are  truly  parasitic  organisms.  The  testimony 
is  now  uium.'nous  in  France,  India,  America,  Italy,  and  (Jermany  that  these 
bodies  aro  always  present  in  the  malarial  fevers.  There  is  no  evidence  to 
show  that  they  are  ever  present  in  any  other  disease.  I  can  speak  on  this 
point  with  some  conlidence,  having  for  years  been  in  the  habit  of  making 
blood  examinations. 

Tlie  rLiation  of  the  parasites  to  the  symptoms  of  the  diseasv.  has  been 
worked  out  in  part  by  (Solgi,  who  has  shown  that  corresponding  to  the 
paroxysm  there  is  a  ])rocess  of  segmentation. 

The  relation  of  tho  different  })hase8  of  growth  to  the  varieties  of  ma- 
larial fever  has  not  yet  been  thoroughly  established,  but  the  following 
points  may  be  referred  to :  The  typical  intermittents  aro  assmnated  with 
large  f(jrms  of  the  parasites,  of  which  several  varieties  have  been  described. 
<iolgi  Iiiis  descril)ed  two  distinct  forms  which  he  considers  the  causes  of 
tertian  and  quartan  fevers,  and  makes  all  other  types  de|)p)ul  on  con\bina- 
tions  of  these  This  jirobably  holds  good  for  a  largo  pro})ortion  of  inter- 
iiiittents.  With  tho  remittents,  Marchiafava  and  Celli  have  described  a 
liistinct  species,  and  look  upon  the  crescents  as  representing  a  jdiasc  in  its 
ik'vol(H)ment.  1'ho  pernicious  malarial  fevers  are  al  )  jissoeiated  with  this 
variety,  which  the  Italian  observers  call  the  "small  plasmodium."  Tho 
crescents  nuiy  occur  also  in  acute  cases,  but  are  nu)st  constant  in  malarial 
("lehexia.  Tho  flagellate  bodies  do  not  appear  to  have  anydelinite  reUuion 
to  tlie  different  forms  of  the  disease. 

Tlie  general  symptoms  and  tho  morbid  anatomy  of  malaria  aro  in  har- 


'  I'op  ait  excellent  account  of  these  htcmatozoa  and  their  developm»3nt,  sec  Celli,  in 
l''ortsfliritto  dor  Medicin,  1801. 


u 


I   V 


144 


SPECIFIC  INFECTIOrS   DISEASES. 


M' 


i^ ;;  '1 


mony  with  tlie  chanp;es  wliich  this  parasite  induces.  Tho  destruction  of 
the  red  blood-coi'j)usck\s  by  it  can  be  traced  in  all  stages.  Ti»e  preseiicu 
of  the  pigment  in  the  blood  and  the  ^  isoera,  so  characteristic  of  malaria, 
results  from  the  transformation  of  the  hannoglobin  by  the  plasmodin. 
The  anaemia  is  a  direct  consecjuence  of  the  wide-spread  destruction  of  ilio 
corfjusdes  by  the  parasites.  The  constancy  of  their  presence,  the  fact  of 
their  causing  rapid  destruction  of  the  red  blootl-corpuscles,  and  ilio 
remarkable  coincidi'nce  of  their  disappearance  contemporaneously  with 
the  symptoms  on  the  administration  of  (juiiiine,  are  points  strongly  in 
favor  of  their  ttiological  relation  with  the  disease.  There  arc  still  many 
gaps  in  our  knowledge.  Wo  do  not  know  how  the  parasite  enters,  or 
how  or  in  what  form  it  leaves  the  body  ;  how  and  where  it  is  propaguliil ; 
under  what  outside  conditioiis  it  develoi)s,  whether  free  or  in  some  acjuatic 
plant  or  animal.  No  record  of  its  successful  cultivation  has  been  jxib- 
lished. 

]\Ieantinie,  awaiting  further  knowledge,  advantage  may  be  taken  of  its 
constant  presence  in  malaria.  This  alone,  without  reference  to  the  true 
nature  of  the  organism,  is  a  fact  of  the  highest  importan{!e.  To  be  aide, 
everywhere  and  under  all  circumstances,  to  differentiate  between  malaiiii 
and  other  forms  of  fever  is  one  of  tlie  most  important  advances  whirli 
has  been  made  of  late  years  in  practical  medicine,  one  which  will  revolu- 
tionize the  study  of  fevers  in  troi)ical  and  subtropical  countries,  and 
should,  within  a  short  time,  bring  some  order  out  of  the  chaos  which  at 
present  exists  rej^arding  the  different  forms  which  there  prevail.* 

Morbid  Anatomy. — T'he  changes  result  from  the  disintegration  of 
the  red  blood-corinisclcs,  accumulation  of  the  pigment  thereby  formed,  and 
possibly  the  influence  of  toxic  materials  produced  by  the  })arasite.  Casts 
of  simple  malarial  infection,  the  ague,  are  rarely  fatal,  and  our  knowlediri' 
of  the  morbid  anatomy  of  the  disease  is  drawn  from  the  pernicious  niahi- 
ria  or  the  chrojiic  cachexia.  Rupture  of  the  enlarged  spleen  may  onur 
sjmntaneously,  but  more  commonly  from  trauma.  A  case  of  tho  kind  was 
admitted  umler  my  colleague,  llalsted,  in  June,  1881),  and  Dock  has  re- 
cently re{)orted  two  cases. 

(1)  Pernicious  Malaria. — The  condition  dejiends  upon  tho  diiratioi 
of  the  inft'ction  and  u|)on  whether  the  patient  has  hail  previous  attai  ks, 
The  blood  is  hydnemic  and  the  serum  nuiy  oven  be  tinged  with  lia-nni- 
globin.  The  red  blood-corpuscles  present  the  endoglobular  forms  of  tlif 
j)ara.site  and  are  in  all  stages  of  destruction.  The  spleen  is  enlurpMl, 
often  only  moderately;  thus,  of  two  fatal  cases  recently  in  my  wards  the 
si)leens  measured  Vi  x  8  ctin.  and  14  x  8  ctm.  respectively.     If  a  I'n'sh 

*  One  rises  fri)iii  tlu'  inTtisal  of  tlic  recent  Traite  lics  Malndien  (h'n  Pays  Chnntl-'.  1')' 
rCi'lsch  and  Kienor,  witli  ix  fcclinj;  tliat  (lie  key  to  many  of  the  cuinplcx  iirol)li'ni>  iliif'' 
iliscussi'd  and  a  totally  didiTt-nt  ooncpjition  of  many  of  the  features  of  malaria  \\«\M 
have  been  obtained  had  tliey  studied  tlie  diceaso  from  the  standpoint  of  their  country- 
man Laveniu. 


K 


MALARIAL   FEVER. 


145 


infection,  the  epleon  is  usually  very  soft,  and  the  pulp  lake-colored  and 
lurbiil.  In  cases  of  intense  reinfection  the  spleen  may  be  enlarged  and 
linn.  Tlie  amount  of  pigment  in  the  spleen  elements  is  enormously 
iiicnascd.  The  liver  is  swollen  and  turbid.  In  very  acute  cases  there  is 
not  necessarily  any  macroscoj)ic  pigmentation,  though  microscopically 
tiie  rapillaries  may  be  stulTed  with  degenerating  red  blood-corpuscles 
ileeiilv  pigmented.  Perivascular  (portal)  iutlltration  has  been  found  in  a 
verv  acute  case  in  a  young  man  (Dock).  1'ho  brain  usually  sho^s  inter- 
esting changes.  In  severe  cases  of  some  duration  the  tissue  is  stained, 
sometimes  chocolate-colored.  In  mild  cases  the  discoloration  is  present, 
i)Ut  less  marked.  The  blood-vessels,  especially  the  arterioles  and  capil- 
hiries,  contain  hirge  numbers  of  parasites,  with  partial  or  total  destruction 
of  red  blood-corpuscles,  and  pigmented  leucocytes.  Occlusions  of  arterioles 
l)y  means  of  parasites  are  often  seen.  Aniemia  and  (udema  are  commoner 
than  congestion.     The  kidneys  show  analogous  conditions. 

(v^)  Malarial  Cachexia. — A  patient  the  subject  of  chronic  paludism, 
usually  dies  of  auajmia  or  of  h;umorrliage  associated  with  it.  The  most 
eliiinieteristic  cases  of  the  kind  which  have  come  under  my  observation 
Imve  been  in  the  workmen  returning  froni  the  Panama  Canal,  victims  of 
the  so-called  Cliagres  fever 

Tlie  ana'mia  is  profouinl,  ])articularly  if  the  patient  has  died  of  fever. 
The  spleen  is  greatly  enlarged,  and  may  weigh  from  seven  to  ten  pounds. 
If  the  disease  has  persisted  for  any  length  of  time,  it  is  firm  and  resists 
cutting.  The  capsule  is  thickened,  the  parenchyma  brownish  or  yel- 
luwi-sh-hrown,  witii  areas  of  pigmentation,  or  in  very  protracted  cases 
it  is  extremely  melauosed,  particularly  in  the  trabecuUe  and  about  the 
vessels. 

The  liver  nuiy  be  greatly  enlarged ;  but,  as  a  rule,  the  increase  in  size 
immoderate  in  proportion  to  that  of  the  spleen.  It  may  present  to  the 
iiaktil  eye  a  grayish-brown  or  slate  color  due  to  the  large  amount  of  ])ig- 
inent.  In  the  portal  canals  and  beneath  the  capsule  the  connective 
tissue  is  imjiregnated  with  nu'lanin.  Varying  with  the  duration  of  the 
ilisease,  the  shade  of  color  of  the  liver  ranges  from  a  light  gray  to  a  deep 
I'lute-gray  tint.  The  texture  is  firm,  but  there  is  not  necessarily  any  great 
increase  in  the  connective  tissue.  Histologically,  the  pigment  is  seen  in 
the  KiiptTer's  cells  and  the  iierivascular  tissue. 

The  ki()neys  nuiy  be  enlarged  and  ))res('nt  a  grayisli-red  color,  or  areas 
of  i>ii:inentation  may  be  seen,  'i'lie  ])igment  nniy  be  dilTusely  scattered 
iiiid  [lariicularly  marked  about  the  l)lood-vessels  and  the  Malpighian 
hiiilies,(jr  it  is  often  abundant  in  the  cells  of  the  convoluted  and  collecting 
tn'oiiles.  The  peritonstum  is  usually  of  a  deep  slate-color.  The  mucous 
iiuinliiane  of  the  stonuich  and  intestines  nuiy  have  the  same  hue,  due  to 
the  pij^inent  in  and  about  the  blood-vessels.  In  .some  cases  this  is  conlined 
to  the  lymph  nodules  of  Poyor's  patches,  causing  the  shaven-beard  appear- 
ance. ' 


::!.' 


146 


SPECIFIC   INFECTIOUS  DISEASES. 


(3)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. 

(a)  The  Liver. — Paludal  hepatitis  plays  a  very  important  rdle  in  tlip 
history  of  malaria,  as  described  by  French  writers.  Kelsch  and  Kiuner 
devote  over  sixty  pages  to  a  description  of  the  various  fornis,  parencliyiii- 
atous  and  interstitial,  describing  under  the  latter  three  dilTerent  vaiii'- 
ties.  The  perusal  of  this  section  of  their  work  by  no  means  carries  con- 
viction that  all  the  forms  which  they  describe  are  associated  definitelv 
with  nudaria.  Many  of  the  patients  were  the  subjects  of  chronic  alcoliol- 
ism,  and  the  most  important  diagnostic  point  upon  which  they  seem  to 
have  placed  reliance  was  melanosis  of  the  spleen,  sometimes  with  j)i<;- 
mentaliou  of  (Jlisson's  sheath.  The  existence  of  a  cirrhosis  dependent 
upon  the  irritation  of  large  quantities  of  pigment  in  the  liver  is  uncjiies- 
tioned,  but  only  those  cases  in  which  the  history  of  chronic  malaria  is 
definite,  and  in  which  the  melanosis  of  both  liver  and  spleen  coexist, 
should  be  regarded  as  of  paludal  origin.  The  atfection  in  this  country  is 
of  extraordinary  rarity.  In  the  post-mortem  room  of  the  Philadelpliiii 
Hospital  I  have  frequently  seen,  in  subjects  in  whom  the  s])lcen  was 
deeply  pigmented,  the  portal  sheaths  of  the  liver  stained,  and  a  slight 
increa.se  in  the  connective  tissue ;  but  it  is  begging  the  question  to  say 
that  in  such  patients,  who  liavo  almost  certainly  been  habitual  consumers 
of  bad  whisky,  the  condition  of  the  liver  was  due  to  malaria.  No  instance 
of  malarial  (cirrhosis  has  been  shown  at  the  Philadelphia  Pathological 
Society  since  its  foundation.  Welch  tells  me  he  knows  of  but  one  speci- 
men which  luis  been  shown  in  New  York,  and  that  was  from  an  Al* 
gerian. 

{/})  Pneumonin  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  (kqjCMd  directly  upon  the  malarial  poison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  I  have  no  personal 
knowledge  of  such  a  speciiil  pneumonia  It  certainly  does  not  occur  in 
the  intermittent  or  remittent  fevers  which  prevail  in  Philadelphia  ami 
lialtiuutre.  The  question  was  formerly  warmly  discussed  in  this  country, 
atul  I  may  refer  to  the  attempt  on  the  part  of  Manson  to  distinguish  spe- 
cial forms  depending  upon  the  malarial  poison.  The  exhaustive  and  criti- 
cal review  of  the  subject  by  W.  T.  Howard,  in  1859,  })ut  a  check  to  many 
of  the  speculations  on  the  subject.  The  French  authors  quoted  ;iliovo 
recognize  as  common  in  chronic  paludism  a  form  distinguished  by  an 
irregular  course,  an  absence  of  many  of  the  characteristic  symptoms,  by  a 
rapid  swelling  of  the  liver  and  spleen,  and  a  special  tendency  to  the  for- 
mattv)n  of  lu'crotic  foci.  On  two  occasions  in  the  Philadelphia  Hospital  I 
had  an  opportunity  of  seeing  the  development  of  pneumonia  in  convales- 
cents from  nuilaria — one  of  a  quotidian,  the  other  of  a  quartan  typo, 
They  develojted  in  a  ward  with  several  other  cases  of  pneumonia,  ami  the 
disesise  ran  a  perfectly  normal  course.  In  about  four  hundred  cases  of 
malaria  which  have  been  under  observation  at  the  Johns  Hopkins  Hos- 
pital and  Dispensary  bronchitis  has  been  frequent  as  an  early  symptom, 


M:\: 


MALARIAL   FEVER. 


U\ 


but  we  have  seen  no  indication  of  any  special  form  of  inflammation  of  the 
luiip;s. 

(r)  Xephritis. — Acute  inflammation  of  the  kidneys  is  rare  in  the 
mihlrr  forms.  Albumen  in  the  urine  is  not  infrequent  during  the  chill, 
iiiiil  in  the  course  of  the  continued  or  remittent  fevers.  Kelsch  and 
Kiiiur  describe  several  forms  of  nephritis.  Mo  instance  of  acute  or 
cliruiiic  Bright's  disease  resulting  directly  from  paludism  has  come  under 
my  notice. 

Clinical  Forms  of  Malarial  Fever.— (1)  Intermittent  Fever.— 
Thi.s  form  is  characterized  by  recurring  paroxysms  of  what  are  known  as 
ague,  in  which,  as  a  rule,  chill,  fever,  and  sweat  follow  each  other  in 
onk'ily  sequence.  The  stage  of  incubation  may  be  very  short.  Attacks 
have  occurred  within  twenty-four  hours  after  exposure.  Usually  the  time 
of  iiKiibation  is  from  seven  to  fourteen  days.  On  the  other  hand,  the 
ague  iiuiy  be,  as  is  said,  "  in  the  system,"  and  the  patient  may  have  a 
paroxysm  months  after  he  has  removed  from  a  malarial  region,  though  I 
doubt  if  this  can  be  the  case  unless  ho  has  luid  the  disease  when  living 
tliure. 

Description  of  the  Paroxysm. — The  patient  generally  knows  he  is 
going  to  have  a  chill  a  few  hours  before  its  advent  by  unpleasant  feelings 
ami.  uneasy  sensations,  sometimes  by  headache.  The  paroxysm  is  divided 
into  three  stages — cold,  heat,  and  sweating. 

Cold  Stage. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a 
•k'sirc  to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigas- 
tiiuiii,  .sometimes  by  nausea  and  vomiting.  Even  before  the  chill  begins 
tlie  tlierniometer  indicates  slight  rise  in  temperature.  Gradually  the  i)a- 
tioiit  begins  to  shiver,  the  face  looks  cold,  and  in  the  fully  developed  rigor 
the  whole  body  shakes,  flie  teeth  chatt(!r,  and  tlie  movements  may  often  be 
vidleut  enough  to  shake  the  bed.  Not  only  docs  the  patient  look  cold  and 
hhie,  but  a  surface  thermometer  will  indicate  a  reduction  of  the  skin  tem- 
perature. On  the  other  hand,  the  axillary  or  rectal  temperature  may, 
(luring  the  chill,  be  greatly  increased,  and,  as  shown  in  the  chart,  the 
fever  may  rise  during  the  chill  to  105°  or  1()(J°.  Of  symptom?  as.sociated 
with  the  chill,  nausea  and  vomiting  are  common.  There  may  bo  intense 
lieadaelic.  The  pulse  is  quick,  small,  aiul  hard.  The  urina  is  increa.sed 
ill  quantity.  The  chill  lasts  for  a  variable  time,  from  ten  or  twelve 
iiiiuule.s  to  an  hour,  or  even  longer. 

The  Iiot  sta(je  is  ushered  in  by  transient  flushes  of  heat ;  gradually  tlio 
I'oMue.-i.s  of  the  surface  disappears  and  the  skin  becomes  intensely  hot. 
The  contrast  in  the  patient's  appearance  is  striking :  the  face  is  flushed, 
the  hands  are  congested,  the  skin  reddened,  the  pulse  is  full  and  bound- 
hig,  tlie  heart's  action  is  forcible,  and  the  patient  may  complain  of  a 
thruhliing  headache.  The  rectal  temperature  may  not  increase  much  dur- 
ing thi.s  .stage ;  in  fact,  by  the  termimvtion  of  the  chill  the  fever  may  have 
Mched  its  maximum.    The  duration  of  the  hot  stage  varies  from  half  an 


» 


!:' 


148 


SPECIFIC  INFECTIOUS  DISEASES. 


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MALARIAL  FEVP^Il. 


149 


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150 


SPECIFIC  INFECTIOUS   DISEASES. 


hour  to  three  or  four  hours.  The  patient  is  intensely  thirsty  anil  drinks 
eagerly  of  cold  water. 

iSwra/iti;/  Stax/e. — Beads  of  perspiration  appear  upon  the  faee  and 
jOfradually  the  entire  body  is  bathed  in  a  copious  sweat.  The  unconifdita- 
blo  feeling  associated  with  the  fever  disapj)ears,  the  headache  is  relicvcii, 
and  within  an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually 
sinks  into  a  refreshing  sleep.  The  sweating  varies  much.  It  may  In* 
dreiuihing  in  character  or  it  may  be  slight. 

Cluirt  XI  is  a  fuc-simile  of  a  ward  temperature  chart  in  a  case  of 
tertian  ague.  The  duration  of  the  paroxysms  on  February  1st,  ;3d,  and 
5th  was  from  twelve  to  sixteen  hours.  Quinine  in  two-grain  doses  was 
given  on  the  5th  and  was  sufiicient  to  prevent  the  nn-coming  paroxysms 
on  the  7th,  though  the  temperature  rose  to  100-5°.  The  small  doses,  how- 
ever, were  not  etTective,  and  on  the  9th  he  had  a  severe  chill. 

The  totiil  duration  of  the  paroxysm  is  from  twelve  to  fifteen  hours,  but 
may  be  shorter.  Variations  in  the  paroxysm  are  common.  Thus  the  jia- 
tient  may,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness. 
The  most  common  variation  is  the  occurrence  of  a  hot  stage  alone,  or  with 
very  slight  sweating.  During  the  paroxysm  the  spleen  is  enlarged  and 
the  edge  can  usually  be  felt  below  the  costal  nuirgin.  In  the  interval  or 
intermission  of  the  paroxysm  the  pationt  feels  vei'y  well,  and,  unless  the 
disease  is  unusually  severe,  he  is  able  to  be  up.  Bronchitis  is  a  comnioii 
symptom.  Herpes,  usually  labial,  is  perhaps  as  frequently  seen  in  agiio  as 
in  pneumonia. 

'J'lipcs  of  the  Paroxysm. — The  periodicity  of  the  j)aroxysms  is  one 
of  the  most  striking  features  in  muhirial  fever.  They  occ-ur  with  reg- 
ularity, either  at  tiie  end  of  twenty-four,  forty-eight,  or  seventy-two 
hours. 

Returning  at  the  end  of  twenty-four  hours  the  paroxysm  is  daily,  honce 
the  name  quotidian.  Tliis  is  by  far  the  most  frequent  type  in  the  ainite 
intermittent  fevers  in  this  latitude.  Should  two  attacks  occur  (iailv, 
whicli  is  very  rare,  it  is  called  a  double  quotidian.  The  observations  of 
the  Italian  observers,  more  particularly  Golgi,  have  enabled  us  to  trace 
certain  definite  cycles  of  evolution  in  the  development  of  the  malarial 
parasites,  and  in  the  character  of  the  organism  in  the  dillerent  forms  of 
the  disease.  In  the  quotidian  type  the  plasmodia  are  small  at  first  and 
display  active  movements.  The  parasite  gradually  increases  in  size,  tills 
the  entire  cori)Uscle,  or  at  the  beginning  and  prior  to  the  paroxysm  un- 
dergoes in  ma!iy  of  the  corpuscles  segmentation  or  sporulation. 

If  tiie  paroxysm  occurs  at  the  end  of  forty-eight  hours,  it  happens  upon 
the  third  day;  hence  the  term  tertian  applied  to  this  form.  This  is  the 
next  most  frecjuent  form,  but  it  is  much  less  common  than  the  quotidian 
form.  In  the  tertian  tyj)e  the  blood-corpuscles  contain  small  amnboiii 
bodies  which  gradually  develop,  become  deeply  pigmented,  and,  acnord- 
ing  to  Golgi,  the  segmentation  consists  of  from  fifteen  to  twenty  separate 


MALARIAL  FEVER. 


151 


ImmIIcs,  agj^rogatcd  about  the  central  clump  of  pigment.    Here,  too,  the 
ac'iiuiitiitioii  ocours  just  prior  to  and  during  the  cliill. 

Occiiniiig  at  the  end  of  seventy-two  hours  the  paroxysm  is  on  the 
fourth  (liiy,  lujnce  the  nanu;  quartan  ague.  This  is  rare,  and  in  the  past 
scvtn  years  I  have  met  with  but  six  or  eight  well-marked  instances.  In 
this  form  the  ammboid  bodies  become  rapidly  pigmented.  Tlie  move- 
ments are  slower.  They  grow  gradually  in  the  red  blood-corpuscles,  and, 
uecDnliiii,'  to  Cfolgi,  attain  considerable  size  without  removing  all  the 
liaMiio;,'I(ibin  from  the  corpuscles.  Prior  to  the  chill,  segmentation  of  the 
bodies  takes  place  into  from  nine  to  twelve  dilTerent  portions. 

Oilier  types,  such  as  quintan  or  sextan,  need  not  be  considered,  as  they 
are  very  rare. 

i'i)Hi-s('  of  the  Disease. — After  a  few  paroxysms,  or  after  the  disease  has 
persisted  for  ten  days  or  two  weeks,  the  patient  may  get  well  without  any 
speeial  medication.  In  cases  in  which  we  have  been  studying  the  ha?ma- 
tozoa  I  have  repeatedly  known  the  chills  to  stop  spontaneously.  Such 
eases,  however,  are  very  liable  to  recurrence.  Persistence  of  the  fever 
leads  to  aiuemia  and  a  hajmatogenous  jaundice,  owing  to  the  destruction 
of  the  red  blood-disks  by  the  parasites.  Ultimately  the  coiulition  may  be- 
eorne  chronic,  and  will  be  described  under  malarial  cachexia.  Cases  of 
iiiterniitteiit  fever  yield  promptly  and  immediately  to  treatment  by  qui- 
nine. 

(-1)  Continued  and  Remittent  Form  of  Malarial  Fever.— Under  this 
head  will  bo  described  that  form  of  fever  in  which  there  are  no  distinct 
iiiteriiiissiotis.  but  in  which  the  temperature  range  is  constantly  above 
normal,  though  there  are  marked  remissions.  It  is  not  an  uncommon  dis- 
t'iise  in  this  locality.  The  severer  forms  of  it  i)revail  in  the  Southern 
States  and  in  tropical  countries  where  it  is  known  chiefly  as  bilious  remit- 
kni  feci')'.  The  entire  group  of  cases  included  under  the  terms  remittent 
ftvn;  hiliitus  remittent,  and  typho-malarial  fevers  requires  to  be  studied 
anew  in  the  light  of  Laveran's  observations. 

Si/iiipfdms. — The  disease  may  set  in  with  a  definite  chill,  or  may  be 
preceded  for  a  few  days  by  feelings  of  malaise.  As  seen  in  this  latitude,  the 
patient  lias  either  chilliness  or  a  distinct  rigor  in  the  beginning.  When 
seen  on  the  second  or  third  day  of  the  disease  he  has  a  Hushed  face  and 
looks  ill.  The  tongue  is  furred,  the  pulse  is  full  and  bounding,  but  rarely 
(iicrotie.  The  temperature  may  range  from  102°  to  103°,  or  is  in  some 
instaiiees  liighor.  The  general  appearance  of  the  patient  is  strongly  sug- 
Kestivi'  of  typhoid  fever,  a  suggestion  still  further  borne  out  by  the  exist- 
tMice  of  acute  splenic  enlargement  of  moderate  grade.  As  in  intermittent 
fiver,  an  initial  bronchitis  may  bo  present.  The  course  of  these  cases  is 
varial)lf.  The  fever  is  continuous,  with  remissions  more  or  less  marked  ; 
'Ktiiiiti.'  |iaroxysnis  with  or  without  chills  may  occur,  in  which  the  tem- 
perature rises  to  105°  or  10G°.  Intestinal  symptoms  are  not  present.  A 
8'iglit  lia  luatogenous  jaundice  may  develop  early.  Delirium,  usually  of  a 
11 


;  '1- 


152 


SPECrPIC  INFECTIOUS  DISEASES, 


mild  type,  ftirty  ocf;\\r.  I'hc  rn»c«  vary  jfrcatly  in  novcrity.  In  some  (ho 
fever  HubsidoB  at  tlur  ciid  of  the  week,  and  tlu;  j)ractilii)iu'r  is  in  ddiilit 
wliethor  ho  hus  luul  to  i\o  witli  a  mild  typhoid  or  a  Biinpie  fehrictda.  In 
other  instunccs  the  fever  ptTHiats  for  from  ten  davH  to  two  weeks,  tluri' 
are  marked  reinisgions,  jiorhapB  chillH,  with  a  furred  tonj^uc  and  low  dc- 
liriuni.  .Iiuindice  is  not  infrequent.  These  are  the  eaHes  to  whi«'h  \h> 
term  bilious  remittent  and  typho-malariul  fevers  are  applied.  In  dilitT 
instances  the  symptoms  become  grave  and  asuunie  a  character  of  the  per- 
nicious type.  It  is  this  form  of  malarial  fever  about  which  so  much  ((in- 
fusion still  exists.  The  similarity  of  the  cases  at  the  outset  to  typlioiil 
fever  is  most  striking,  more  particularly  the  appearance  of  the  facits, 
and  the  patient  lookn  very  ill.  The  cases  develop,  too,  in  the  autumn, 
at  the  very  time  when  typhoid  fever  occurs.  The  fever  yields,  as  a  nilc, 
promptly  to  quinine,  though  hero  and  there  cases  are  met  with,  rarely 
indeed  in  my  experience,  in  which  they  are  refractory.  It  is  just  in  this 
grou})  that  the  observations  of  Laveran  will  bo  found  of  the  greatest 
value. 

The  diaguosh  of  malarial  remittent  fever  may  be  definitely  made  by 
the  examimititm  of  the  blood.  Vandyke  Carter,  in  his  monograph,  alhules 
to  the  value  of  this  method  in  the  fevers  of  India.  In  many  cases  here  we 
are  at  first  unable  to  distinguish  between  typhoid  and  contiiv  d  malarial 
fever  without  a  blood  examination.  A  more  wide-spread  use  oi  this  nieiins 
of  diagnosis  will  enable  us  to  bring  some  order  out  of  the  confusion  wliidi 
exists  in  the  classification  of  the  fevers  of  the  South.  At  present  tlic  fol- 
lowing febrile  affections  are  recognized  by  various  jihysicians  as  oceurrinj: 
in  the  subtropical  regions  of  this  continent :  {a)  Typhoid  fever ;  (h)  typho- 
malarial  fever,  a  typhoid  modified  by  malarial  infection,  or  the  result  of  s 
combined  infection;  (c-)  the  malarial  remittent  fever;  and  {d)  contiiiuod 
thermic  fever  ((Juiteras).  In  these  various  forms,  all  of  which  may  be 
characterized  by  a  continued  pyrexia  with  remissions  or  with  chills  and 
sweats  (for  we  must  remember  that  chills  and  sweats  in  typhoid  fever  arc 
by  no  means  rare),  the  blood  examination  will  enable  us  to  discover  those 
which  depend  upon  the  malarial  poison.  In  this  latitude  we  have  '■! 
the  opportunity  of  seeing  many  of  the  protracted  and  severe  cases,  but  1 
am  inclined  to  think  that  future  observations  will  show  that  apart  from 
the  thermic  fever  there  are  only  two  forms  of  these  continued  fevers  in 
the  South — the  one  due  to  the  typhoid^  and  the  other  to  the  mnlarinJ  in- 
fection. The  typhoid  fever  of  Philadelphia  and  Baltimore  presents  no 
essential  difference  from  the  disease  as  it  occurs  in  Montreal,  a  city  j)ra('- 
tically  free  from  malaria.  Dock  has  shown  conclusively  that  cases  diag- 
nosed in  Texas  as  continued  malarial  fever  were  really  true  typhoid. 

(3)  Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate 
climates,  and  the  number  of  cases  which  now  occur,  for  example,  in  I'liila- 
delphia  and  Baltimore,  is  very  much  less  than  thirty  or  forty  years  a^o. 
Among  the  cases  of  malaria  which  have  been  under  observation  during 


MALARIAL   FEVKR. 


153 


the  past  two  yenrs  there  were  only  two  of  the  pernicious  form.    The  fol- 
lowiiii.'  iiiT  the  most  important  typos: 

{'I)  Tlic  aiinatosf/onn,  in  whi(;h  a  patient  is  struck  down  with  symp- 
t(triisiit  till!  most  intense  cerebral  disturbance,  eitlicr  acute  delirium  or, 
more  fn'(|iu>ntly,  a  rapidly  developing  coma.  A  chill  may  or  may  not 
l»r((tiit'  the  attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry. 
'['he  inifdiisciousncss  may  persist  for  from  twelve  to  twenty-four  hours,  or 
tli(>  patit-nt  nuiy  sink  and  die.  After  regaining  consciousness  u  second 
attack  may  come  on  and  prove  fatal. 

(//)  Ah/id  Form. — In  this,  the  attack  sets  in  usually  with  gastric  symp- 
tdtiis;  tluTc  are  vomiting,  intense  prostration,  and  fcelilencss  out  of  all 
|ini]i(irti()n  to  the  local  symptoms.  The  i)atient  comj)lain8  of  feeling  cold, 
althuiigh  there  nuiy  be  no  actual  chill.  The  temperature  may  be  normal 
or  even  siibnornud ;  consciousness  may  be  retained.  The  j)ulse  is  feeble 
and  small,  and  the  respirations  are  increased.  The  urine  is  often  dimin- 
ijlicil  or  evt  II  suppressed.  This  condition  may  persist  with  slight  exacer- 
bations of  fever  for  several  days  and  the  patient  may  die  in  a  condition  of 
profound  asthenia.  In  u  recent  case  the  patient,  admitted  on  October 
loth,  had  been  ill  since  the  7th,  but  there  were  no  chills.  When  first 
swn  Ir"  was  prostrated  and  weak,  and  looked  as  if  lie  had  been  drinking, 
but  tliirc  was  no  alcoholic  odor  of  the  breath,  and  on  learning  that  he  had 
roeently  come  from  Savannah,  the  blood  was  at  once  examined  and  large 
numbers  of  Laveran's  organisms  were  found,  chiefly  of  the  small  intra- 
corpuscular  variety.  The  temi)erature  was  oidy  101°.  During  the  next 
live  days  the  prostration,  extreme  depression,  and  vomiting  continued; 
the  luilso  ranged  from  TO  to  80,  and  the  temperature,  after  the  first  day, 
ilid  not  rise  above  9H°,  but  sank  as  low  as  90°.  This  is  essentially  the 
samp  as  described  as  the  asthenic  or  adynamic  form  of  the  disease. 

('•)  lltt'^uorrhnyic  Forms. — In  all  the  severe  types  of  malarial  infec- 
tion, t'sjii'cially  if  persistent,  hemorrhage  may  occur  from  the  mucous 
momhraiu's.  An  important  form  is  the  malarial  hamaturia,  which  in 
some  instances  assumes  a  very  malignant  type.  Paroxysms  of  ague  may 
|irec('d('  the  attack,  but  in  many  eases  called  malarial  luematuria  there  is 
no  febrile  paroxysm.  The  condition  is  usually  ha^moglobinuria,  though 
!)lood-c()rpuscles  are  present  also.  In  severe  cases  there  is  bleeding  from 
the  mucous  membranes.  Jaundice  is  present,  but  to  a  variable  extent, 
and  is  luvniatogenous,  due  to  the  destruction  of  the  red  blood-corpuscles. 
Malarial  liivmaturia  occurs  in  epidemic  form  in  many  regions  of  the 
SoutluTii  States,  and  in  some  seasons  proves  very  fatal. 

Many  different  forms  of  pernicious  malarial  fever — diaphoretic,  synco- 
|wl,  pneumonic,  pleuritic,  choleraic,  cardiac,  gastric;,  and  gangrenous — all 
of  wliiili  depend  upon  some  special  symptom,  have  been  described. 

(+)  Malarial  Cachexia. — The  symptoms  of  chronic  malarial  poisoning 
aivviry  varied.  It  may  follow  the  frequ«'nt  recurrence  of  ordinary  inter- 
mittent fever,  a  common  sequence  in  this  country.     A  patient  has  chills 


■  -   I 


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» 


15i 


SPECIFIC  INFECTIOUS  DISEASES. 


for  scvoral  weeks,  is  improperly  or  irnperfoetly  treated,  und  on  oxpo^^nre 
the  chilLs  recur.  This  riiuy  be  repented  for  neverul  inoiithH  until  tin  pu. 
tinut  pre.sent8  the  two  striking  features  of  iiuilarial  eachexiu — narnclv, 
iiiKriniu  and  an  cuUu'tjvd  splcrn.  Cases  developing  without  chills  or  with. 
out  fehrile  paroxysms  are  almost  unknown  in  this  region.  Tliey  may 
occur,  however,  in  intensely  nuilarial  districts,  but  in  such  cases  tlif  pa- 
tients  have  fever,  though  chills  may  not  sujiervene.  The  most  pronounced 
types  of  malarial  cachexia  which  we  meet  with  here  are  in  sailors  from  the 
West  Indies  and  Central  Anu'rica.  There  is  profound  aniemia;  the  Idudd 
(H>unt  may  be  as  low  as  one  million  per  cubic  millimetre;  the  skin  has  a 
salTron-yellow  or  lemon  tint,  not  often  the  light-yellow  tint  of  pernii  ions 
ana'niia,  but  a  darker,  dirtier  yellow.  The  spleen  is  greatly  enlar;,'^!, 
firm,  and  hard.  It  rarely  reaches  the  dimeusions  of  the  largo  leukaniic 
organ,  but  comes  next  to  it  in  size. 

Tiio  general  symptoms  are  those  of  ordinary  anajmia — breathlessiuss on 
exertion,  (edenui  of  the  ankles,  liaMnorrhages,  particularly  into  the  n'tiiia, 
as  noted  by  Stephen  Mackenzie.  Occasionally  the  bleeding  is  severe,  ami 
I  have  twice  known  fatal  h.x'nuitemesis  to  occur  in  association  witli  tlie 
enlarged  spleen.  The  fever  is  variable.  The  tcmi)eraturo  nuiy  be  low  for 
days,  not  reaching  above  99-5°.  In  other  instances  there  may  be  iiri;'- 
ular  fever,  and  the  temperature  rises  gradually  to  1()2'5°  to  103°.  Tlie 
oases  in  fact  present  a  picture  of  splenic  anaemia. 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  casc.-i  re- 
cover. The  spleen  is  gradually  reduced  in  size,  but  it  may  take  stvcral 
months  or,  indeed,  in  some  instances,  several  years  before  tlie  agu(-(.ai(e 
entirely  disappears. 

Among  the  rarer  symptoms  which  may  develop  as  a  result  of  mala- 
rial intoxication  may  bo  mentioned  par<(j>legia,  cases  of  which  liave 
been  described  by  Gibney,  Suckling,  and  others.  Some  of  tlie  cases  are 
doubtful,  and  have  been  attributed  to  malaria  simply  because  the  paralysis 
was  intermittent.  It  is  a  condition  of  extreme  rarity.  No  case  is  men- 
tioned by  Kelsch  and  Kiener.  Suckling's  case  had  had  several  attariis  of 
malaria,  the  last  of  which  preceded  by  about  two  weeks  the  onset  of  the 
nervous  symptoms,  which  were  headache,  giddiness,  loss  of  speech,  and 
paraplegia.  The  attack  was  transient,  but  lie  had  a  subsequent  attack 
which  also  followed  an  ague-fit.  The  patient  was  an  old  soldier  who  had 
had  syphilis,  a  point  which  somewhat  complicated  the  case.  O/rA/V/vhas 
been  described  m  developing  in  malaria  by  Charvot  in  Algiers  and  J'edeli 
in  Kome. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  malaria  is  nsually 
easy.  The  continued  and  remittent  and  certain  of  the  pernicious  case* 
offer  difficulties,  which,  however,  are  now  greatly  lessened  or  entirely  over- 
come since  Laveran's  researches  have  given  us  a  positive  diagnostic  imli 
cation.  Many  forms  of  intermittent  pyrexia  are  mistaken  for  malarial 
fever,  particularly  the  initial  chills  of  tuberculosis  and  of  septic  iufectiou 


MALARIAL   FKVEK. 


165 


If  tlio  [invctitioncr  will  take  to  liciirt  the  losson  thut  an  intermittent  fever 
wliiili  rcsislii  (luinine  is  not  nmhiriul,  he  will  avoiil  many  errors  in  tliaji- 
Uii>\A.  In  the  Ho-oalled  maskfil  intermittent  or  diiml)  aj^ne,  the  fel)rile 
tiKiiiifi-iiitionw  are  more  irregular  and  the  symptoinH  less  proiKtunced  ;  hut 
(HCiiHiiiimlly  chills  occur,  and  the  therapeutical  tost  usually  renjoves  evory 
ilimhl  ii>  the  diaj^'tioisiH. 

'I'lic  malarial  poison  is  supposed  to  influence  n\any  afTeetions'  in  a 
rcniarkahle  way,  giving  to  them  a  paroxysmal  character.  A  whole  series 
of  niiiinr  ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  at- 
tributi'd  to  certain  occult  effects  of  paludism.  1'he  more  closely  such 
Liuses  are  investigated  the  loss  definite  a])peurs  the  connection  with  nuila- 
ria.  Practitioners  in  districts  entirely  exempt  front  the  disease  have  to 
(Ital  will:  ailments  which  present  the  same  odd  periodicity,  and  which  the 
physicians  of  the  Atlantic  coast  attril)ute  to  a  "  touch  of  malaria." 

Treatment. — We  do  not  know  us  yet  how  the  jmison  reaches  tho 
8vsti'iii.  lnfe(!tion  seems  most  liahle  to  occur  at  night.  In  regions  in 
wliicli  the  disease  prevails  extensively  the  drinking-water  should  he  hoiled. 
IVisdiis  going  to  a  nudarial  region  should  take  ahout  ten  grains  of  qui- 
niiie  daily.  During  tho  paroxysm  the  patient  should,  in  tho  cold  stage, 
1)0  wrapped  in  hlankets  and  given  hot  drinks.  The  reacdionary  fever  is 
raiviy  dangerous  even  if  it  reaches  a  high  grade.  The  hody  may,  however, 
Iji'  spoiiijed.  Quinine  shotdd  then  he  (trdered,  so  as  to  check  the  on-coming 
liaroxysni.  It  should  be  given  in  solution.  From  ten  to  thirty  grains  in 
liividi'd  doses  through  tho  day  will  almost  invariably  stop  the  next  par- 
oxysm. No  preparatory  treatment  is  necessary  ;  no  other  drugs  need  bo 
irivcM.  The  remedy  is  a  specific  in  the  truest  sense  of  the  term.  In  not  a 
single  instance  among  the  several  hundred  cases  of  intermittent  fever  which 
1  have  had  under  observation  during  the  past  seven  years  did  qnitnno  fail 
to  check  the  paroxysms.  The  mode  of  administration  is  of  little  moment, 
*o  lonfj;  as  the  patient  gets  a  sufliicient  (|uantity  into  his  system.  In 
^"hitidii  or  in  capsule  it  is  the  most  etlicient.  I'he  j)ills  and  compressed 
t;il»lcts  are  more  uncertain,  as  they  may  not  be  dissolved.  A  rpiestion  of 
interest  is  the  efficient  doso  of  quinine  necessary  to  cure  the  disease.  I 
huve  a  number  of  charts  showing  thut  grain  doses  three  times  a  day  will, 
in  many  cases,  prevent  the  paroxysm,  but  not  always  with  the  certainty  of 
the  larjrcr  doses.  It  is  safer  to  give  at  least  from  twenty  to  thirty  grains 
iliiily  for  tho  first  three  days  and  then  to  continue  tho  remedy  in  smaller 
lioses  for  two  or  three  weeks.  Other  remedies  in  acute  forms  of  n)alaria 
lire  useless. 

In  the  pernicious  forms,  and  when  it  is  desirable  to  get  tho  system  as 
nipidly  muler  its  influence  as  possible,  tho  drug  should  be  administered 
liypoderniically  (as  the  bisulphato  in  thirty-grain  doses  with  five  grains  of 
tartaric  acid)  every  two  or  three  hours.  For  the  extreme  restlessness  in 
these  eases  opium  is  indicated,  and  cardiac  stimulants  (such  as  alcohol 
I  and  strychnine)  are  necessary.     If  in  tho  comatose  form  tlie  internal  tern- 


»  i 


i    it    ' 


156 


SPE(;IFIC  INFECTIOUS  DISEASES. 


perature  is  raised,  tho  patient  slioukl  bo  put  i!:  a  batli  and  douched  with 
cold  water. 

For  malaria)  anipmia,  iron  and  arsenic  arc  indicated. 


m 


XXII.   ANTHRAX. 

{Malignnut  Pustule;  Splenic  Fever ;  Chnrbon :  Wonl-snrler's  Di'neaae.) 

Definition. — An  acute  infectious  disease  caused  o\  the  bncilius  an- 
tfiniris.  It  is  a  wide-spread  alTection  in  animals,  particularly  in  sheopand 
cattle.  In  man  it  occurs  sporadically  or  as  a  result  of  accidental  absorp- 
tion of  the  virus. 

litiolog^y. — The  infectious  agent  is  a  non-motile,  rod-shaped  nrpn- 
ism,  the  harillux  aiithracis,  which  has,  by  the  researches  of  I'ollendor,  Da- 
vaine,  Koch,  and  I'astour,  become  tlic  best  known  jierhaps  of  all  imthd- 
gonic  mictobes.  The  bacillus  lias  a  length  of  from  two  to  ten  times  the 
diameter  of  a  red  blood-corpuscle;  t'^o  rods  arc  often  united.  They  iiiul- 
ti|)ly  by  fission  with  great  rapidity  and  grow  with  facility  on  various  cult- 
ure media,  extending  into  long  lilaments  which  interlace  and  produce  a 
dense  mycelium.  Tho  spore  fornuvtion  is  seen  with  great  readiness  in 
these  filaments.  Tho  bacilli  themselves  arc  readily  destroyed,  but  the 
spores  are  very  resistant,  and  survive  after  prolonged  immersion  in  u  live- 
|)er-cent  solution  of  carbolic  acid,  and  resist  for  some  minutes  a  teuipira- 
'.iire  of  212"  Fahr.  Thoy  are  capable  also  of  resisting  gastric  digestion. 
Outside  the  body  the  spores  are  in  all  probability  very  durable. 

(ieographically  and  zoologically  the  disease  is  tho  most  wide-spread  nf 
all  infectious  disorders.  It  is  much  more  prevalent  in  Europe  and  in  Asia 
than  in  America.  The  ravages  among  the  herds  of  cattle  in  Uussia  and 
Sil)eria,  and  among  sheep  in  certain  parts  of  Euro{)e,  arc  not  equalled  bj 
ary  other  animal  plague.  In  this  country  the  disease  is  rare.  So  fur  us  I 
k'.iow  it  has  ncer  prevailed  on  the  ranches  in  the  Northwest,  but  ciises 
were  not  infrequent  about  Montreal. 

A  protective  inoculation  with  a  mitigated  virus  has  been  introduced  lij 
Pasteur,  and  has  been  adopted  in  certain  anthrax  regions.  Hank  in  li:i^ 
isolated  from  the  cultures  an  albumoso  which  renders  animals  inimmie 
against  the  most  intense  virus. 

In  animals  the  disease  is  conveyed  sometimes  by  direct  inoculatioii,  as 
by  the  bites  and  stings  of  insects,  by  feeding  on  carcasses  of  animals  wliirh 
have  died  of  the  disease,  but  more  commonly  by  feeding  in  jiastuivs  in 
which  the  germs  have  been  preserved.  Pasteur  believes  that  tin'  carlli- 
worm  plays  an  imi)ortant  part  in  bringing  to  the  surface  and  distrilaitinj: 
the  bacilli  which  have  been  propagated  in  the  buried  carcass  of  an  in- 
fected animal.  Certain  fields,  or  even  farms,  may  thus  be  infected  f^ran 
iudefiuite  period  of  time.     It  seems  probable,  however,  that  if  tho  carciuv* 


ANTHRAX. 


157 


Asia 
,!i  iimi 

w  as  I 

t'llSU! 

I'od  i>y 
III  ]yM 
iiuuiie 

ion,  lit 
whii'li 

UTS  III 

ourtli- 

hiitiii? 

all  ill- 

for  iin 


is  not  opened  or  tlic  blood  spilt,  eporca  are  not  formed  in  the  buried 

tiiuiniil. 

A niiiiiiU  vary  in  susceptibility :  horbivora  in  the  liigheat  degree,  then 
tlu!  (•iiinivora,  and  lastly  the  carnivora.  I'he  disease  does  not  occur  n\Hm- 
tuiKMiusly  in  nuin,  but  always  results  from  infection,  either  through  tho 
skill,  the  intestines,  or  in  rare  instances  through  tlie  lungs.  The  disease 
is  foiiiid  in  persons  whoso  occupations  bring  tiiem  into  contact  witii  ani- 
mtils  or  animal  })roduct8,  as  stablemen,  she]>herds,  tanners,  butchers,  and 
those  who  work  in  wool  and  hair. 

\iirious  forms  of  the  disease  have  been  described,  and  two  chief  groups 
niuv  lie  recogni/.ed  :  the  exteriuU  anthrax,  or  malignant  {lustule,  ami  tho 
iutcniiil  anthrax,  of  which  there  are  pulmonary  and  intestinal  forms. 

Oymptoms.— (1)  External  Anthrax. 

(i/)  Miilijinant  PustuU'. — Tho  inoculation  is  usually  on  an  e\posod 
flurfii'i' — the  hands,  arms,  or  face.  At  tho  site  of  inoculation  there  are, 
witiiin  a  few  hours,  itching  and  uneasiness.  (Jraduully  ;v  snuUl  })ai)ulo 
(le'ijups,  which  becomes  vesicular.  Inllamnuitory  induration  extends 
aroiiiitl  this  and  within  thirty-six  hours,  at  the  site  o^  inoculation  there 
is  a  (lark  brownish  eschar,  at  a  little  distance  from  which  there  nuiy  be  a 
series  of  small  vesicles.  Tho  brawny  induration  nuiy  be  extreme.  'J'ho 
(edema  produces  very  great  sv/elling  of  tho  partd.  The  inflammation  ex- 
tends along  the  lymphatics,  and  tho  neighboring  lymph-glands  are  swollen 
ami  sore.  The  tempf'r.ituro  at  first  rises  rapidly,  and  the  febrile  jdienom- 
eiiaaic  marke-.i.  Subserpiently  the  fever  falls,  and  in  nuiny  oases  becomes 
siihiuiiiiial.  iJeatli  nuiy  take  place  in  from  three  to  five  days.  In  cases 
whicii  recovci'  tho  constitutioiud  symptoms  are  slighter,  the  e.schar  gradu- 
ally sloughs  out,  and  tho  wound  heals.  The  cases  vary  much  in  severity. 
In  the  mildest  form  there  nuiy  bo  only  slight  Bwe!ling.  At  the  site  of  in- 
oculation a  i)apule  is  formed,  whicli  raj)idly  becomes  vesicular  and  dries 
into  a  scab,  which  separates  in  the  course  of  a  few  days. 

(h)  isfdWjnant  Anthrax  QHdevm. — This  form  occurs  in  tho  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  chai'acterized  by  the  absence  of  tho 
papule  and  vesicle  forms,  and  by  tho  most  extensive  ci'dcma,  which  may 
follow  rather  tlian  precede  tho  constitutioiud  symptoins.  The  u'dema 
roacbt's  such  a  grade  of  intensity  that  gangreiu»  results,  and  may  involve  a 
Considerable  surface.  The  constitutional  symptoms  then  become  extremely 
grave,  and  the  cases  invariably  prove  fatal. 

A  feature  in  both  tin  so  forms  of  maligniint  pustule,  to  whiih  many 
writers  refer,  is  the  ab.senco  of  feelijig  of  distress  or  anxiety  on  the  part  of 
tlie  patii'ut,  whoso  mental  condition  may  be  perfec^tly  clear.  IIo  nuiy  be 
williou'  any  apprehcn.sion,  even  though  his  condition  is  very  critical. 

The  (litKiuusis  in  most  instances  is  '■•"iily  made  from  the  cluirac^ters  of 
tho  lesion  and  tho  occupation  of  tho  patient.  When  in  doubt,  tho  exami- 
nation (if  tho  fiuid  from  tho  pustule  may  show  tho  presence  of  the  an- 
thrax bacilli.     Cultures  should  bo  made,  or  a  mouse  or  guinea-pig  inocu- 


'  I  / 


158 


SPECIFIC  INFECTIOUS   DISEASES. 


11 


lated.     It  is  to  bo  remembered  that  the  blood  may  not  sliow  the  bacilli  in 
munbora  until  shortly  before  death. 

(2)  Internal  Anthrax. 

(<i)  Jii/rsfindl  Furtti,  Jf>/rost\^  intcstinnUs. — In  these  cases  the  infec- 
tion is  throuifli  the  stomach  and  intestijies,  and  results  from  eating;  the 
flesh  or  driiikinj^  tiie  milk  of  diseased  animals.  The  symptoms  are  those 
of  intense  poisoning.  The  disease  may  set  in  with  a  chill,  followed  bv 
vomiting,  diarrluea,  moderate  fever,  and  pains  in  the  legs  and  back.  In 
acute  cases  there  are  dyspn(ea,  cyanosis,  great  anxiety  atul  restlessness, 
and  toward  the  end  convulsions  or  s{)asnis  of  the  muscles.  IIi«morrli;ii.'e 
may  occur  from  the  mucous  meml)ranes.  Occasionally  there  are  snuill 
j)hlegmonous  areas  on  the  skin,  or  petechia3  develop.  The  spleen  is  en- 
larged. The  blood  is  dark  and  remains  fluid  for  a  loTig  time  after  death. 
Late  in  the  disease  the  bacilli  nuiy  be  found  in  the  blood. 

This  is  one  of  the  i  tims  of  acute  poisoning  which  nuiy  alTect  many  in- 
dividuals together.  Tims  Butler  and  Karl  lluber  describe  an  epideniie 
in  which  twenty-flve  persons  were  attacked  after  eating  the  flesh  of  iin 
animal  which  had  had  anthrax.  Six  died  in  from  forty-eight  hours  to 
seven  days. 

{b)  WiKil-xortcr's  /h'srase. — This  important  form  of  anthrax  is  foiiiid 
in  the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleansed. 
The  hair  and  wool  imported  into  Europe  from  Russia  and  South  America 
appear  to  have  induced  the  li"'gest  number  of  cases.  Many  of  these  (  uses 
show  no  external  lesion.  The  infection  lias  been  swallowed  or  iuiialeil 
with  the  dust.  There  arc  rarely  premonitory  symptoms.  The  patitnt  i? 
seized  with  a  chill,  becomes  faint  and  prostiated,  lias  pains  in  the  back 
and  legs,  and  the  temperature  rises  to  10^°  to  lO;}".  The  breathiiiLr  i> 
rajiid,  and  he  comjilains  of  much  pain  in  the  chest.  There  may  h 
a  cough  and  signs  of  bronchitis.  So  prominent  in  some  instances  arc 
these  bronchial  symptoms  that  a  pulmonary  form  of  the  disease  has  been 
described.  The  pulse  is  feeble  and  very  rapid.  There  may  be  voniitin;', 
ami  death  may  occur  within  twenty-four  hours  with  symptoms  of  piD- 
found  collapse  and  prostration.  Other  cases  are  more  jirotracted,  ami 
there  may  be  diarrluea,  delirium,  and  unconsciousness.  The  recognition 
of  wool-sorter's  disease  as  a  form  of  anthrax  is  due  to  J.  11.  Bell,  of  Mrad- 
ford,  Englaml. 

In  certain  instances  these  jirofound  constitiitidual  symjttoms  of  intirinil 
anthrax  are  associateil  with  the  exlennd  lesions  of  malignant  pustule. 

The  diagnosis  of  internal  anthrax  is  by  no  means  easy,  unless  tin' 
history  points  deflnitely  to  infection  in  the  occupation  of  the  individiiiil 
In  cases  of  (b>ubt  cultures  should  be  made,  and  inoculations  ])erfonniil  in 
animals.  Soiiu'  of  these  cases  may  possiiily  be  caused  by  organisms  <itlu'r 
than  the  bacillus  of  anthrax  (rornil  and  Jiabes). 

Treatment. — In  malignant  juistulo  the  site  of  inoculation  bIiohIiI  b'' 
destroyed  by  the  caustic  or  liot  iron,  and  powdered  bichloride  of  im  ii'iiry 


ilABlES. 


159 


may  be  sprinkled  over  the  exposed  surface.  The  local  development  of 
the  bacilli  ai)out  the  site  of  inocuhition  may  be  prevented  by  the  8ul)cutiv- 
nt'ous  injections  of  solutions  of  carbolic  acid  or  bichloride  of  mercury. 
Tlic  injections  should  be  made  at  various  points  around  the  pustule,  and 
niiiy  1)0  repeated  two  or  three  times  a  day.  The  internal  treatment  should 
be  conliued  to  the  administration  of  stimulants  and  plenty  of  nutritious 
food.  Davies-Colley  advises  ii>ecacu».nha  powder  in  doses  of  from  five  to 
ten  irraius  every  three  or  four  hours. 

In  inulijinant  forms,  particularly  the  intestimu  cases,  little  can  be  done. 
Active  pMi'<,'atives  may  be  jriven  at  the  outset,  so  as  to  remove  the  infect- 
ing miitorial.     Quinine  in  large  doses  has  been  recommended. 


XXIII.  RABIES. 

{Lyssa ;  Jli/Urophuhia.) 

Deilnition. — An  acute  disease  of  animals,  dependent  upon  a  specific 
virus,  and  communicated  by  inoculation  to  man. 

Etiology. — In  man  ti>e  disease  is  very  variously  dihtributod.  In 
Uiis.-ia  it  is  common,  in  North  (Jermany  it  is  extremely  rare,  owin<jr  to  the 
wise  provision  that  dl  dogs  shall  be  muzzled.  In  Knghind  and  France  it 
is  nuieh  more  couii;.on.  In  this  country  the  disease  is  very  rare.  Since 
isdT  1  liave  seen  but  two  cases. 

Caniiu's  are  specially  liable  to  the  disease.  It  is  found  most  frequently 
ill  the  (idg,  the  wolf,  and  the  cat.  All  animals  arc,  howi-ver,  susceptible; 
and  it  is  communicable  by  inoculation  to  the  ox,  hors(>,  or  pig.  The 
iliseasc  is  propagated  chiefly  by  the  dog,  which  .seems  specially  susceptible. 
In  the  Western  States  the  skunk  is  said  to  })e  very  liable  to  the  disease. 
Tiie  nature  of  the  poison  is  as  yet  unknown.  It  is  contained  chietly  in 
the  nervous  system  and  is  met  with  in  tbo  secretions,  particularly  in  tho 
riiiliva. 

A  variable  time  elapses  between  tho  introduction  of  the  virus  and  the 
apiiearance  of  the  symptoms.  Ilorsley  states  that  this  dejieiids  v.]wn  tlie 
fiill'iwing  factors:  "  (f?)  Age.  The  iacubalion  is  shorter  in  cliildren  tlian 
Hi  adults.  For  obviou.»  reasons  the  former  are  more  frequently  attacked. 
(A)  Part  infected.  The  rapidity  of  <mset  of  the  symptoms  is  greatly  do- 
tcrniiticd  Ity  the  part  of  the  body  which  nuiy  happen  to  have  Imhti  bitten. 
\Uunds  about  tln!  face  and  head  are  espeeiaily  dangerous  :  next,  in  order 
in  dcgroea  of  mortality  come  bites  on  the  hand->.  then  injuries  on  i.kv. 
iither  parts  of  the  body.  This  relative  order  m,  no  doubt,  greatl'  de- 
ppiulent  upon  the  fact  that  the  face,  head,  and  lmn<is  are  usually  naKcd, 
while  tho  other  parti-;  are  clothed,  (c)  The  extent  and  severity  of  tho 
w^onnd.  Puncture  wounds  are  the  most  dangerous;  the  laceratimiH  are 
htal  in  proportion  to  the  extent  ol  the  surfuce  ailoEded  for  absorptum  ol 


i  iih 


n 


il  I 


160 


SPECIFIC   INFECTIOUS  DISEASES. 


tl»e  virus,  (d)  TIjc  animal  conveying  the  infection.  In  order  of  decreas- 
ing severity  come:  first,  the  wolf;  second,  the  cat;  third,  the  dog;  ami 
fourth,  other  animals."  Only  a  limited  number  of  those  bitten  by  rabid 
dogs  become  alTtcted  by  the  disease;  according  to  Ilorsley,  not  more  than 
fifteen  per  cent.  On  the  other  hand,  the  death-rate  of  those  pernons 
bitten  by  wolves  is  higher,  not  less  than  forty  per  cent. 

The  incnbation  period  in  man  is  extremely  variable.  The  average  is 
from  six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two 
weeks.  It  may  be  prolonged  to  three  months.  It  is  stated  that  the  incu- 
bation may  be  prolonged  for  a  year  or  even  two  years,  but  this  has  not 
been  definitely  settled. 

Symptoms. — 'I'hree  stages  of  the  disease  are  recognized  : 

(1)  I'rcinonitory  .sfar/e,  iu  which  there  may  be  irritation  about  the 
bite,  or  pain  or  numbness.  The  patient  is  depressed  and  melancholy; 
and  complains  of  headjiclu^  and  loss  of  appetite.  He  is  very  irritable  and 
sleepless,  and  has  a  constant  sense  of  impniding  danger.  There  is  often 
greatly  imu'cjised  sensibility.  A  bright  light  or  a  loud  voice  is  distressing. 
Tiie  larynx  nuiy  be  injected  and  the  first  symptoms  of  difliculty  in  swal- 
lowing are  experienced.  The  voice  aLso  becomes  hnsky.  There  is  a 
sligiit  rise  iu  the  temperature  and  the  pulse. 

(2)  Furious  Staye. — This  is  characterized  by  great  excitability  and 
restlessness,  ami  an  extreme  degree  of  hypera^sthesiji.  "  Any  afl'orent 
stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  of  ii 
verbal  suggesticm — will  cause  a  violent  retlex  spasm.  In  man  this  symp- 
tom constitutes  the  most  distressing  feature  of  tlio  malady.  The  spasms, 
which  atTect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceed- 
ingly painful  and  are  accompanied  by  an  intense  sense  of  dyspno-a,  even 
when  tiio  glottis  is  widely  opened  or  tracheotomy  has  been  performed" 
(lli)rsl('y).  Any  attempt  to  take  water  is  followed  by  an  intensely  pain- 
ful spasm  of  the  muscles  of  the  larynx  and  of  the  elevators  of  tiie  iiyoid 
bone.  It  is  this  whicli  makes  the  i)atieiit  dread  the  very  sight  of  water 
and  gives  the  jmpular  name  to  the  disease.  These  spasmodic  attacks  ma} 
be  associated  witli  maniacal  syni])tom8.  In  the  intervals  between  tliem 
the  patient  is  (piiet  and  I  lie  mind  unclouded.  The  te!uperature  in  this 
stage  is  usually  elevated  and  may  reach  from  100°  to  103°.  In  sonic  in- 
stances 1  lie  disease  is  afebrile.  The  patient  nrely  attempts  to  injinf  hi'* 
attendants,  and  in  tiie  intense  spasms  may  be  particularly  anxioii^^  to 
avoid  hurting  any  one.  There  are,  however,  occasional  fits  of  fiirioii'; 
mania,  and  the  patient  may,  in  the  contractions  of  the  muscles  of  the 
larynx  and  j)harynx,  give  utteratice  to  odd  sounds.  This  stage  lasts  from 
a  day  and  a  half  to  three  days  and  gradually  passes  into  the — 

(;))  Pn rah/ fie  Sfui/c. —  In  rodents  the  preliminary  and  furious  stages 
arc  absent,  as  a  rule,  and  the  paralytic  stage  may  he  marked  from  tlu'  out- 
s(>t — the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  fwm 
«ix  to  eighteen  hours.     Tlie  patient  then  becomes  quiet;  the  spasms  n^ 


RABIES. 


161 


loii^'or  occur ;  there  is  gradual  unconsciousness ;  the  heart's  action  becomes 
nio)i>  aiul  more  enfeebled,  and  death  occurs  by  syncope. 

Morbid  Anatomy. — The  lesions  are  in  the  cerebro-spinal  system. 
The  blood-vessels  are  congested;  there  is  perivascular  exudation  of  leuco- 
ovtos ;  and  there  are  minute  haemorrhages.  According  to  Gowers,  these 
are  particularly  intense  in  the  medulla.  The  pharynx  is  congested,  the 
mucous  membrane  of  the  stomach  is  hypera;mic,  and  not  infrequently 
covered  with  a  blood-stained  mucus.  The  larynx,  tracliea,  and  bronchi 
sliow  acute  congestion.  There  are  no  special  changes  in  the  abdominal  or 
thoracic  viscera.  The  inoculation  experiments  show  that  the  virus  is  not 
prosout  in  the  liver,  spleen,  or  kidneys,  but  is  abundant  in  the  spinal  cord 
and  lirain. 

Treatment. — Proj)hylaxis  is  of  the  greatest  importance,  and  by  a 
systoinatic  muzzling  of  dogs  the  disease  can  be,  as  in  Germany,  practically 
eradicated. 

Tlio  bitos  should  be  carefully  washed  and  thoroughly  cauterized  with 
caustic  potash  or  concentrated  carbolic  acid.  It  is  best  to  keep  the  wound 
constantly  open  for  at  least  five  or  six  weeks.  When  once  established  the 
disease  is  hopelessly  incurable.  No  measures  have  been  found  of  the 
slifrlitcst  avail,  consequently  the  treatment  must  be  palliative.  The  pa- 
tient should  be  kept  in  a  darkened  room,  in  charge  of  not  more  than  two 
ciirefiil  attendants.  To  allay  the  spasm,  chloroform  may  be  administered 
ai\d  ni()ri)hia  given  hypodermically.  It  is  best  to  use  tliese  jiowerful  reme- 
dies from  the  outset,  and  not  to  temporize  Avith  chloral,  bromide  of  potas- 
sium, and  other  less  potent  drugs.  By  the  local  application  of  cocaine, 
the  sensitiveness  of  the  throat  may  bo  diminished  suHiciently  to  enable 
the  patient  to  take  liquid  nourishment.  Sometimes  he  can  swallow  read- 
ily.   Nutrient  enemata  may  be  administered. 

Preventive  Inoculation. — Pasteur  has  found  that  the  virus,  when  propa- 
gated through  a  series  of  rabbits,  increases  rapidly  in  its  virulence;  so  that 
whereas  subdural  inoculation  from  the  brain  of  a  mad  dog  takes  from  fif- 
teen to  twenty  days  to  produce  the  disease,  in  successive  inoculations  in  a 
series  of  rabbits  the  incubation  period  is  gradually  reduced  to  seven  days. 
The  spiiud  cord  of  these  rabbits  contains  the  virus  in  great  intensity,  but 
when  preserved  in  dry  air  the  virus  gradually  diniinishos  in  intensity.  If 
now  (|()<j;3  are  inoculated  with  cords  preserved  for  from  twelve  to  fifteen 
days,  and  then  with  cords  oserved  for  a  shorter  period,  i.  e.,  with  .i  pro- 
gressively stronger  virus,  they  gradually  acquire  immunity  against  the  dis- 
ease. A  dog  treati'd  in  this  V"<"  will  resist  inociilatioji  with  material  from 
a  perfectly  fre.sh  c  '..  tn  rabid  rabbit,  which  otherwise  would  inevi- 
tably have  proved  A.  Relying  upon  these  experiments,  Pa.steur  began 
inoeuliitions  in  the  human  subject  utdng,  on  successive  days,  material  from 
t'ord-  in  which  the  virus  w  h  of  varying  degrees  of  intensity. 

There  is  still  much  di.,ou.ssion  as  to  the  full  value  of  this  uK^thod, 
hut  if  the  protective  inoculation  can  be  successfully  performed  in  dogs, 


102 


SPECIFIC   INFECTIOUS  DISEASES. 


there  is  no  reason  wliy  tlie  siinie  should  not  hold  good  for  man ;  and  the 
figiircs  published  annually  from  the  I'ustcur  Institute  sliow  that  in  ))(>r. 
sons  bitten  by  animals  known  to  have  been  rabid,  the  mortality  after  iii- 
oculation  is  only  alutut  O'tiO  per  cent. 

Pseudo-rabies. — 'i'his  is  a  very  interesting  affection,  which  mav 
closely  r('S('ml)l(!  iiydrophobia,  but  is  really  nothing  more  than  a  neurotic 
or  hysterical  nuinifestation.  A  nervous  })erson  bitten  by  a  dog,  eillicr 
rabid  or  sujiposcd  to  be  rabid,  devel()j)s  within  a  few  months,  or  even  later, 
symptoms  soiiicwhat  resembling  the  true  disease,  lie  is  irritable  and  ilc- 
pressed.  Ho  constantly  declares  Ids  condition  to  be  serious  and  that  ho 
will  inevitably  become  mad.  He  may  have  paroxysms  in  winch  he  says  lie 
is  unable  to  drink,  grasps  at  his  throat,  and  becomes  emotional.  The  tcni- 
perature  is  not  elevated  and  tho  disease  does  not  progress.  It  lasts  niiu  h 
longer  than  the  true  rabies,  and  is  amenable  to  treatment.  It  is  not  im- 
proba1)lc  that  a  majority  of  the  cases  of  alleged  recovery  in  this  disease 
have  been  of  this  hysterical  form.  In  a  case  which  Burr  reported  from 
my  clinic  a  few  years  ago  the  patient  had  paroxysmal  attacks  in  whicli  he 
could  n(»t  swallow.  He  was  greatly  excited  and  alarmed  at  the  sight  of 
water  and  was  extremely  emotional.  The  attack  histed  for  a  coujjIc  of 
weeks  and  yielded  to  treatment  with  powerful  electrical  currents. 


XXIV.  TETANUS. 

(Liichjnii',) 

Definition.  —  An  infectious  inalady  characterized  by  tonio  ppasms  of 
the  jnusdcs  with  nuirkud  exacerbations.  Tho  virus  is  produced  by  it 
but  dlus  which  occurs  in  earth  and  sometimes  in  putrefying  lluids  and 
manure. 

Etiologfy. — Tt  occurs  as  an  iiliopathic  affection  or  follows  trauma.  It 
is  frc<iu<nt.  in  some  localities  and  has  j»revailed  extensively  in  ejiidcinio 
form  among  new-born  children,  when  it  is  known  as  tetanus  or  trismus 
neonatoruiu.  It  is  more  common  in  hot  than  in  temperate  climatts, 
and  in  the  coIohmI  than  in  the  Caucasian  race.  This  is  particuluiiy 
the  case  with  tetanus  following  confinement  and  in  tetanus  ncoiiati)- 
rum.  In  certain  of  the  West  India  Islands  more  than  one  half  of  t lie 
mortality  among  the  negro  children  has  been  duo  to  this  cause.  In  a  inii- 
jority  of  tho  eases  there  is  an  injury  which  may  be  of  the  most  trilling' 
character.  It  is  more  common  after  punctured  and  contused  than  afii  r 
incised  wounds,  and  frequently  follows  those  of  tho  hands  ai'(I  feet.  Tin' 
disease  usiudly  appears  within  two  weeks  of  the  injury.  In  some  nulit.iiv 
campaigns  tetanus  has  prevailed  extensively,  but  in  others,  as  in  the  hw 
civil  war,  tho  cases  have  been  comparatively  few.  Idiopathic  tetann-  i- 
rare  in  man,  but  it  has  sometimes  followed  expoeure  to  cold  or  after  sIki^- 
ing  on  the  damp  ground. 


TETANUS. 


163 


The  infections  natnre  of  tetanus  was  suggested  by  its  endemic  occur- 
reri'c  ami  from  tlie  manner  of  its  behavior  in  certain  institutions.  V'et- 
eriiiiiriiUis  have  long  been  of  tiiis  belief,  aa  cases  are  apt  to  occur  together 
in  horses  in  one  sta-jle.  In  the  United  States  attention  was  early  called  to 
this  foatiiro  by  lIjo  prevalence  of  the  disease  in  the  eastern  end  of  Long 
Islaiiil. 

The  Tetanus  Bacillus. — The  observations  of  Uosenbach,  Nicolai'er,  and 
Kitasatd  have  denu)nstrated  that  there  is  in  connection  with  the  disease  a 
specitic  organism  which  can  be  isolated  and  cultivated.  The  bacillus  forms 
a  slender  rod  with  rounded  ends  and  nuiy  grow  into  long  threads.  It  is 
inotilt',  grows  at  ordinary  temperatures,  and  is  anaerobic.  With  small  quan- 
tiiifs  of  the  culture  the  disease  may  be  transmitted  to  animals,  which  die 
with  symptoms  of  tetanus.  An  extremely  interesting  fact  is  the  separa- 
tion liv  Hrieger,  from  the  cultures  as  well  as  from  a  subject  dead  of  teta- 
nus, of  j)()is(tnous  substances  capable  of  producing  the  disease.  Of  these 
ptomaines  oiu',  li-/(inin,  cinisca  the  characteristic  symptoms  of  teunus;  an- 
other causes  tremors,  convulsions,  aiul  subsequently  j)aralysi8 ;  and  a  third 
causes  at  once  intense  clonic  and  tonic  spasms.  Another  point  of  interest 
is  tile  fact  that  protection  in  animals  can  be  procured  by  inoculating  an 
aninial  with  the  blood  of  another  which  has  had  the  disease.  The  organ- 
ism has  been  found  in  the  earth  and  in  j)utrefying  fluids,  and  Nicolaier 
has  caused  the  disease  by  inoculating  with  dilTerent  sorts  of  surface  soil. 

Morbid  Anatomy. — No  characteristic  lesions  have  been  found  in 
il  ■  (ord  or  in  the  brain.  Congestions  occur  in  different  parts,  and  j)cri- 
v..seular  exudations  and  granular  changes  in  the  nerve-cells  have  been 
founil.  The  condition  of  the  wound  is  variable.  The  nerves  are  often 
'ouinl  injured,  reddened,  and  swollen.  In  the  tetanus  neonatorum  the 
uinhiliens  may  be  inflamed. 

Symptoms. — After  an  injury  the  disea.se  sets  in  usually  within  ten 
(lays.  In  Yandell's  statistics  at  least  two  fifths,  and  in  J  )S0\)]\  Jones's 
four  fifths,  occurred  before  the  fifteenth  day.  The  patient  complains  at 
first  of  slight  stiffness  in  the  neck,  or  a  feeling  of  tightness  in  the  jaws,  or 
ilitlieulty  in  mastication.  Occasionally  chilly  feelings  or  acitual  rigors  may 
pieeede  these  symptoms,  (iradually  a  tonic  spasm  of  the  muscles  of  these 
parts  develops,  producing  the  condition  of  trismus  or  lockjaw.  The  eye- 
brows Muvy  be  raised  and  the  angles  of  the  mouth  drawn  out,  causing  the 
?o-calh'(l  sardonic  grin — risus  .snrdonirus.  In  children  the  8i)asm  may  bo 
oiintiiied  to  these;  jiarts.  Sometimes  the  attack  is  associated  with  paralysis 
"f  tlie  facial  muscles  and  difficulty  in  swallowing — the  head  tetanus  of 
Rose,  which  has  most  commonly  followed  injuries  in  the  neighborhood  of 
iho  fifth  nerve,  (iradually  the  paroxysms  extend  and  involve  the  muscles 
of  tlie  hotly.  Those  of  the  back  are  most  affected,  so  that  during  the  spasm 
the  unfortunate  victim  may  rest  upon  the  head  and  heels,  a  position  known 
as  njnst/iotoHon.  The  rectus  abdominalis  muscle  has  been  torn  across  in 
the  spiiam.     The  entire  trunk  and  limbs  may  be  perfectly  rigid — orthoto- 


I.' 


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164 


SPECIFIC  INFECTIOUS   DISEASES. 


II  ' 

no.?.  Flexion  to  one  side  is  less  common — pleurosthofotios  ;  wliilc  simsm 
of  tlio  muscles  of  the  abdomen  may  cause  tlio  body  to  be  bent  forwunl  - 
einprunthotonos.  In  very  violent  attacks  the  thorax  is  conii)re88ed,  the  res- 
pirations are  nij)id,  and  spasm  of  the  glottis  may  occur,  causing  a«i»li}\i;i. 
The  paroxysms  last  for  a  variable  period,  but  even  in  the  intervals  the 
relaxation  is  not  complete.  The  slightest  irritation  is  suHicient  to  cuu-i' 
a  spasiu.  1'hc  paroxysms  are  a.ssociated  with  agonizing  ])ain,  and  ih*' 
|;;*tient  may  bo  lield  us  in  a  vise,  unable  to  utter  a  word.  Usually  he  is 
^>r'*^bcd  in  a  nrofiisc  sweat.  T.ie  temperature  may  remain  normal  throii}.'li- 
out;  or  e'w»w  only  a  slight  elevation  toward  the  close.  In  other  cases  tin- 
pyrexia  is  marked  from  the  outset;  the  temperature  reaches  105"  or  ItuP, 
and  before  death  109°  or  110°.  In  rare  instances  the  temperature  may 
reach  a  still  higher  point.  Death  either  occurs  during  the  i)aroxy8m  fi-din 
heart-failure  or  as])hyxia,  or  is  duo  to  exhaustion. 

Diagnosis. — Well-developed  cases  following  a  trauma  could  not  lie 
mistakefi  for  any  other  disease.  The  spasms  are  not  unlike  those  of 
strychnia-poisoning,  and  in  the  celebrated  Palmer  murder  trial  this  was 
the  plea  for  the  defence.  The  jaw-muscles,  however,  are. never  involved 
early,  if  at  all,  and  between  the  paroxysms  in  strychnia-poisoning  there  is 
no  rigidity.  Certain  cases  of  the  so-called  cephalic  tetanus  in  which  there 
is  ditticulty  of  swallowing  might  be  mistaken  for  hydrophobia,  but  in  this 
disease  there  is  never  the  stiffness  of  the  jaws  nor  paroxysms  in  which  the 
cervical  and  dorsal  muscles  are  affected.  In  tetany  the  distribution  of  tlio 
spasm  at  the  extremities,  the  peculiar  position,  the  greater  involvement  of 
the  hands,  and  the  condition  under  which  it  occurs,  are  sullicient  to  make 
the  diagnosis  clear. 

Prognosis. —Two  of  tlie  Hippocratic  aphorisms  express  tersely  the 
general  prognosis  oven  at  the  present  day  :  "  The  spasm  supervening  on  a 
wound  is  fatal,"  and  "such  persons  as  are  seized  with  tetanus  die  witliiii 
four  days,  or  if  they  pass  these  they  recover." 

The  mortality  in  the  traumatic  cases  is  not  less  than  eighty  per  eiiit. 
(Conner) ;  in  the  idiopathic  cases  it  is  under  fifty  per  cent.  According,'  to 
Yandell  the  mortality  is  greatest  in  children.  Favorable  indications  are 
— late  onset  of  the  attack,  localization  of  the  sptisms  to  the  muscles  of  tlie 
neck  and  jaw,  and  an  absence  of  fever.  Most  of  the  cases  of  loose's  head 
tetanus,  the  so-called  tetanus  hydrophohicus,  recover. 

Treatment. — The  jiatient  should  be  kept  in  a  darkened  room,  aliso- 
lutely  (juiet,  and  attended  by  only  one  person.  All  possible  sources  of 
irritation  should  be  avoided.  Veterinarians  appreciate  the  importance  of 
this  complete  seclusion,  and  in  well-equipped  infirmaries  there  may  Ite 
seen  a  brick  padded  chamber  in  which  these  cases  are  treated. 

When  the  lockjaw  is  extreme  it  may  be  impossible  to  feed  the  patient, 
under  which  circumstances  it  is  best  to  use  rectal  injections,  or  to  fee«i  Iiy 
a  catheter  passed  through  the  nose.  The  spasm  should  be  controlloil  by 
chloroform,  which  may  be  repeatedly  given  at  intervals.    It  is  more  satis- 


SYIMIILIS. 


165 


factory  to  keep  the  patient  thoroughly  under  the  influence  of  morphia 
(fivcii  liyp(»iU'rniically.  Chlonil  liydnite,  bromide  of  potiissium,  Calubiu' 
bciiii,  riirani,  Indian  licmp,  belladonna,  and  other  drugs  have  been  reconi- 
nicntlid,  and  recovery  occasionally  follows  their  use.  As  the  toxic  agents 
a|)|H'ar  to  bo  produced  by  bacilli  at  the  site  of  the  lesion,  thorough  cleuua- 
iiig  and  antiseptic  treatment  should  be  curried  out. 


XXV.  SYPHILIS. 

Definition. — A  specific  disease  of  slow  evolution,  propagated  by 
iiiociilation  (ac«|uired  syphilis),  or  by  hereditary  transmission  (congenital 
sypliilirt).  In  the  accjuired  form  the  site  of  inoculation  becomes  the  scat  of 
■A  Hpccial  tissue  change — primary  Ivaiun.  After  an  interval  of  two  or  three 
months  constitutional  symptoms  develop,  with  alTcctions  of  the  skin  and 
iiincoiirt  membranes — necoudary  lexions.  And,  finally,  after  a  period  of 
tlii(M\  four,  or  niore  years,  graindomatous  growths  develop  in  the  viscera, 
nuiijcles,  bones,  or  skin — tertiary  lesiona. 

I.    (iKNKKAL   ETIOLOOY    AND   MoKBID   ANATOMY. 

The  nature  of  the  virus  is  still  doubtful.  Lustgarten  found  in  the 
himi  cliiincre  and  in  gummata  a  rod-shaped  bacillus  of  ;i  or  4  /i  in  length, 
wliich  he  claims  is  specitic  and  peculiar  to  the  disease.  This  organism 
closely  resembles  the  smegma  bacillus,  which  is  found  beneath  the  pro- 
piiee.  but  from  its  occurrence  in  gumnuitous  growths  it  is  hardly  possible 
tliiii  tlicy  can  be  identical.  Further  observations  are  required  before  the 
question  oiui  be  considered  settled. 

Syphilis  is  peculiar  to  nuin,  and  cannot  bo  transmitted  to  the  lower 
aniiiiais.    All  arc  susceptible  to  the  contagion,  and  it  occurs  at  all  ages. 

Modes  of  Infection. — (1)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  sexual  conyress,  but  the  designation  venereal  disease,  lues 
niwrm,  is  not  always  correct,  as  there  are  numy  other  modes  of  inocula- 
tion, 

{'l)  .[tridental  Infection. — In  surgical  and  in  midwifery  practice,  phy 
sioians  arc  not  infrequently  inoculated.  It  is  surprising  that  infection 
from  tlu'sc  sources  is  not  more  common  I  have  known  personally  of  six 
C11S08.  Midwifery  chantu'es  are  usually  on  the  fingers,  but  I  have  met 
with  one  instance  on  the  back  of  the  hand.  liip,  mouth,  and  tonsillar 
Hires  result  as  a  rule  from  improper  practices.  Wet-nurses  are  sometimes 
iiifecteil  on  the  nipple,  and  it  occasionally  happens  that  relatives  of  the 
cliild  arc  accidentally  contaminated.  One  of  the  most  lamentable  forms 
of  accidental  infection  is  the  transmission  of  the  disease  in  humanized 
vaoi'iiu'  lymph.  Tiiis,  however,  is  extremely  rare.  The  conditions  under 
\Wiich  it  (,(!('urs  have  beeii  already  referred  to  (see  Vaccination). 

(3)  Hereditary  Transmission. — This  may  be,  and  is  most  common, 


166 


SPECIFIC   INFECTIOUS  DISEASES. 


from  (rt)  thd  fiitluT,  the  niotlior  being  hciilthy  (sperm  inlu'ritaiice).  It  is, 
uiir*)rtiiiiiit(>ly,  nil  every-diiy  experience  to  see  ca-ses  of  conj^tMiitiil  Hyplijlu 
in  wiiieii  tlie  infei-lion  is  cleurly  paternal.  A  Hyphiiitio  fatiier  may,  liow- 
ever,  beget  a  healthy  (^hild,  even  when  the  disease  is  fresli  and  fnll-hldwn. 
On  tlie  otiier  liand,  in  very  rare  instanees,  a  man  may  have  had  sy|i|iili> 
wiien  young,  undergo  treatment,  and  for  years  present  no  signs  of  di.-ca.-i, 
and  yet  liis  lirst-horn  may  show  very  eliaraeteristie  lesions.  Happily,  in  a 
hirge  nuijority  of  instances,  when  the  treatment  lias  been  thorough,  iIk 
offspring  escape.  'J'he  closer  the  begetting  to  the  priiiuiry  sore,  the  greater 
the  chance  of  infection.  A  man  with  tertiary  lesions  may  beget  Ik  ahliv 
children.  As  a  general  ride  it  may  be  said  that  with  judicious  trealiiunt 
the  transmissive  power  rarely  exceeds  three  or  four  years. 

(b)  Mati-rnal  transmission  (germ  inheritance).  It  is  a  remarkaMc 
and  interesting  fact  that  a  woman  who  has  borne  a  syphilitic  child  is  lur- 
self  immune,  and  cannot  be  infected,  though  she  may  present  no  signs  if 
the  disease.  This  is  known  as  Colles's  law,  and  was  thus  stated  by  tlif 
distinguished  Dublin  surgeon:  "That  a  child  Ixirn  of  a  mother  who  is 
without  obvious  venereal  symptoms,  and  which,  without  being  exposed  [« 
any  infection  subsecjuent  to  its  birth,  shows  this  disease  when  a  few  week- 
old — this  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it  er 
merely  handle  and  dress  it ;  and  yet  this  child  is  never  known  to  infect  \u 
own  mother,  even  though  she  suckle  it  while  it  has  venereal  ulcers  of  tlie 
lips  and  tongue."  In  a  nuijority  of  these  eases  the  mother  luis  received  a 
sort  of  ]n'otective  inoculation,  without  having  had  actual  manifestations  uf 
the  disease. 

A  woman  with  acquired  syphilis  is  liable  to  bear  infected  children. 
The  father  nuiy  not  bo  affected.  In  a  large  nund)er  of  instances  Ijotli 
parents  arc  diseased,  the  one  having  infected  the  ether,  in  which  case  the 
chances  of  f(etal  infection  arc  greatly  increa.sed. 

(<•)  Placental  transmission.  The  mother  nuiy  be  infected  after  emi- 
ception,  in  which  case  the  child  may  be,  but  is  not  necessarily,  born  n\\)\\- 
ilitic. 

Morbid  Anatomy. — The  primary  Irsimi,  or  chancre,  shows :  {a)  A  dif- 
fuse infiltration  of  the  connective  tissue  with  small,  round  cells,  (h) 
Larger  epithelioid  cells,  (r)  Giant  cells.  (</)  The  Lustgarten  bacilli,  in 
small  numbers,  {c)  Changes  in  the  snudl  arteries,  chiefly  thickening  of 
the  intinui,  and  alterations  in  the  nerve-fibres  going  to  the  part  (licrkelev). 
The  sclerosis  is  due  in  part  to  this  acute  obliterative  endarteritis.  Asj^o- 
ciated  with  the  initial  lesions  are  changes  in  the  adjacent  lymph-glandf, 
which  undergo  hyperplasia,  and  finally  become  indurated.  | 

The  scniixlary  h'nions  of  syphilis  are  too  varied  for  descrij)tion  here. 
They  consist  of  condylomata,  skin  eruptions,  alTections  of  the  eye,  etc. 

The  tertiary  hsinnn  consist  of  circumscribed  tumors  known  as  gum- 
niata,  and  of  an  artciitis,  which,  however,  is  not  peculiar  to  the  disoiise. 

Gummata. — Syphilomata  develop  in  the  bones  or  periosteum —hew 


SYI'IIILIS. 


167 


thi'V  lire  called  nodes — in  the  mu.scU'H,  skin,  hrivin,  lunjj,  liver,  kidneys, 
lii'iiit,  testes,  and  iidrenais.  Tiiev  vary  in  size  from  small,  almost  micro- 
.sci)|nt',  l>oilies  to  lar^e,  Holitl  tumors  from  three  to  tive  centimetres  in  diam- 
I'ttT.  They  are  usually  tirm  and  hard,  but  in  the  skin  and  on  the  mneoua 
iiu'iiiltranes  they  tend  to  break  down  rapidly  and  ulcerate.  On  cross-sec- 
tidii  a  niediiim-Ki/ed  u;uinma  has  a  ;,'rayisli-\vhite,  homop-neous  appear- 
ance, prescntinfjf  in  the  centre  a  tirm,  caMutus  substance,  and  at  the  pe- 
ii|(liciy  a  translucent,  fibrous  tissue.  Often  there  are  j,'roups  of  three  or 
more  surrounded  by  dense  siderotic?  tissue.  They  aro  usually  very  linn 
ami  iiard.  Histologically,  a  small  ;;umnui  consists  of  a  ^ranidation  tissue 
coiiipuscd  of  rounded  cells.  Owin/^  to  insuHlcient  blood-supply,  c(»a^ida- 
timi  iiccrosia  takes  pUu-e  in  the  centre  with  the  fornuition  of  a  flbro-caseous 
iiiiittrial,  while  the  f,'rowth  extends  at  the  nuiruins  with  the  f,'radual  i)ro- 
iliK'tinM  of  tibre-cells.  I'ltimately  the  central  caseous  part  nuiy  be  ab- 
sDihi'd,  and  healin;^  takes  place  with  the  development  of  a  librous  scar. 
'I'lic  arteritis  will  be  considered  in  a  separate  section. 

II.     Acyi  IKKI)   SYI'IIILIH. 

Primary  Stage. — This  e.xtends  from  the  appearance  of  the  initial  soro 
iiiiiil  tlie  onset  of  the  constitutioiuil  symptoms,  iiiui  has  a  variable  dura- 
linn  (jf  from  six  to  twelve  weeks.  The  initial  sore  appears  within  a  month 
aflir  inoculation,  aiul  it  tirst  shows  itself  as  a  snuill  red  |)apule,  which 
iriadually  enlarjifes  and  breaks  in  the  centre,  leaving  a  snndl  ulcer.  The 
lissiie  iibout  this  becomes  indurated  so  that  it  ultinuitely  has  a  fjristly,  car- 
iilaj,'iiious  ct)nsistence — hence  the  name,  hard  or  induratetl  (dumcre.  The 
size  attained  is  variable,  and  when  snuill  the  .^ore  may  be  overlooked,  ))ar- 
ticiilarly  if  it  is  just  within  the  urethra.  The  glands  in  the  lymph-district 
iif  the  (liiniere  enlarge  and  be(!omo  hard.  Suppuration  both  in  the  initial 
lisinii  and  in  the  glaiuls  nuiy  occur  as  a  secondary  change.  The  general 
oomlition  of  the  patient  in  this  stage  is  good.  Tlure  may  be  no  fever 
and  110  impairment  of  health. 

SBcondary  Stage. — Tho  first  constitutional  symjitoms  are  usiuilly  mani- 
fistcil  witliin  three  months  of  tho  appearance  of  the  prinuiry  .sore.  They 
rarely  develop  earlier  than  the  sixth  or  later  than  the  twelfth  week.  Tho 
s.vni|)tnnis  are:  (a)  /V/rr,  .slight  or  intense,  and  very  variable  in  charac- 
tir.  A  inild  continuous  pyrexia  is  not  uncommon,  the  temperature  not 
risiiiiT  ahiive  101°.  The  fever  may  have  a  distinctly  remittent  character; 
but  the  most  renuirkable  and  puzzling  type  of  i;y])hilitie  fever  is  the  inter- 
"iitieiii,  wliicli  often  leads  to  error  in  diagnosis.  The  fever  nuvy  come  on 
within  a  inoiilh  after  exposure  and  ri.se  to  104°  or  1()'>°,  with  oscillations 
"t  live  or  six  degrees  (Yeo)  A  remark  ible  case  is  reported  by  Sidney 
'lulli|is.  in  which  pyrexia  persisted  for  nonth-i,  with  paroxysms  resem- 
''liiiif  ill  all  respects  tertian  ague,  and  whic  .  "esisted  ijuinine  and  yielded 
promptly  to  mercury  and  potassium  iodide.  Although  usually  a  secondary 
iimnifestation,  the  fever  of  syphilis  may  occur  lute  in  the  disease. 
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SPECIFIC  INFECTIOUS  DISEASES. 


1.1* 


|i1l;'''M? 


(b)  AnxBmia. — In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anaemia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tiiigeing  of  the  conjunctivai  or  of  the  skin,  an  haamatogenous 
icterus.  This  syphilitic  cachexia  may  in  some  instances  be  extreme.  Tim 
red  blood-corpuscles  do  not  show  any  special  alterations.  "^I'lie  blood- 
count  may  fall  to  three  millions  per  cubic  millimetre,  or  even  lower,  and 
the  haemoglobin  to  forty  or  fifty  per  cent  (Ilayem).  No  characteristic 
organisms  have  been  found  in  the  blood. 

(t)  Cutaneous  Lesions. — Skin  eruptions  of  all  forms  may  devcloji. 
The  earliest  and  most  common  is  a  rash — macular  sijj)hiJide  or  syjfhiUtic 
roseola — which  occurs  on  the  abdomen,  the  chest,  and  on  the  front  of  the 
arms.  The  face  is  often  exempt.  The  spots,  which  are  reddish-brown 
and  symmetrically  arranged,  persist  for  a  week  or  two.  Next  in  frequency 
is  a  papular  sypli  Hide,  which  may  form  acne-like  indurations  about  tho 
face  and  trunk,  often  arranged  in  groups.  Other  forms  arc  the  jmsfuhir 
rash,  which  may  so  closely  simulate  variola  that  the  patient  may  be  sent 
to  a  small-pox  hospital.  A  squamous  syphilide  occurs,  not  unlike  ordi- 
nary psoriasis,  except  that  the  scales  are  less  abundant.  The  rash  is  more 
copper-colored  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  the  perinaeum  and  groins,  the 
axilla?,  between  the  toes,  and  at  the  angles  of  the  mouth,  the  so-called 
mucous  patches  develop,  which  are  flat,  warty  outgrowths,  with  well-defined 
margins  and  surfaces  covered  with  a  grayish  secretion.  They  are  among 
the  most  distinctive  lesions  of  syphilis. 

Frequently  tiid  hair  falls  out  (alopecia),  either  in  patches  or  by  a 
general  thinning.  Occasionally  the  nails  become  affected  (syphilitic 
onychia). 

(d)  Mucous  Lesions. — "With  the  fever  and  the  roseolous  rash  the  throat 
and  mouth  become  sore.  The  pharyngeal  mucosa  is  hyperoemic,  the  ton- 
sils are  swollen  and  often  present  small,  kidney-shaped  ulcers  with  gray- 
ish-white borders.  AIucous  patches  arc  seen  on  the  inner  surfaces  of  the 
cheeks  and  on  the  tongue  and  lips.  Sometimes  on  the  tongue  there  are 
whitish  spots  (leucomata),  which  are  seen  most  frequently  in  smokers,  and 
which  Hutchinson  regards  as  the  joint  result  of  syphilitic  glossitis  and  the 
irritation  of  hot  tobacco-smoke.  Hypertrophy  of  the  ])apilloe  in  various 
portions  of  the  mucous  membrane  produces  the  syphilitic  wurt^  or  condy- 
lomata Avhich  are  most  frequent  about  the  vulva  and  anus. 

{e)  Other  L^esions. — Iritis  is  common,  and  usually  affects  one  eye  be- 
fore the  other.  It  develops  in  from  three  to  six  months  after  the  chancre. 
There  may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  seviTcr 
forms  there  is  great  pain,  and  the  condition  is  serious  and  demands  care- 
ful management.  Choroiditis  and  retinitis  are  rare  secondary  symptoms. 
Ear  affections  are  not  common  in  the  secondary  stage,  but  instances  are 
found  in  which  sudden  deafness  develops,  which  may  be  due  to  labyrinth- 
ine disease ;  more  commonly  the  impaired  hearing  is  due  to  the  extension 


SYPniLIS. 


169 


of  iullammation  from  the  throat  to  the  middle  ear.  Epididymitis  is  an 
occasional  secondary  lesion. 

Tertiary  Stage. — No  hard  and  fast  line  can  be  drawn  between  the 
lesions  of  the  secondary  and  those  of  the  tertiary  period ;  and,  indeed,  in 
exceptional  cases,  manifestations  which  usually  ai)])ear  late  may  set  in 
even  before  the  primary  sore  has  properly  healed.  The  special  affections 
of  this  stage  are  certain  skin  eruptions,  gummatous  growths  in  the  viscera, 
and  amyloid  degenerations. 

(a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and 
destruction  of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars 
are  loft.  They  are  also  more  scattered  and  seldom  symmetrical.  One 
of  the  most  characteristic  of  the  tertiary  syphilides  is  rui)ia,  the  dry 
stratified  crusts  of  which  cover  an  ulcer  which  involves  the  deeper  layers 
of  the  skin  and  in  healing  leaves  a  scar. 

{h)  Gummata. — These  may  develop  in  the  skin,  subcutaneous  tissue, 
muscles,  or  internal  organs.  The  general  character  has  been  already 
described.  When  they  develop  in  the  skin  they  tend  to  break  down  and 
ulcerate,  leaving  ugly  sores  which  heal  with  difficulty.  In  the  solid 
organs  they  undergo  fibroid  transformation  and  produce  puckering  and 
deformity.  On  the  mucous  membranes  these  tertiary  lesions  load  to 
ulceration,  in  the  healing  of  which  cicatrices  are  formed ;  thus,  in  the 
larynx  great  narrowing  may  result,  and  in  the  rectum  ulceration  with 
fibroid  thickening  and  retraction  may  lead  to  stricture. 

(c)  Amyloid  Degeneration. — Syphilis  plays  a  most  important  role  in 
the  production  of  this  affection.  Of  244  instances  analyzed  by  Fagge, 
76  had  syphilis,  and  of  these  42  had  no  bone  lesions.  It  follows  the 
acquired  form  and  is  very  common  in  the  rectal  disease  in  women.  In 
congenital  lues  amyloid  degeneration  is  rare. 

{(})  Sclerosis — Syphilis  is  an  important  factor  in  inducing  degenera- 
tive changes  in  certain  tissues.  In  locomotor  ataxia  the  association  be- 
tween this  disease  and  sclerosis  of  the  posterior  columns  of  the  cord  is  far 
too  frequent  to  be  accidental,  but  the  precise  relations  cannot,  with  our 
present  knowledge,  be  explained.  "With  regard  to  arterio-sclerosis,  the  part 
played  by  syphilis  is  unquestioned,  but  the  nature  of  the  connection  of  the 
two  processes  remains  doubtful. 

III.   Congenital  Syphilis. 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired 
disease  may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  foetus  do  not 
here  concern  us.  The  child  may  be  born  healthy-looking,  or  with  well- 
marked  evidences  of  the  disease.  In  the  majority  of  instances  the  former 
is  tlie  case,  and  within  the  first  month  or  two  the  signs  uf  the  disease 
appear. 

Symptoms. — («)  At  Birth. — When   the   disease   exists  at   birth  the 


A'^  n 


I'l    • 


170 


SPECIFIC  INFECTIOUS  DISEASES. 


child  is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usuallv 
present,  commonly  in  the  form  of  bulloB  about  the  wrists  and  ankles,  and 
on  the  hands  and  feet  (pemphigus  neonatorum).  The  child  snuffles,  the 
lips  are  ulcerated,  the  angles  of  the  mouth  fissured,  and  there  is  en- 
largement of  the  liver  and  spleen.  The  bone  symptoms  may  be  marked, 
and  the  epiphyses  may  even  be  separated.  In  such  cases  the  childron 
rarely  survive  long. 

(b)  Early  Manifcstntions. — When  born  healthy  the  child  thrives,  is 
fat  and  plump,  and  shows  no  abnormity  whatever ;  then  from  tlie 
fourth  to  the  eighth  week,  rarely  later,  a  nasal  catarrh  develops,  syphilific 
rhinitis,  which  impedes  respiration,  and  produces  the  characteristic 
symptom  which  has  given  the  name  snuffles  to  the  disease.  The  dis- 
charge may  be  sero-purulent  or  bloody.  The  child  nurses  with  gn^at 
difliculty.  In  severe  cases  ulceration  takes  place  with  necrosis  of  the 
bone,  leading  to  a  depression  at  the  root  of  the  nose  and  a  deformity 
characteristic  of  congenital  syphilis.  This  coryza  may  be  mistaken  at 
first  for  an  ordinary  catarrh,  but  the  coexistence  of  other  manifestations 
usually  makes  the  diagnosis  clear.  The  disease  may  extend  into  tlic 
Eustachian  tubes  and  middle  ear  and  lead  to  deafness. 

The  cutaneous  lesions  develop  with  or  shortly  after  the  onset  of  the 
snuffles.     The  skin  often  has  a  sallow,  earthy  hue.    The  eruptions  are 
first  noticed  about  the  nates.    There  may  be  an  erythema  or  an  eczematous 
condition,  but  more  commonly  there  are  irregular  reddish-brown  patches 
with  well-defined  edges.     A  papular  syphilide  in  this  region  is  by  no 
means  uncommon.     Fissures  develop  about  the  lips,  either  at  the  angles 
of  the  mouth  or  in  the  median  line.     These  rhagades,  as  they  are  called, 
are  very  characteristic.     There  may  be  marked  ulceration  of  the  muco- 
cutaneous surfaces.     The  secretions  from  these  mouth  lesions  are  very 
virulent,  and  it  is  from  this  source  that  the  wet-nurse  is  usually  infected. 
Hot  only  the  nurse,  but  members  of  the  family,  may  be  contaminated. 
There  are  instances  in  which  other  children  have  been  accidentally  inocu- 
lated from  a  syphilitic  infant.     The  hair  of  the  head  or  of  the  eyebrows 
may  fall  out.     The  syphilitic  onychia  is  not  uncommon.    Enlargement  of 
the  glands  is  not  so  frequent  in  the  congenital  as  in  the  acquired  disease. 
When  the  cutaneous  lesions  are  marked,  the  contiguous  glands  can  usually 
be  felt.     As  pointed  out  by  Gee,  the  spleen  is  enlarged  in  many  cases. 
The  condition  may  persist  for  a  long  time.     Enlargement  of  the  liver. 
though  often  present,  is  less  significant,  since  in  infants  it  may  be  due  to 
various  causes.    These  are  among  the  most  constant  symptoms  of  con- 
genital  syphilis,  and   usually   develop  between   the   third  and  twelfth 
weeks.    Frequently  they  are  preceded  by  a  period  of  restlessness  and  wake- 
fulness, particularly  at  night.     Some  authors  have  described  a  pct'uliar 
syphilitic  cry,  high-pitched  and  harsh.    Among  rarer  manifestations  arc 
hajmorrhages — the  syphilis   hcsmorrhagica   neonatorum.      The  blocdinir 
may  be  subcutaneous,  from  the  mucous  surfaces,  or,  when  early,  from  tlio 


SYPHILIS. 


171 


umbilicus.  All  of  such  cases,  however,  are  not  syphilitic,  and  the  disease 
must  not  be  confounded  with  the  acute  haemoglobinuria  of  new-born  in- 
fants, which  Winckel  describes  as  occurring  in  e2)idemic  form,  and  which 
is  probably  an  acute  infectious  disorder. 

{{:)  Late  Manifestations. — Children  with  congenital   syphilis  rarely 
thrive.    Usually  they  present  a  wizened,  wasted  appearance,  and  a  pre- 
maturely aged  face.     In  the  cases  which  recover,  the  general  nutrition 
may  remain  good  and  the  child  may  show  no  further  manifestations  of 
the  disease ;  commonly,  howe  'er,  at  the  period  of  second  dentition  or  at 
pulierty  the  disease  reappears.     Although  the  child  may  have  recovered 
from  the  early  lesions,  it  does  not  develop  like  other  children.     Growth  is 
slow,  development  tardy,  and  there  are  facial  and  cranial  characteristics 
which  often  render  the  disease  recogniza.    .  at  a  glance.    A  young  man  of 
nineteen  or  twenty  may  neither  look  older  nor  be  more  developed  than  a 
boy  of  ten  or  twelve.     Fournier  describes  this  condition  as  infantilism. 
The  forehead  is  prominent,  the  frontal  eminences  are  marked,  and  the 
skull  may  be  very  asymmetrical.     The  bridge  of  the  nose  is  depressed, 
the  tip  retrousse.     The  lips  are  often  prominent,  and  there  are  striated 
lints  running  from  the  corners  of  the  mouth      The  teeth  are  deformed 
and  may  present  appearances  which  Jonathan  Ilntchinson  claims  are 
specific  and  peculiar.     The  upper  central  incisors  of  the  permanent  svi 
are  the  teeth  which  give  information.     The  specific  alterations  are — the 
teeth  are  peg-shaped,  stunted  in  length  and  breadth,  and  narrower  at  the 
cutting  edge  than  at  the  root.     On  the  anterior  surface  the  enamel  is 
well  formed,  and  not  eroded  or  honeycombed.     At  the  cutting  edge  there 
is  a  single  notch,  usually  shallow,  sometimes  deep,  in  which  tlie  dentine  is 
exposed. 

Among  late  manifestations,  particularly  apt  to  appear  about  puberty, 
is  the  interstitial  keratitis,  which  usually  begins  as  a  slight  steaminess  of 
the  corneas,  which  present  a  ground-glass  appearance.  It  affects  both 
eyes,  tliongh  one  is  attacked  before  the  other.  It  may  persist  for  months, 
and  usually  clears  completely,  though  it  may  leave  opacities,  which  pre- 
vent clear  vision.  Iritis  may  also  occur.  Of  ear  offedions,  apart  from 
those  which  develop  as  a  sequence  of  the  pharyngeal  disease,  a  form  occurs 
about  the  time  of  puberty  or  earlier,  in  which  deafness  comes  on  rapidly 
and  persists  in  s{)ite  of  all  treatment.  It  is  unassociav  d  with  obvious 
lesions,  and  is  probably  labyrinthine  in  character.  Bone  lesions,  occurring 
oftenest  after  the  sixth  year,  are  not  rare  among  the  late  manifestations  of 
hereditary  syphilis.  The  tibiae  are  most  frequently  attacked.  It  is  really 
!» elu'onic  gummatous  periostitis,  which  gradually  leads  to  great  thicken- 
ing of  the  bone.  The  nodes  of  congenital  syphilis,  which  are  often  mis- 
taken for  rickets,  are  more  commonly  diffuse  and  affect  the  bones  of  the 
"pper  and  lower  extremities.  They  are  generally  symmetrical  and  rarely 
painful.    They  may  develop  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.     Glutton  has  described  a  symmetrical  synovitis 


172 


SPECIFIC  INFECTIOUS  DISEASES, 


!<; 


of  the  knee  in  hereditary  syphilis.  Lastly,  it  must  be  borne  in  mind  that 
enlargement  of  the  spleen  may  be  one  of  the  late  manifestations,  and  may 
occur  either  alone  or  in  connection  with  disease  of  the  liver.  At  the 
University  Hospital,  Philadelphia,  I  had  under  observation  for  more  tlian 
a  year  a  girl  of  thirteen,  small  and  feebly  developed,  with  a  luetic  facias, 
whose  spleen  reached  as  low  as  the  level  of  the  navel.  The  condition  was 
not  thought  to  be  due  to  inherited  syphilis  until  she  developed  osseous 
lesions. 

Gummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late 
hereditary  syphilis. 

IV.  Visceral  Syphilis. 

A.  Syphilis  of  the  Brain  and  Cord. — The  following  lesions  occur: 

(1)  (riimmata,  forming  definite  tumors,  ranging  in  size  from  a  pea  to 
a  walnut.  T'hey  are  usually  multiple  and  attached  to  the  pia  nuiter,  some- 
times to  the  dura.  Very  rarely  they  are  found  unassociated  with  the 
meninges.  When  small  they  present  a  uniform,  translucent  appearance, 
but  when  large  the  centre  undergoes  a  fibro-cascous  change,  while  at  tlie 
periphery  there  is  a  firm,  translucent,  grayish  tissue.  They  may  closely 
resemble  large  tuberculous  tumors.  The  growths  are  most  common  in 
the  cerebrum.  They  may  be  multiple  and  may  even  attain  a  consid- 
erable size  without  becoming  caseous.  Occasionally  gummata  undergo 
cystic  degeneration.  In  the  cord  large  gummatous  growths  are  not  so 
common.  In  an  instance  recently  reported  by  me  a  tumor,  from  tliroe 
eighths  to  one  fourth  of  an  inch  in  diameter,  was  completely  within  tlie 
cord  opposite  the  fourth  cervical  nei've,  and  there  were  numerous  gum- 
mata in  the  cauda  equina. 

(2)  Gummatous  Mcni7igitis. — This  constantly  occurs  in  the  neighbor- 
hood of  the  larger  growths,  and  there  may  be  local  meningeal  thickening 
several  centimetres  in  extent,  in  which  the  pia  is  infiltrated  and  the  ar- 
teries greatly  thickened.  This  by  no  means  uncommon  form  may  run  a 
subacute  or  a  chronic  course. 

(3)  Gummatous  Arteritis. — The  lesions  may  be  confined  to  the  arteries 
which  present  the  nodular  tumors  to  be  described  hereafter. 

(4)  Foci  of  sclerosis,  which  Lancereaux  holds  may  be  distinguislied 
from  non-specific  forms  by  a  much  greater  tendency  of  the  neuroglia  ele- 
ments to  undergo  fatty  transformation,  and  by  the  secondary  alterations, 
as  areas  of  softening,  which  occur  in  the  neighborhood.  Keither  the  dif- 
fuse nor  the  nodular  cerebral  sclerosis,  met  with  particularly  in  children, 
appears  to  have  any  special  relation  to  inherited  syphilis. 

(5)  Whether  a  localized  encephalitis  or  myelitis  can  result  from  the 
action  of  the  syphilitic  poison  without  involvement  of  the  blood-vessels  is 
doubtful.  In  a  case  of  multiple  arterial  gummata  recently  in  my  ward, 
Thomas  found  iu  the  lumbar  region  of  the  cord  foci  of  inflammatory  soft- 
ening. /I  .  ' 


SYPHILIS. 


173 


Secondary  Changes. — In  the  brain  gummatous  arteritis  is  one  of  the 
common  causes  of  softening,  which  may  be  extensive,  as  when  the  middle 
cfit'bnil  artery  is  involved,  or  when  there  is  a  large  i)atch  of  syphilitic 
meningitis.  In  such  instances  the  process  is  really  a  meningo-encepha- 
litis,  and  the  symptoms  arc  due  to  the  secondary  changes  in  the  brain-sub- 
stiineo,  not  directly  to  the  gumma.  In  the  neighborhood  of  a  gummatous 
growth  intense  encephalitis  or  myelitis  may  develop,  and  within  a  few 
days  cliange  the  clinical  picture.  Gummatous  arteritis  may  lead  to  weak- 
ening of  the  wall  of  the  vessel  and  rupture  with  meningeal  haemorrhage. 

Syphilitic  disease  of  the  nerve-centres  may  occur  in  the  inherited  or 
acquired  form,  most  commonly  in  the  latter.  In  the  congenital  cases  the 
tumors  usually  develop  early,  but  may  be  as  late  as  the  twenty-first  year 
(11.  C.  Wood).  In  the  acquired  form  the  nerve  lesions  belong,  as  a  rule, 
to  tlie  late  manifestations,  and  patients  may  have  quite  forgotten  the  ex- 
istence of  a  primary  infection,  and  in  very  many  instances  the  secondary 
manifestations  have  been  slight.  Heubner,  to  whom  we  owe  so  much  in 
connection  with  this  subject,  has  seen  it  as  late  as  the  thirtieth  year.  On 
the  other  hand,  in  exceptional  instances,  it  may  occur  very  early,  and  con- 
vulsions and  brain  syi;  'itoms  have  been  reported  within  three  months  of 
the  primary  sore.  In  •  ie  of  my  cases,  in  which  there  was  endarteritis 
followed  by  dilatation  anu  [perforation,  the  patient  had  had  a  hard  chancre 
eighteen  months  before,  with  severe  secondary  symptoms. 

Symptoms. — The  chief  features  of  cerebral  syphilis  are  those  of  tumor, 
whicli  will  be  considered  subsequently  under  that  section.  They  may  be 
classified  here  as  follows  : 

(1)  Psychical  features.  A  sudden  and  violent  onset  of  delirium  may 
be  the  first  symptom.  In  other  instances  prior  to  the  occurrence  of 
delirium  there  have  been  headache,  alteration  of  character,  and  loss  of 
memory.  The  condition  i.iay  be  accompanied  by  convulsions.  There  may 
be  no  neuritis,  no  palsy,  and  no  localizing  symptoms. 

{2)  More  commonly  following  headache,  giddiness,  or  an  excited  state 
wliicli  may  amount  to  delirium,  the  patient  has  an  epileptic  seizure  or  de- 
velops hemiplegia,  or  there  is  involvement  of  the  nerves  of  the  base.  Some 
of  these  cases  display  a  prolonged  torpor,  a  special  feature  of  brain  syphi- 
lis to  which  both  Buzzard  and  Heubner  have  referred,  which  may  persist 
for  as  long  as  a  month.  H.  0.  Wood  describes  with  this  a  state  of  au- 
tomatism occurring  particularly  at  night,  in  which  the  patient  behaves 
like  "  a  restless  nocturnal  automaton  rather  than  a  man." 

(3)  A  clinical  picture  of  general  paralysis — dementia  paralytica.  The 
question  is  still  in  dispute  whether  this  syphilitic  encephalopathy,  which 
so  closely  resembles  general  paralysis,  is  a  distinct  and  independent  affec- 
tion. ]\Iickle,  who  has  carefully  reviewed  the  subject,  concludes  that 
syphilis  may  directly  produce  the  inflammatory  changes  in  the  brain,  while 
in  otiier  instances  it  directly  predisposes  to  this  affection.  It  is  a  some- 
what remarkable  feature  that  the  cases  which  present  the  clinical  picture 


'  1  p-if 


174 


SPECIFIC  INFECTIOUS  DISEASES. 


i|r-  I 


of  general  paresis  are  most  frequently  those  which  have  not  had  any  focal- 
izing syniiitoms,  unci  they  may  not  hi've  convulsions  until  tlie  disease  is 
well  advanced.  Another  peculiarity  is  the  fact  that,  like  the  late  sclerosis, 
the  condition  is  not  very  amenable  to  the  specific  treatment ;  though 
Mitchell  mentions  an  instance  which  he  regarded  as  general  paresis,  l)ui 
which  subsefpiently  came  into  the  hands  of  II.  C.  Wood,  who  cured  tlic 
case  with  iodi(le  of  potassium. 

(4)  ^lany  cases  of  cerebral  syphilis  display  the  symptoms  of  brain 
tumor — headache,  optic  neuritis,  vomiting,  and  convulsions.  Of  these 
symptoms  convulsions  are  the  most  important,  and  botli  Founder  and 
Wood  liave  laid  great  stress  on  the  value  of  this  symptom  in  persons  over 
thirty.  The  first  symptoms  may,  however,  rather  resemble  embolism  or 
thrombosis ;  thus  there  may  be  sudden  hemiplegia,  with  or  without  loss  of 
consciousness. 

The  symptoms  of  »pinal  syphilis  are  extremely  varied  and  may  be 
caused  eitlier  by  large  gummatous  growths  attached  to  the  meninges,  hi 
which  case  the  features  are  those  of  tumor;  or  by  meningitis  with  secon- 
dary spastic  changes ;  or  again  by  scleroses  developing  late  in  the  disease, 
the  relation  of  which  to  syphilis  is  still  obscure. 

Diar/iiosis. — The  history  is  of  the  first  importance,  but  it  may  be  ex- 
tremely difficult  to  get  a  reliable  account.  Careful  examination  should  be 
made  for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of 
the  skin  eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character 
of  the  symptoms  is  often  of  great  assistance.  They  are  multiform,  vari 
able,  and  often  such  as  could  not  be  explained  bv  a  single  lesion ;  thus 
there  may  be  anomalous  spina!  symptoms  or  involvement  of  the  nerves  of 
the  brain  on  both  sides.  And  lastly  the  result  of  treatment  has  a  definite 
bearing  on  the  diagnosis,  as  the  symptoms  may  clear  up  and  disappear 
with  the  use  of  antisyphilitic  remedies. 

B.  Syphilis  of  the  Lung. 

This  is  a  very  rare  disease.  During  twenty  years  I  have  not  seen  more 
than  half  a  dozen  specimens  in  which  there  was  no  question  as  to  tlie 
nature  of  the  trouble.  Early  in  my  professional  life  I  learned  to  recognize 
the  disease  from  the  teaching  of  Wilks,  and  became  familiar  with  the  ex- 
cellent specimens  preserved  at  Guy's  Hospital.  In  my  ten  years'  work  in 
Montreal  not  a  single  specimen  was  recognized  at  the  dissections  at  tlie 
General  Hospital,  In  1878  and  1884  I  saw  several  characteristic  examples 
in  London  and  Germany.  During  five  years  in  Philadelphia,  for  the 
greater  part  of  which  time  I  was  connected  with  the  Philadelphia  Hospi- 
tal, which  has  perhaps  as  rich  luetic  material  as  is  to  be  found  anywhere, 
only  one  or  two  specimens  were  seen.  Three  admirable  illustrations  of 
pulmonary  gummata  have  occurred  at  the  Johns  Hopkins  Hospital  dmi"? 
the  past  two  years.  I  mention  these  details  because  the  subject  is  one 
which  has  always  interested  me,  and  I  have  been  constantly  on  the  lookout 
for  the  disease.     It  has  been  a  continual  surprise  that  it  slaould  be  so  com- 


SYPHILIS. 


175 


nion  in  certain  localities,  bnt  I  find  that  my  experience  as  to  its  compara- 
tive rarity  tallies  very  closely  with  that  of  pathologists  and  hospital  physi- 
cians in  this  country  and  in  Europe.  The  literature  of  the  subject  is 
extensive,  but  from  the  clinical  aspect  largely  worthless,  as  it  preceded 
Kuch's  discovery  of  the  bncHUis  tubercuhms. 

Eliolofiy  mid  Morbid  Anatomy. — Syi)hilis  of  the  lung  occurs  under 
the  following  forms : 

(1)  Tha  iv/iife  pneiononin  of  the  fietns.  Tliis  may  aflect  large  areas 
or  iin  entire  lung,  which  tlien  is  firm,  heavy  and  airlens,  even  though  the 
child  may  have  been  born  alive.  On  section  it  has  a  grayish-wiiite  appear- 
jinco — the  so-called  white  hepatization  of  Virchow.  The  chief  change  is 
in  the  alveolar  Avails,  Avhich  are  greatly  thickened  and  infiltrated,  so  that, 
as  Wagner  expressed  it,  the  condition  resembles  a  dilTuso  syj)hiloma.  In 
the  early  stages,  for  example,  in  a  seven  or  eight  months'  fu'tus,  there  may 
bo  scattered  miliary  foci  of  this  induration  chiefly  about  the  arteries. 
The  air-cells  are  filled  with  desquamated  and  swollen  epithelium. 

(2)  In  the  form  of  definite  giimmatn,  which  vary  in  size  from  a  pea  to 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  but,  as 
a  rule,  arc  more  numerous  toward  the  root.  They  present  a  grayish-yellow 
caseous  appearance,  are  dry  and  usually  imbedded  in  a  translucent,  more 
or  less  firm,  connective  tissue.  In  a  case  from  my  wards  recently  described 
by  Councilman,  there  was  extensive  involvement  of  the  root  of  the  lungs. 
Bunds  of  connective  tissue  passed  inward  from  the  thickened  pleura  and 
between  these  strands  and  surrounding  the  gummata  there  Avas  in  places 
a  mottled  red  pneumonic  consolidation.  In  the  caseous  nodules  there 
is  typical  liyaline  degeneration.  Councilman  describes  as  the  primary 
lesion,  atrophy  of  the  alveolar  AA'alls  Avith  hyaline  degeneration  of  the  capil- 
laries, not  the  syphilitic  endarteritis,  Avhich  is  Avell  marked,  and  to  which 
the  lesions  are  attributed.  The  bronchi  are  usually  involved,  and  sur- 
rounding the  gummata  there  may  be  a  diffuse  broncho-pneumonia,  which 
does  not  appear  to  have  any  peculiar  characters. 

(3)  A  majority  of  authors  follow  Vircliow  in  recognizing  the  fibrous 
interstitial  pneumonia  at  the  root  of  the  lung  and  jiassing  along  the  bron- 
chi and  vessels  as  p;'obably  syphilitic.  This  much  may  bo  said,  that  in  cer- 
tain oases  gummata  are  associated  with  these  fibroid  changes.  Again,  this 
conilition  alone  is  found  in  persons  Avith  Avell-marked  syphilitic  history  or 
with  other  visceral  lesions.  It  seems  in  many  instances  to  be  a  purely 
sclerotic  process,  advancing  sometimes  from  the  pleura,  more  commonly 
from  the  root  of  the  lung,  and  invadi7ig  the  interlobular  tissue,  gradually 
producing  a  more  or  less  extensive  fibroid  change.  It  rarely  involves 
more  than  a  portion  of  a  lobe  or  portions  of  the  lobes  at  the  root  of  the 
lung,    The  bronchi  are  often  dilated. 

Symptoms. — Is  there  a  syphilitic  phthisis,  an  ulceratiA'c  and  destruc- 
tive disease,  due  to  lues  ?  Personally  I  have  no  knowledge  of  such  an 
ailection,  either  clinically  or  anatomically,  and  the  cases  which  I  have  seen 


-    1 
I  fill 

lit 


176 


SPECIFIC   INFECTIOUS  DISEASES. 


Ijl  U.  ] 

II' "■■    ' 

demonstrated  do  not  soem  to  mo  to  have  characters  distinctive  enougli  tn 
separate  them  from  ordinary  tuberculous  idithisis.  Certain  Frenclx  writrr.s 
recognize  not  only  a  chronic  syphilitic  jjhthisis  but  an  acute  sypliiliiie 
{)iu^umonia  in  adidts,  simulating  acute  pneumonic  phthisis.  Clinicallv, 
pulmonary  8yj)hilis  is  not  of  much  importance,  as  the  cases  can  rarely  lio 
diagnosed,  and  the  symjitoms  which  arise  are  usually  those  of  bronchi, 
ectasis  or  of  chronic  interstitial  pneumonia.  The  white  pneumonia  is 
usually  found  in  the  still-born. 

Diagnosis. — It  is  to  bo  borne  in  mind,  in  the  first  place,  tliat  hospital 
pliysicians  and  pathologists  the  world  over  bear  witness  to  the  extreme 
rarity  of  lung  syphilis.  In  the  second  place,  the  therapeutic  test  upon 
which  so  much  reliance  is  placed  is  by  no  means  conclusive.  AVitli  jnil- 
monary  tubiu-culosis  there  should  now  be  no  confusion,  owing  to  the  readi- 
ness with  which  the  presence  of  bacilli  is  determined.  Bronchiectasy  in 
the  lower  lobo  of  a  lung,  dependent  ujion  an  interstitial  pneumonia  of 
syphilitic  origin,  could  not  be  distinguished  from  any  other  form  of  the 
disease.  In  jxn-sons  with  well-marked  syphilitic  lesions  elsewhere,  when 
obscure  pulmonary  symptoms  occur,  or  if  there  are  signs  of  chronic  inter- 
stitial pneumonia  with  dilated  bronchi,  and  no  tubercle  bacilli  are  present, 
the  condition  may  possibly  be  duo  to  syphilis.  So  far  as  my  experience 
goes,  tuberculous  phthisis  occurring  in  a  syphilitic  subject  has  no  special 
peculiarities.  The  lesions  of  syphdis  and  tuberculosis  could  of  course  co- 
exist in  a  lung.  Since  writing  the  above,  the  recent  paper  of  Satterthwaite 
has  appeared,  ■  t  one  of  the  cases  upon  which  it  is  based  could  prop- 

erly be  regard'  yphilitic  in  the  absence  of  an  examination  for  tuber- 

cle bacilli.  Much  more  suggestive  of  true  syphilitic  phthisis  is  Case  I  of 
McLane  Tiffany's  series,  but  it  too  may  have  been  tuberculous.  It  is  quite 
possible  that  a  large  caseous  gumma  may  break  down  and  form  a  cavity, 
but  the  existence  of  an  extensive  ulcerative  and  destructive  disease  of 
tlio  lungs  (comparable  to  tuberculosis)  due  to  syphilis  has  not  yet  been 
proved. 

c.  Syphilis  of  the  Liver. 

This  occurs  in  three  forms:  (a)  Diffuse  SyjiMlitic  Hepatitis. — This  i? 
most  common  in  cases  of  congenital  syphilis.  The  liver  preserves  its 
form,  is  large,  hard,  and  resistant.  Sometimes  it  has  a  yellow  look,  com- 
pared by  Trousseau  to  sole-leather,  or  an  ajipearanco  not  unlike  the  amy- 
loid liver.  Careful  inspection  shows  grayish  or  whitish  points  and  line? 
corresponding  to  the  interlobular  new  growth.  Microscopically,  grent 
increase  in  the  connective  tissue  is  seen,  and  in  many  places  foci  of  small- 
celled  infiltration.  Sometimes  these  uodules  are  visible,  forming  firm 
miliary  gurnmata  which  in  cicatrizing  produce  more  or  less  deformity. 
Larger  gurnmata  may  also  be  present. 

{h)  Gurnmata. — As  a  result  of  congenital  syphili  these  may  occur:; 
childhood  or  in  adult  life.  In  acquired  syphilis  they  rarely  come  on  be- 
fore the  second  year  after  infection.     In  the  early  stage  there  are  pale 


SYPHILIS. 


177 


grayish  nodules,  varying  in  size  from  a  pea  to  a  marble.  The  larger, 
which  arc  usually  liniitod  toward  the  liver  tissue,  present  yellowish  cen- 
tres at  fu'st;  but  later  there  is  a  "  pale  yellowish,  cheese-like  nodule  of 
iircnilar  outline,  surrounded  by  a  llbroua  zone,  the  outer  edge  oi'  which 
lusfs  itsi'lf  in  the  lobular  tissue,  the  lobules  dwindling  gradually  in  its 
(Miisp.  This  fibrous  zone  is  never  very  broad ;  tlio  cheesy  centre  varies  in 
coiisisteiu-'e  from  a  gristle-like  toughness  to  a  pulpy  softness ;  it  is  some- 
tiiiios  mortar-like,  from  cretaceous  change"  (Wilks).  When  numerous, 
till'  most  extensive  deformity  of  the  liver  is  produced  in  the  gradual  heal- 
inj,f  uf  these  gummata.  On  the  surface  there  are  deep,  scar-like  depres- 
sions, and  the  entire  organ  may  bo  divided  into  a  cluster  of  irregular 
iiiiissivs,  held  together  by  fibrous  tissue.  To  this  condition  the  term  boty- 
riii'l  has  been  given,  from  its  resemblance  to  a  bunch  of  grapes.  As  a 
lull',  the  gummata  gradually  undergo  fibroid  transformation.  They  nuiy, 
however,  soften  and  liquefy,  and,  according  to  Wilks,  may  form  a  fluctu- 
ating tumor. 

(r)  Occasionally  the  syphilitic  changes  are  chiefly  manifested  in  GUs- 
soii'm  .sheath.,  in  a  thickening  of  the  capsule,  producing  iieri-hepatitis,  and 
increase  in  the  connective  tissue  in  the  porial  canals,  so  that  on  section 
tlio  organ  presents  a  number  of  branching  fibrous  scars  which  may  cause 
considerable  deformity. 

Si/)iip/o)ns. — The  symptoms  of  syphilitic  hepatitis  are  very  variable. 
In  tiie  new-born  icterus  is  not  uncommon,  but  the  condition  of  the  liver 
can  scarcely  be  recognized.    In  the  adult  there  are  two  groups  of  cases  : 

Tlic  ])atient  presents  a  picture  of  cirrhosis  of  the  liver;  there  are 
digostive  disturbances,  slight  icterus,  loss  of  weight,  and  ascites.  If  signs 
of  syphilis  are  present  in  other  organs,  the  condition  may  be  suspected, 
or  if  after  removal  of  the  fluid  the  liver  is  felt  to  be  extremely  irregular, 
the  diagnosis  may  be  made  almost  with  certainty.  As  these  cases,  with 
proper  treatment,  may  recover,  they  form  a  certain  contingent  of  the 
casus  reported  as  recovery  in  ordinary  cirrhosis  of  the  liver. 

In  a  second  group  of  cases  the  patient  is  anjemic,  passes  large  qnan- 
titii's  of  pale  nrine  containing  albumen  and  tube-casts ;  the  liver  is  en- 
larged, perhaps  irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symp- 
toms may  supervene,  or  the  patient  may  be  carried  off  by  some  intercurrent 
disease.  Extensive  amyloid  degeneration  of  the  sjileen,  the  intestinal  mu- 
cosa, and  of  the  liver,  with  gummata,  are  found. 

The  diaijnosis  of  syphilis  of  the  liver  is  very  important,  since  upon  it 
tlie  proper  treatment  depends.  If  with  a  history  of  infection  the  liver 
is  enlarged  and  irregular,  and  the  general  health  fairly  good,  the  con- 
dition is  probably  syphiloma.  Occasionally  tumors  of  a  definite  form  may 
l)e  produced  by  the  gummata.  For  two  years  I  showed  repeatedly,  at  my 
clinic  at  the  University  Hospital,  Philadelphia,  a  boy  aged  eleven,  who 
had  a  prominent  tumor  in  the  epigastrium  connected  with  the  liver,  the 
nature  of  which  was  obscure  until  well-marked  bone-lesions  developed. 


If 


lit 


n 


Ht'T- 


178 


SPECIFIC  INFECTIOUS  DISEASES. 


11 


mi 


In  another  caso,  a  tniiii,  iij^'cd  thirty,  wum  sent  to  mo  for  ntlvioo  concoriuriT 
llio  niiikinf^  of  uii  cyplonitory  in(!iHion  to  dcteriniiio  the  luitiiro  of  a  firin, 
iiTcf^iihir  tumor  wliich  occupuul  i\w  ((jti;,'astri(!  rcf^'ion,  and  was  ovidcntlv 
connccti'd  with  tho  Ktft  lol)e  of  the  livi-r.  It  had  histcd  for  more  tliun  a 
year,  liad  increased  Hlij,'htly,  and  had  not  impaired,  to  any  nuirked  de;.n(e, 
the  ^(^neral  Iicaitii.  'I'his  fact,  to<,'etii((r  with  a  well-marked  history  of 
ucfiuired  sy|)liiiis,  U-d  me  to  place  him  upon  a  ri^dd  aiitisyphilitic  treat- 
ment, with  tiu!  result  that  within  six  montiis  the  entire  tumor  disappeared. 

1).  Syphilis  of  the  Digestive  Tract. 

1'he  wsop/ioi/n.s  is  very  rarely  atlected.  Stenosis  is  the  usual  result. 
Gummatii  of  the  s/u/iuirh  occur  occasiotudly.  Syphilitic  ulceration  lias 
been  found  in  the  stonuuih,  in  the  snudl  intestine,  and  in  the  ea'cum. 

The  most  common  seat  of  syjdiilitic  disease  in  this  tract  is  the  rcrlum. 
The  alfection  is  found  most  commonly  in  women,  and  results  from  the 
develoi)ment  of  {fiimnuita  in  the  fiubmucosa  above  the  intenuil  spliinctcr. 
The  process  is  slow  and  te<li()us,  and  may  last  for  yetirs  before  it  tiiiallv 
induces  stricture.  The  symptoms  arc  usually  those  of  narrowing  of  the 
lower  bowel.  The  condition  is  readily  recogidzed  by  rectal  examination. 
The  history  of  gradual  on-coming  stricture,  the  state  of  the  patient,  ami 
the  fact  that  there  is  a  hard,  fibrous  niirrow  og,  iu)t  an  elevated  crater-like 
ulcer,  usually  render  easy  the  diagnosis  from  nuiligiumt  disease.  In  nieili- 
cal  practice  these  cases  come  under  observiition  for  other  sym])toms,  jiar- 
ticularly  amyloid  degeneration;  aiul  the  rectal  disease  may  bo  entirely 
overlooked,  and  oidy  discovered  post  mortem. 

E.  Circulatory  System. 

Si/philis  of  the  Heart. — A  fresh,  warty  endocarditis  due  to  syphilis  is 
not  recognized,  though  occusionally  in  persons  dead  of  the  disease  this 
form  is  present,  as  is  not  uncommon  in  conditions  of  debility.  Outgrowth.s 
on  the  valves  in  connection  with  gummata  have  been  reported  by  Janeway 
and  others,  and  in  Lang's*  monograph  there  are  thirteen  cases  wliich  lie 
reports  as  syphilitic  endocai'ditis,  most  of  them  of  the  librous  or  sclerotic 
variety. 

Syphilitic  myocarditis  appears  either  in  the  form  of  diffuse  fibroid  in- 
duration or  as  definite  gummata.  Laiig  has  collected  many  cases  from  the 
literature,  a  majority  of  which  were  of  the  former  descri2)tion.  Gummata, 
however,  occur  not  infrecpiently  as  definite  and  characteristic  tumors  in 
the  myocardium.  Kupture  may  take  place,  as  in  the  cases  reported  l)y 
Dandridge  and  Nalty,  or  sudden  death,  as  in  the  cases  of  Cayley  and  rearco 
Gould. 

Syphilis  of  the  Arteries. — Syphilis  is  believed  to  play  an  important 
role  in  arterio-sclerosis  and  aneurism.  Its  connection  with  these  procesi>cs 
will  be  considered  later ;  here  we  shall  refer  only  to  the  syphilitic  arteri- 
tis.   This  occurs  in  two  forms : 

*  *  Die  Syphilis  (les  Ilerzens,  Wien,  1889. 


■0^::'. 


SYPHILIS. 


179 


(a)  An  ohliffrafiuf/  r)i(fttrfrrifiti,('hari\vlvri7.0(\  byn  prol  if  oration  of  tlio 
sulu'iKliitlic'lial  tissno.  'I'ho  now  grovtli  lies  within  tho  oliistio  luiniim,  and 
rn;iy  irriulually  till  tlio  ontiro  Itimon ;  Iumioo  tlio  torm  ol)litorutin{,'.  Tlio 
mtiliii  and  lulvtntitiiv  aro  also  infiltratod  with  small  colls.  This  form  of 
ciidartoritis  described  by  Jloubner  is  not,  however,  characteristic  of  syphi- 
lis,  and  its  prosoncc  alone  in  an  artery  could  not  bo  considered  pathof?- 
iioiiiotiio.  If,  ht)wevor,  there  aro  giinunata  in  other  ])arts,  or  if  the  con- 
(lilinii  about  to  bo  descril)ed  exists  in  adjacent  arteries,  the  jiroccss  nuiy 
bo  ro<j;ardod  as  syphilitic. 

{/))  (rummatoHS  Peri-nrferitis. — With  or  without  involvement  of  tho 
iiitiiiia,  nodular  gumnuvta  may  develop  in  tho  adventitia  of  tho  artery, 
lirotluoing  globular  or  ovoid  swellings,  which  nuiy  attain  considerable  size. 
'I'lioy  are  not  infrecpiently  seen  in  tho  cerebral  arteries,  which  seem  to  bo 
sj)ecially  prone  to-  this  affection.  'J'his  form  is  spccilic  and  distinctive 
of  -syphilis.  Tho  disease  usually  affects  tho  smaller  vessels  and  nuiy  bo 
fauiid  in  the  coronary  arteries,  and  particularly  in  those  of  tho  brui  .. 

F.  Renal  Syphilis. — Chimmata  occasionally  develop  in  the  kidi.iuj, 
pavtit'ularly  in  cases  in  which  there  is  extensive  gummatous  he^^ititis. 
'riiey  are  rarely  numerous,  and  occasionally  lead  to  scattered  cicatrice. 
Clinically  the  alfection  is  not  recognizable. 

fi.  Syphilitic  Orchitis.-  -This  affection  is  of  special  significance  to  tho 
pliysii'lan,  as  its  detection  frequently  clinches  tho  diagnosis  in  obscuro 
internal  disorders.     Syphilis  occurs  in  the  testes  in  two  forms: 

(rt)  The  (jummntous  growth,  forming  an  indurated  mass  or  group  of 
masses  in  tho  substance  of  tho  organ,  and  sometimes  ditficulfc  to  distin- 
guish from  tuberculous  disease.  The  area  of  induration  is  harder  and  it 
iitTc'fts  the  body  of  the  testes,  while  tubercle  more  commonly  involves  the 
(.'liidiilymis.  It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften, 
anil  suppurate,  and  is  usually  painless. 

(//)  There  is  an  interstitial  orchitis  regarded  as  syphilitic,  which  leads 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.  It  is  a  slow, 
progrossive  change,  coming  on  without  pain,  usually  involving  one  organ 
more  tlian  another. 

General  Diagnosis  of  Syphilis. — There  is  s(ddom  any  doubt 
concerning  the  existence  of  syphilitic  lesions.  The  negative  statements 
of  the  patient  must  be  taken  with  extreme  caution,  as  persons  will  lie 
•icliborately  with  reference  to  primary  infection,  when  it  is  in  their  best 
interest  to  make  a  straightforward  truthful  statement.  It  is  to  be  re- 
iiienibered  that  syphilis  is  common  in  the  community,  and  there  are  prob- 
ably more  families  with  a  luetic  than  with  a  tuberculous  taint.  It  is  pos- 
sible that  the  primary  sore  may  have  been  of  trifling  extent,  or  iirethral 
masked  by  a  gonorrhcea,  and  the  patient  may  not  have  had  severe 


and 


so'ondary  symptoms,  but  such  instances  are  extremely  rare.  Inquiries 
>?lio..l(l  bo  made  into  the  history  to  ascertain  if  the  patient  has  had  skin 
rashes,  sore  throat,  or  if  the  hair  has  fallen  out.    Careful  inspection  should 


:i 


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180 


SPECIFIC  INFECTIOUS  DISEASES. 


be  made  of  the  throat  and  skin  for  signs  of  old  lesions.  Scars  in  tlie 
groins,  the  result  of  buboes,  may  be  taken  as  positive  evidence  of  infec- 
tion (Hutchinson).  The  ci';  trices  on  the  legs  are  often  copper-colored, 
though  this  cannot  be  regarded  as  peculiar  to  syphilis.  The  bones  should 
be  examined  for  nodes.  In  doubtful  cases  the  scar  of  the  primary  sore 
may  be  found,  or  there  may  be  signs  of  atrophy  or  of  hardening  of  tlie 
testes.  In  women,  special  stress  has  been  laid  upon  the  occurrence  of 
frequent  miscarriages,  which,  in  connection  with  other  circumstances,  are 
always  suggestive. 

In  the  congenital  disease,  the  occurrence  within  the  first  three  montlis 
of  snuffles  and  skin  rashes  is  conclusive.  Later,  the  characters  of  tlie 
syphilitic  facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some 
obscure  visrcral  lesion.  Other  distinctive  features  are  the  symmetrical  de- 
velopment of  nodes  on  the  bones  and  the  interstitial  keratitis. 

In  doubtful  cases  much  stress  is  laid  by  some  writers  upon  the  thera- 
peutic test,  by  placing  the  patient  upon  antisyphilitic  treatment.  In  the 
case  of  an  obstinate  skin  rash  of  doubtful  character,  which  has  resisted  all 
other  forms  of  medication,  this  has  much  greater  weight  than  in  obscure 
visceral  lesions.  I  have  on  several  occasions  known  such  marked  im- 
provement to  follow  large  doses  of  iodide  of  potassium  that  the  diagnosis 
of  syphilitic  lesion  was  greatly  strengthened,  but  the  subsequent  course 
and  the  post-mortem  have  shown  that  the  disease  was  not  syphilis. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  begin- 
ning of  recorded  history,  and  unless  man's  nature  wholly  changes— 
and  of  this  we  can  have  no  hope — will  continue.  Ilesisting  all  attempts 
at  solution,  the  social  evil  remains  the  great  blot  upon  our  civilization, 
and  inextricably  blended  with  it  is  the  question  of  the  prevention  of  syphi- 
lis. Two  measures  are  available — the  one  personal,  the  other  adminis- 
trative. 

Personal  purity  is  the  prophylaxis  which  we,  as  physicians,  are  espe- 
cially bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some 
harder  than  to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this 
lesson  upon  young  and  old  who  seek  our  advice  in  matters  sexual.  Cer- 
tainly it  is  better,  as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  former 
is  not  feasible  there  are  other  altars  than  those  of  Venus  upon  which  a 
young  man  may  light  fires.  He  may  practise  at  least  two  of  the  five 
means  by  which,  as  the  physician  Eondibilis  counselled  Panurge,  carnal 
concupiscence  may  be  cooled  and  quelled — hard  work  of  body  and  hard 
work  of  mind.  Idleness  is  the  mother  of  lechery ;  and  a  young  man  will 
find  that  absorption  in  any  pursuit  will  do  much  to  cool  passions  which, 
though  natural  and  proper,  cannot  in  the  exigencies  of  our  civilization 
always  obtain  natural  and  proper  gratification. 

The  second  measure  is  a  rigid  and  systematic  regulation  of  prostitu- 
tion. The  state  accepts  the  responsibility  of  guarding  citizens  against 
small-pox  or  cholera,  but  in  dealing  with  syphilis  the  problem  has  been 


SYPHILIS. 


181 


too  complex  and  has  hitherto  baffled  solution.  On  the  one  hand,  inspec- 
tion, segregation,  and  regulation  are  difficult  if  not  impossible  to  carry 
out ;  on  the  other  liand,  public  sentiment,  in  Anglo-Saxon  communities 
at  least,  is  as  yet  bitterly  opposed  to  this  plan.  While  this  feeling,  though 
unreasonable,  as  I  think,  is  entitled  to  consideration,  the  choice  lies  be- 
twei.i  two  evils — licensing,  even  imperfectly  carried  out,  or  wide-spread 
disease  and  misery.  If  the  oflfender  bore  the  cross  alone,  I  would  say, 
forbear ;  but  the  physician  behind  the  scenes  knows  that  in  countless  in- 
stances syphilis  has  wrought  havoc  among  innocent  mothers  and  helpless 
infants,  often  entailing  life-long  suffering.  It  is  for  them  he  advocates 
protective  measures. 

Treatment. — We  must  admit  that  various  organizations  react  very 
(litTerently  to  the  poison  of  syphilis.  There  are  individuals  who,  although 
receiving  brief  and  unsatisfactory  treatment,  display  for  years  no  traces  of 
the  disease.  On  the  other  hand,  there  are  persons  thoroughly  and  sys- 
tematically treated  from  the  outset  who  display  from  time  to  time  well- 
marked  indications  of  the  disease.  Certainly  there  are  grounds  for  the 
opinion  that  persons  who  have  suffered  very  slightly  from  secondary 
symptoms  are  more  prone  to  have  the  severer  visceral  lesions  of  the  later 
stage. 

When  we  consider  that  syphi'is  is  one  of  the  most  amenable  of  all  dis- 
eases to  treatment,  it  is  lamentable  that  the  later  stages  which  come  under 
the  charge  of  the  physician  are  so  common.  This  results,  in  great  part, 
from  carelessness  of  the  patient,  who,  wearied  with  treatment,  cannot  un- 
derstand why  he  should  continue  to  take  medicine  after  all  the  symptoms 
have  disappeared ;  but,  in  part,  the  profession  also  is  to  blame  for  not 
insisting  more  urgently  in  every  instance  that  acquired  syphilis  is  not 
cured  in  a  few  months,  but  takes  at  least  two  years,  during  which  time 
tlie  patient  should  be  under  careful  supervision.  The  treatment  of  the 
disease  is  now  practically  narrowed  to  the  use  of  two  remedies,  justly 
termed  specifics — namely,  mercury  and  iodide  of  potassium.  The  former 
is  of  special  service  in  the  secondary,  the  latter  in  the  tertiary  manifesta- 
tions of  the  disease ;  but  they  are  often  combined  with  advantage. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  pow  .,  the 
hydrargyrum  cum  creta,  which  Hutchinson  recommends  to  be  given  in 
pills,  one-grain  dose  with  a  grain  of  Dover's  powder.  One  pill  irom  four 
to  six  times  a  day  will  usually  suffice.  I  warmly  endorse  the  excellent 
results  which  are  obtained  by  t>.is  method,  under  which  the  patient  often 
gains  rapidly  in  weight,  and  the  general  health  improves  remarkably.  It 
may  be  continued  for  months  without  any  ill  effects.  Other  forms  given 
Ijythe  month  are  the  pilules  of  the  biniodide  (gr.  ^\),  or  of  the  protiodido 
Igr.  ^),  tliree  times  a  day. 

Inunction  is  a  still  more  effective  means.  A  drachm  of  the  ordinary 
mercuriid  ointment  is  thoroughly  rubbed  into  the  skin  every  evening  for 
six  days;  on  the  seventh  a  warm  bath  is  taken,  and  on  the  eighth  the  mer- 


I'ii    ■  Ml 


«.  r 


II 


i  li 


,  I 


182 


SPECIFIC  INFECTIOUS  DISEASES. 


curial  course  is  resumed.  At  least  half  an  hour  should  be  given  to  cacli 
inunction.  It  is  well  to  apply  it  at  different  places  on  successive  diiys. 
The  sides  of  the  chest  and  abciomen  and  the  inner  surfaces  of  the  arms 
and  thighs  are  the  best  positions. 

The  mercury  may  be  given  by  direct  injection  into  the  muscles.  If 
proper  precautions  are  taken  in  sterilizing  the  syringe,  and  if  the  injec- 
tions are  made  into  the  muscles,  not  into  tlie  subcutaneous  tissue,  ab- 
scesses rarely  result.  One  third  of  a  grain  of  the  bichloride  in  twenty 
drops  of  water  may  be  injected  once  a  week,  or  from  one  to  two  grains  of 
calomel  in  glycerin  (:^0  minims). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
and  in  institutions,  is  fumigation.  It  may  be  carried  out  effectively  by 
means  of  Lee's  lamp.  The  patient  sits  on  a  chair  wrapped  in  bhuiKots, 
with  the  head  exposed.  The  calomel  is  volatilized  and  deposited  with 
the  vapor  on  the  patient's  skin.  The  process  lasts  about  twenty  minutes, 
and  the  patient  goes  to  bed  wrapped  in  blankets  without  washing  or  div- 
ing the  skin.  A  patient  under  mercurial  treatment  should  avoid  stimu- 
lants and  live  a  regular  life,  not  necessarily  abstaining  from  business. 
Green  vegetables  and  fruit  should  not  be  taken.  Salivation  is  to  be 
avoided.  The  teeth  should  be  cleansed  twice  a  day,  and  if  the  gums  be- 
come tender,  the  breath  fetid,  or  the  tongue  swollen  and  indented,  the 
drug  should  be  suspended  for  a  week  or  ten  days. 

In  congenital  syphilis  the  treatment  of  cases  born  with  bullae  and  otiier 
signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  witliin  a 
few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone,  or. 
if  this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
should  a  wet-nurse  be  employed.  The  child  is  most  rapidly  and  thor- 
oughly brought  under  the  influence  of  the  drug  by  inunction.  The  mer- 
curial ointment  may  be  smeared  on  the  flannel  roller.  This  is  not  a  very 
cleanly  method,  and  sometimes  rouses  the  suspicion  of  the  mother.  It 
is  preferable  to  give  the  drug  by  the  mouth,  in  the  form  of  gray  powder, 
half  a  grain  three  times  a  day.  In  the  late  manifestations  associated 
with  bone  lesions,  the  combination  of  mercury  and  iodide  of  potassium 
is  most  suitable  and  is  well  given  in  the  form  of  Gilbert's  syrup,  whicli 
consists  of  the  biniodide  of  mercury  (gr.  j),  of  potassium  iodide  (  z  ss.), 
and  water  (  3  ij).  Of  this  a  dose  for  a  child  under  three  is  from  live  to 
ten  drops  three  times  a  day,  gradually  increased.  Under  these  measures, 
the  cases  of  congenital  syphilis  usually  improve  with  great  rapidity.  The 
medication  should  be  continued  at  intervals  for  many  months,  and  it  U 
well  to  watch  these  patients  carefully  during  the  period  of  second  dentition 
and  at  puberty,  and  if  necessary  to  place  them  on  specific  treatment. 

In  the  treatment  of  the  visceral  lesions  of  syphilis,  which  come  more 
distinctly  within  the  province  of  the  physician,  iodide  of  potassium  is  of 
equal  or  even  greater  value  than  mercury.  Under  its  use  ulcers  rapidly 
heal,  gummatous  tumors  melt  away,  and  wo  have  an  illustration  of  a  spe- 


SYPHILIS. 


183 


cific  action  only  equalled  by  that  of  mercury  in  the  secondary  stages,  by 
iron  in  certain  forms  of  anaemia,  and  by  quinine  in  malaria.  It  is  as  a 
nilo  well  borne  in  an  initial  dose  of  ten  grains,  or  ten  minims  of  the  satu- 
nited  solution ;  given  in  milk  the  patient  docs  not  notice  the  taste.  It 
sliould  be  gradually  increased  to  thirty  or  more  grains  three  times  a  day. 
In  syphilis  of  the  nervous  system  it  may  be  nsed  in  still  larger  doses. 
Si'j,aun,  who  has  specially  insisted  upon  the  advantage  of  this  plan,  urges 
that  the  drug  should  be  pushed,  as  good  effects  are  not  obtained  with  the 
moderate  doses. 

When  syphilitic  hepatitis  is  suspected  the  combination  of  mercury  and 
iodide  of  potassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  or 
Xiemcyer's  pill  (as  it  is  often  called)  of  calomel,  digitalis,  and  squills  will 
be  found  very  useful.  A  patient  of  mine  with  recurring  ascites,  on  whom 
paracentesis  was  repeatedly  performed  and  who  had  an  enlarged  and  irregu- 
lar liver,  took  this  pill  for  more  than  a  year  with  occasional  intermissions, 
and  ultimately  there  was  a  complete  disappearance  of  the  dropsy  and  an 
extraordinary  reduction  in  the  volume  of  the  liver.  Occasionally  the 
iodide  of  sodium  is  more  satisfactory  than  the  iodide  of  potassium.  It  is 
loss  depressing  and  agrees  better  with  the  stomach.  Many  patients  possess 
a  remarkable  idiosyncrasy  to  the  iodide,  but  as  a  rule  it  is  well  borne. 
Severe  coryza  with  salivation,  and  oedema  about  the  eyelids,  .ire  its  most 
common  disagreeable  effects.  Skin  eruptions  also  are  frequent.  I  have 
known  patients  unable  to  take  more  than  from  twenty  to  thirty  grains 
without  suffering  from  an  erythematous  rash ;  much  more  common  is  the 
acne  eruption.  Occasionally  an  urticarial  rash  may  develop  with  spots  of 
purpura.  Some  of  these  iodide  eruptions  may  closely  resemble  syphilis. 
llutcliiuson  has  reported  instances  in  which  they  have  proved  fatal. 

Upon  the  question  of  syphilis  and  marriage  the  family  physician  is 
often  called  to  decide.  He  should  insist  upon  the  necessity  of  two  full 
years  elapsing  between  the  date  of  infection  and  the  contracting  of  mar- 
riage. This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  and 
there  should  be  at  least  a  year  of  complete  immunity  from,  all  manifesta- 
tions of  the  disease. 

In  relation  to  life  insurance,  an  individual  with  syphilis  can  not  be 
regarded  as  a  first-class  risk  unless  he  can  furnish  evidence  of  prolonged 
and  thorough  treatment  and  of  immunity  for  two  or  three  years  from  all 
manifestations.  Even  then,  when  we  consider  the  extraordinary  frequency 
of  the  cerebral  and  other  complications  in  persons  who  have  had  this  dis- 
ease and  who  may  even  have  undergone  thorough  treatment,  the  risk  to 
the  company  is  certainly  increased. 

13 


I 


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':! 


i:i 


*ll 


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■:  5ii, 


!;■'*' 


ti!  i 


184  SPECIFIC  INFECTIOUS  DISEASES. 


XXVI.  TUBERCULOSIS. 

I.  General  Etiology  and  Mouuid  Anatomy. 

Definition. — An  infective  disease,  caused  by  the  bacillus  tuberculosis^ 
the  lesions  of  which  are  characterized  by  nodular  bodies  called  tubercles 
or  diffuse  infiltrations  of  tuberculous  tissue  which  undergo  caseation  or 
sclerosis  and  may  finally  ulcerate,  or  in  some  situations  calcify. 

Etiology.— 1.  Zo'dlogical  Distribution. — Tuberculosis  is  one  of  the 
most  wide-spread  of  maladies. 

In  cold-blooded  animals  it  is  rare,  owing  doubtless  to  temiieratiire 
conditions  unfavorable  to  the  development  of  the  bacillus.  Among  rep- 
tiles in  confinement  it  is,  however,  occasionally  seen  (Sibley).  In  fowls  it 
is  an  extremely  common  disease,  but  recent  facts  indicate  that  there  are 
differences  in  aA'ian  tuberculosis  sufficient  to  warrant  its  separation  from 
the  ordinary  form. 

Among  domestic  animals  tuberculosis  is  widely  but  unevenly  dis- 
tributed. Among  ruminants,  bovines  are  chiefly  affected.  The  statistics 
of  the  Berlin  abattoir  show  that  in  the  years  1887-'88  tuberculosis  was 
found  in  4,300  cattle.  In  this  country  it  is  extremely  difficult  to  get 
satisfactory  statistics  of  the  prevalence  of  the  disease.  At  the  meeting  of 
the  United  States  Veterinary  Medical  Association  in  1889,  it  was  stated 
in  a  rr^solution  that  from  ten  to  fifteen  per  cent  of  the  dairy  stock  of  the 
Eas'.lern  States  was  tuberculous. 

In  Baltimore,  A.  W.  Clement,  United  States  veterinary  inspector,  in- 
forms me  that  of  5,297  cattle  slaughtered  in  Maryland  only  159  were 
tuberculous. 

In  sheep  the  disease  is  very  rare.  In  pigs  it  is  common,  but  not  so 
common  in  this  country  as  in  Europe.  In  the  inspection  of  one  thousand 
hogs,  which  was  made  by  A.  W.  Clement  and  myself  in  Montreal  in  1880, 
tuberculosis  was  seen  only  once  or  twice.  At  the  Berlin  abattoii  in 
1887-'88  there  were  6,393  pigs  affected  with  the  disease. 

Horses  are  rarely  attacked.  Dogs  and  cats  are  not  prone  to  the  disease, 
but  cases  are  described  in  which  infection  of  pet  animals  has  taken  place 
from  phthisical  masters.  Among  the  semi-domestic  animals,  such  as  the 
rabbit  and  guinea-pig,  the  disease  under  natural  conditions  is  rare, 
although  these  animals,  particularly  the  latter,  are  extremely  susceptible 
to  the  disease  Avhen  inocnlatdd.  iimong  apes  and  monkeys  in  the  wild 
state,  tuberculosis  is  unknown,  but  in  confinement  it  is  the  most  formi- 
dable disease  with  which  they  have  to  contend. 

The  impr  int  etiological  fact  in  connection  with  tuberculosis  in  ani- 
mals is  the  Wide-spread  occurrence  of  the  disease  in  bovines,  from  which 
class  we  derive  nearly  all  the  milk  and  a  very  largo  proportion  of  the 
meat  used  for  food. 

2.  Geographical  Distribution.— The  disease  exists  in  all  countries.   It 


TUBERCULOSIS. 


186 


prevails  more  in  the  large  citi»  and  wherever  the  population  is  massed 
together  Thus,  while  the  general  death-rate  from  it  is  three  per  thou- 
sand, that  of  Vienna  is  7'7,  and  of  Munich  and  Glasgow  four  per  thousand. 
Ilirscii,  from  whose  classical  work  these  facts  are  taken,  thinks  that  geo- 
grapliical  position  has  less  influence  than  has  been  supposed.  Italy  and 
England  suffer  alike,  and  the  disease  is  very  prevalent  in  the  West  Indies 
and  the  South  Sea  islands.  Toward  the  poles  it  is  rare.  It  is  a  common 
disease  in  Canada,  and  prevails  extensively  among  the  French  Canadians 
and  the  English.  Altitude  is  a  more  potent  factor  than  latitude.  In  the 
high  regions  of  the  Alps  and  Andes,  and  in  the  central  plateau  of  Mexico 
the  disease  is  very  rare.  Mountainous  countries,  such  as  Switzerland,  have 
a  very  low  death-rate  from  tuberculosis. 

3.  Race. — No  race  is  immune.  The  Indians  of  this  continent  are 
very  prone  to  the  disease.  Matthews,  whose  experience  with  the  native 
race  is  large,  states  that  the  disease  is  on  the  increase  among  them.  lie 
quotes  the  ratio  from  the  United  States  census,  1880,  as  white  IGC, 
negroes  18G,  Indians  286.  The  death-rate  in  the  older  reservations,  as 
in  New  York,  is  three  times  as  great  as  in  Dakotji.  In  the  Blood  Indian 
Reserve  of  the  Canadian  Northwest  Territories,  Surgeon  Kennedy 
(N.  W.  M.  P.)  has  given  me  the  figures  for  six  years.  In  a  population  of 
about  2,000  there  were  127  deaths  from  pulmonary  consumption,  twenty- 
three  per  cent  of  the  total  rate.  This  does  not  include  deaths  from 
"diseases  of  infancy."  This  enormous  death-rate,  it  is  to  be  remembered, 
occurs  in  a  tribe  occupying  one  of  the  finest  climates  of  the  world  among 
tlie  foot-hills  of  the  Rocky  Mountains,  a  region  in  which  consumption  is 
extremely  rare  among  the  white  population,  and  in  which  cases  of  tuber- 
culosis from  the  eastern  provinces  do  remarkably  well. 

The  negro  race  is  very  susceptible  to  tuberculosis,  more  particularly  the 
glandular  and  osseous  forms.  Of  the  427  cases  of  pulmonary  tuberculosis 
at  the  Johns  Hopkins  Hospital  for  the  two  years  ending  June  1,  1891, 
there  were  41  cases  in  the  colored — i.  e.,  about  1: 10.  The  ratio  of  colored 
to  wliite  of  all  patients  in  the  wards  has  been  1  to  7. 

4.  The  Bacillus  Tuberculosis. — The  history  of  the  discovery  of  the 
bacillus  presents  many  points  of  interest.  Confidently  expected  by  such 
observers  as  Villemin,  Chauveau,  Cohnheim,  and  others,  and  claimed  to 
liave  been  demcac...i'ated  by  many,  notably  by  Klebs  and  Aufrecht,  it  re- 
mained for  Koch  to  demonstrate  its  existence  and  its  invariable  association 
with  the  disease.  The  investigations  which  he  had  previously  made  upon 
anthrax  and  experimental  traumatic  infections,  by  perfecting  the  methods 
of  research,  paved  the  way  for  this  brilliant  discovery.  His  preliminary 
article*  and  his  more  elaborate  later  work  f  should  be  carefully  studied  by 
any  one  who  wishes  to  appreciate  the  value  of  scientific  methods.     It  forms 

*  Berliner  klinische  Wochensohrift,  1882. 

f  Mittheilungen  a.  d.  k.  Gesundheitsainte,  Bd.  3. 


I 


186 


SPECIFIC  INFECTIOUS  DISEASES. 


m  i 


Sr'-'; 


one  of  the  moat  masterly  demonstrations  of  modern  medicine.  Its  thor- 
oughness appears  in  the  fact  that  in  the  nine  years  which  have  elapsed 
since  its  announcement  the  innumerable  workers  at  the  subject  have  not, 
so  far  as  I  know,  added  a  solitary  essential  fact  to  those  presented  by  Koch. 

Morpholoyical  Characters. — The  tubercle  bacillus  is  a  short,  tine  rod, 
often  slightly  bent  or  curved,  and  has  an  average  length  of  nearly  half  the 
diameter  of  a  red  blood-corpuscle  (3  to  4  i*).  When  stained  it  often  pre- 
sents a  beaded  appearance,  which  some  havo  attributed  to  the  presence  of 
spores. 

With  the  basic  aniline  dyes  it  stains  slowly,  except  at  the  body  tem- 
perature, but  retains  the  dye  after  treatment  with  acids — a  characteristic 
which  separates  it  from  all  other  known  forms  of  bacteria,  with  the  excep- 
tion of  the  bacillus  of  leprosy. 

Modes  of  Growth. — It  grows  on  blood-serum,  glycerin-agar,  or  on  po- 
tato— most  readily  on  the  former.  The  cultures  must  be  kept  at  blood- 
heat.  They  grow  slowly,  and  do  not  appear  until  about  the  end  of  the 
second  week.  The  colonies  form  thin,  grayish-white,  dry,  scale-like  masses 
on  the  surface  of  the  culture  medium.  Successive  inoculations  may  bo 
made  from  the  cultures,  and  at  the  end  of  an  indefinite  series  material 
from  one  of  them  inoculated  into  a  guinea-pig  will  produce  tuberculosis. 

Products  of  the  Growth. — Little  is  yet  known  of  the  chemical  charac- 
ters of  the  materials  which  result  from  the  growth  of  the  tubercle  bacilli. 
Koch's  tuberculin  is  stated  to  be  a  glycerin  extract  of  the  cultures.  Crook- 
shank  and  Ilerroun  have  separated  an  albumose  and  a  ptomaine. 

Distribution  of  the  Bacilli. — The  bacilli  are  found  in  all  tuberculous 
lesions ;  in  some  in  great  abundance,  in  others  sparsely.  They  aro  par- 
ticularly numerous  in  actively  developing  tubercles,  but  in  the  chronic 
tuberculous  processes  of  lymph-glands  and  of  the  joints  they  are  scanty. 
When  a  tuberculous  focus  communicates  with  a  vein  or  with  lymph-ves- 
sels, the  bacilli  may  bo  spread  widely  thi'oughout  the  body.  In  old  lesions 
they  may  not  be  found  in  the  sections,  and  the  demonstration  of  the  true 
nature  may  be  possible  only  by  culture  or  inoculation. 

The  Bacilli  outside  the  Body. — Patients  with  advanced  pulmonary 
tuberculosis  throw  off  in  the  expectoration  countless  millions  of  the  bacilli 
daily.  Some  idea  of  the  extraordinary  numbers  may  be  gained  from  the 
studies  of  Nuttall.*  From  a  patient  in  my  ward,  with  moderately  advanced 
disease,  the  amount  of  whose  expectoration  was  from  seventy  to  a  hundred 
and  thirty  cubic  centimetres  daily,  he  estimated  by  his  method  that  there 
were  in  sixteen  counts,  between  January  10th  and  March  1st,  from  cue 
and  a  half  to  four  and  a  third  billions  of  bacilli  thrown  off  in  the  twenty- 
four  hours.  These  figures  emphasize  the  danger  associated  Avith  phthisical 
sputa  unless  most  carefully  dealt  with.  When  expectorated  and  allowed 
to  dry,  the  sputum  rapidly  becomes  dust,  and  is  distributed  far  and  wide. 

*  Johns  Hopkins  Hospi^il  Bulbtin,  May,  1891. 


TUBERCULOSIS. 


187 


.1 ':  I 


Tlie  observations  made  by  Cornet  under  Koch's  supervision  are  in  this 
( oiuKiction  most  instructive.  He  collected  the  dust  from  the  walls  and 
bedsteads  of  various  localities,  and  determined  its  virulence  or  innocuous- 
ness  by  inoculation  into  susceptible  anii  als.  Material  was  gathered  from 
twenty-one  wards  of  seven  hospitals,  three  asylums,  two  prisons,  from 
the  surroundings  of  sixty-two  phthisical  patients  in  private  practice, 
!ind  from  twenty-nine  other  localities  in  which  tuberculous  patieiits  were 
only  transient  frequenters  (out-patient  departments,  streets,  etc.).  Of 
one  hundred  and  eighteen  dust  samples  from  hospital  wards  or  the 
rooms  of  phthisical  patients,  forty  were  infective  and  produced  tubercu- 
losis. Negative  results  were  obtained  with  the  twenty-nine  dust  samples 
fioiu  the  localities  occasionally  occupied  by  consumptives.  Virulent  ba- 
( nil  were  obtained  from  the  dust  of  the  walls  of  fifteen  out  of  twenty-one 
medical  wards.  It  is  interesting  to  note  that  in  two  wards  with  many 
phthisical  patients  the  results  were  negative,  indicating  that  the  dust  in 
such  regions  is  not  necessarily  infective.  The  infectiousness  of  the  medi- 
cal and  surgical  divisions  of  a  hospital  is  in  the  proportion  of  7G-6  to  12'5. 
In  a  room  in  which  a  tuberculous  woman  had  lived,  the  dust  from  the 
wall  in  the  neighborhood  of  the  bed  was  infective  six  weeks  after  her 
tlcath.  No  bacilli  were  found  in  the  dust  of  an  inhalation-chamber  for 
consumptives. 

The  tubercle  bacillus  is  thus  a  wide-spread  organism  in  regions  fre- 
quented by  phthisical  patients. 

5.  Modes  of  Infection. — {«)  Hereditary  Transmission, — In  extremely 
rare  instances  the  disease  is  congenital.  A  few  undoubted  cases  have 
been  reported  in  man  and  in  the  calf.  The  rarity  with  which  it  occurs 
may  be  gathered  from  the  fact  that  of  15,400  calves  killed  at  the  Berlin 
abattoir  there  wore  only  four  instances  of  tuberculosis.  Cases  of  con- 
genital tuberculosis  in  man  have  occasionally  been  described. 

Baumgarten  holds  that  in  many  cases  the  virus  is  transmitted,  but  the 
disease  does  not  appear  until  some  time  after  birth,  lie  bases  this  opin- 
ion upon  the  following  facts : 

The  great  frequency  of  tuberculosis  in  sucklings.  Tims,  in  1G,581  au- 
topsies on  sucklings,  Frobelius  found  41G  with  tuberculous  lesions.  In 
^10  cases  of  tuberculosis  in  children  under  two,  from  Parrot's  clinic, 
there  were  23  under  three  months,  and  a  total  of  111  under  one  year. 
It  seems  probable  that  in  many  of  these  cases  the  virus  itself  was  trans- 
mitted. 

The  common  occurrence  of  tuberculosis  in  the  bones  and  in  the  joints 
of  children,  regions  to  which  it  seems  unlikely  that  the  bacilli  would  be 
conveyed  in  accidental  infection.  To  make  this  objection  valid  we  should 
i'C(|uire  a  series  of  cases  of  bone  tuberculosis  in  children  in  which  exami- 
nation showed  the  lymph  portals  of  the  bronchi  and  the  mesentery  to  be 
free  from  disease.  He  regards  the  late  manifestation  as  analogous  to  tlio 
nypJiilis  hereditaria  tarda,  and  suggests  that  the  growth  of  the  germs  is. 


::l; 


188 


SPECIFIC  INFECTIOUS  DISEASES. 


as  a  rule,  restrained  or  held  in  check  by  the  actively  developing  tissues  of 
the  child. 

Tuberculosis  unquestionably  may  be  inherited,  but  in  what  way  and 
how  often  are  unsettled  problems.  Congenital  disease  is  extremely  rare, 
but  there  is  no  inherent  improbability  in  a  prolonged  latency  of  the  virus. 
That  it  may  be  present  without  the  existence  of  actual  tubercles  is  indi- 
cated by  an  experiment  of  Birch-Uirschfeld,  who  found  that  portions  of 
tlie  viscera  of  a  fa?tu8  born  of  a  phthisical  mother,  though  not  itself 
tuberculous,  were  infective  to  guinea-pigs. 

In  any  series  of  cases  of  pulmonary  tuberculosis  there  is  a  suspicious 
number  in  which  the  ascendants  have  also  been  tuberculous.  Thus,  in 
427  cases  at  the  Johns  Hopkins  Hospital  there  were  53  in  which  the 
mother  was  affected,  52  in  which  the  father  had  tuberculosis,  and  10.5  in 
which  brother  or  sister  had  had  the  disease.  The  estimates  by  various 
authors  range  from  10  per  cent  (Louis),  25  per  cent  (Walshe),  to  even  50 
per  cent.  Fagge  very  justly  remarks  that  it  is  impossible  to  draw  a  line 
between  hereditary  and  accidental  tuberculosis,  and  naturally  the  cliil- 

dren  of  an  affected  par- 
ent are  more  liable  to 
accidental  contamina- 
tion. Maternal  is  very 
much  more  common  tlian 
paternal  inheritance.  A 
family  tree,  such  as  is 
here  given,  of  six  gener- 
ations tells  its  own  tale. 
It  is  interesting  to  note 
the       almost     constant 


1783-1887 


transmission  through  the 
mother. 

(b)  Inoculation. — Tlie 
infective  nature  of  tuber- 
culosis was  first  demon- 
strated by  Villemin,  who 
showed  conclusively  in 
1865  that  it  could  be 
transmitted  to  aniniald 
by  inoculation.  The 
question  was  hotly  con- 
tested, and  Villemin's  ob- 
servations were  confirmed  by  Simon,  Andrew  Clark,  and  others,  but  Bur- 
don  Sanderson,  Wilson  Fox,  and  others  held  that  the  disease  could  be 
transmitted  by  non- tuberculous  materials.  The  beautiful  experiments 
of  Cohnheim  and  Salamonson,  who  produced  tuberculosis  in  the  eyes 
of  guinea-pigs  and  rabbits  by  inoculating  fresh  tubercle  into  the  ante- 


Chart  XII. — Heredity  in  pulmonary  tuberculosis. 


TUBERCULOSIS. 


189 


rior  chamber,  confirmed  and  extended  Villemin's  original  observations 
and  i)aved  the  way  for  the  reception  of  Koch's  announcement.  It  is 
now  universally  conceded  that  only  tuberculous  matter  can  produce,  when 
iiiociiliited,  tuberculosis.  In  man  tuberculosis  is  not  often  transmit- 
ted by  inoculation,  and  when  it  does  occur  the  disease  usually  remains 
local.  This  mode  of  infection  is  seen  in  persons  whoso  occupation  brings 
them  in  contact  with  dead  bodies  or  animal  products.  Demonstrators  of 
morbid  anatomy,  butchers,  and  handlers  of  hides  are  subject  to  a  local 
tubercle  of  the  skin,  which  forms  a  reddened  mass  of  granulation  tisrsue, 
usually  capping  the  dorsal  surfaces  of  the  hands  or  fingers.  This  is  the 
go-called  post-mortem  wart,  the  verruca  nccroyenica  of  Wilks.  The  dem- 
onstration of  its  nature  is  shown  by  the  presence  of  tubercle  bacilli,  and 
by  inoculation  experiments  in  animals. 

The  statement  that  liaennec  contracted  phthisis  from  this  source  is 
probably  false,  since  he  did  not  die  until  twenty  years  after  the  inocula- 
tion and  in  the  interval  presented  no  manifestations.  The  possibility, 
however,  of  general  infection  must  be  borne  in  mind.  Gerber  reports 
that  after  accidental  inoculation  of  the  hand  from  a  case  of  phthisis 
he  had  for  months  a  "  Leichen-tubercle,"  which  was  excised.  Shortly 
afterward  the  lymph-glands  of  the  axilla  became  enlarged  and  pain- 
ful, find  when  removed  showed  characteristic  tuberculous  changes,  with 
bacilli. 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  asso(!iated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of 
cleansing  the  wound  by  suction. 

Other  means  of  inoculation  have  been  described :  as  the  wearing  of 
ear-rings,  washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tubercu- 
lous subject,  or  inoculation  from  a  cut  by  a  broken  spit-glass  of  a  con- 
sumptive ;  and  Czerny  has  reported  two  cases  of  infection  by  transplanta- 
tion of  skin. 

It  has  been  urged' by  the  opponents  of  vaccination  that  tuberculosis,  as 
well  as  syphilis,  may  be  thus  conveyed,  but  of  this  there  is  no  evidence, 
and  the  lymph  from  the  vesicles  of  revaccinated  consumptives  has  been 
shown  by  many  observers  to  be  non-infective.  It  may  be  said,  on  the 
wliole,  that  inoculation  in  man  plays  a  trifling  role  in  the  transmission  of 
tuberculosis. 

(f)  Infection  ihronyh  the  A  ir. — It  has  been  fully  proved  that  the  ex- 
pired air  of  tuberculous  patients  is  not  infective.  On  the  other  hand,  the 
virus  is  contained  in  enormous  amounts  in  the  sputum,  which,  when  dried, 
IS  soon  widely  disseminated  in  the  form  of  dust,  and  unless  carefully 
sterilized  constitutes  a  great  medium  of  transmission.  A  belief  in  the 
contagiousness  of  pulmonary  tuberculosis  has  existed  from  the  days  of  the 
early  Greek  physicians,  and  has  persisted  among  the  Latin  races. 

The  investigations  of  Cornet  afford  conclusive  proof  tlzat.  the  dust  of  a 


^if. 


'I  ,    >• 


190 


SPECIFIC  INFECTIOUS  DISEASES. 


room  or  other  locality  frequented  by  patients  with  pulmonary  tubercu- 
losis is  infective.  The  bacilli  are  attaclied  to  fine  particles  of  dust  and  in 
this  way  gain  entrance  to  the  system  through  the  lungs.  The  foUowinjr 
are  some  of  the  facts  in  favor  of  this  view  : 

(1)  Primary  tuberculous  lesions  are  in  u  majority  of  all  cases  connecud 
with  the  respiratory  system.  The  frequency  with  which  foci  are  met  witli 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statis- 
tics of  the  Paris  morgue  sliow  that  a  considerable  proportion  of  all  persons 
dying  of  accident  or  by  suicide  present  evidences  of  the  disease  in  these 
parts.  The  post-mortem  statistics  of  hospitals  show  the  same  wide-sproad 
prevalence  of  infection  through  the  air-passages.  Biggs  reports  that  more 
than  60  per  cent  of  his  post-mortems  showed  lesions  of  pulmonary  tuber- 
culosis. In  one  hundred  and  twenty-five  post-mortems  at  the  Foundling 
Hospital,  New  York,  the  bronchial  glands  were  tuberculous  in  every  case. 
In  adults  the  bronchi.al  glands  nuiy  bo  infected  while  the  individual  is  in 
good  health.  II.  P.  Loomis  found  in  eight  of  thirty  cases  in  which  tliere 
were  no  signs  of  old  or  recent  tuberculous  lesions  that  the  bronchial  glumis 
were  infective  to  rabbits. 

(2)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence 
of  the  bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resist- 
ance of  the  individual.  The  investigations  of  Cornet  upon  the  death-rate 
from  consumption  among  certain  religious  orders  devoted  to  nursing  give 
some  striking  facts  in  illustration  of  this.  In  a  review  of  thirty-eiglit 
cloisters,  embracing  the  average  number  of  4,028  residents,  among  2,099 
deaths  in  the  course  of  twenty-five  years,  1,1320  (G2'88  per  cent)  were  from 
tuberculosis.  In  some  cloisters  more  than  three  fourths  of  the  deaths  are 
from  this  disease,  and  the  mortality  in  all  the  residents,  up  to  the  fortietli 
year,  is  greatly  above  the  average,  the  increase  being  due  entirely  to  the 
prevalence  of  tuberculosis.  It  has  been  stated  that  nurses  are  not  more 
prone  to  the  disease  than  other  individuals,  but  Cornet  says  that  of  a  hun- 
dred nurses  deceased,  sixty-three  died  of  tuberculosis.  The  more  perfect 
the  prophylaxis  and  hygienic  arrangements  of  an  asylum  or  institution, 
the  lower  the  mortality  from  tuberculosis.  The  mortality  in  prisons  has 
been  shown  by  Baer  to  bo  four  times  as  great  as  outside.  The  death-rate 
from  phthisis  is  estimated  at  15  per  cent  of  the  totfil  mortality,  while  in 
prisons  it  constitutes  from  40  to  50  per  cent,  and  in  some  countries,  as 
Austria,  over  60  per  cent.  Flick  has  studied  the  distribution  of  the  deaths 
from  tuberculosis  in  a  single  city  ward  in  Philadelphia  for  twenty-five 
year?  His  researches  go  far  to  show  that  it  is  a  house  disease.  About 
33  per  cent  of  infected  houses  have  had  more  than  one  case.  Less  than 
one  third  of  the  houses  of  the  ward  became  infected  with  tuberculosis 
during  the  twenty-five  years  prior  to  1888.  Yet  more  than  one  half  of 
the  deaths  from  this  disease  during  the  year  1888  occurred  in  those  in- 


TUBERCULOSIS. 


191 


fertcd  liouscs.  There  ure,  however,  opposinjf  facts.  The  statistics  of  the 
IJidtiiptou  Consumption  Hospital  show  that  doctors,  nurses,  and  attendants 
lire  riiroly  attacked.  Dottweiler  chiims  that  no  case  of  tuberculosis  has 
boon  contracted  among  his  nurses  or  attendants  at  Falkenstein.  The 
wliolo  question  lias  recently  been  thoroughly  reviewed  by  Heron,*  in 
whose  work  will  also  be  found  a  list  of  cases  of  infection  (prepared  by 
Kot'li)  reported  between  18G7  and  1880. 

(15)  Special  danger  exists  when  the  contact  is  very  intimate,  such,  for 
instance,  as  between  man  and  wife.  On  this  point  much  difference  of 
opinion  exists,  but  the  figures  seem  to  indicate  that  under  tliese  circum- 
stances the  husband  or  wife  is  much  more  liable  subsequently  to  die  of 
consumption.  Of  427  cases  of  pulmonary  tuberculosis  at  the  Johns  Hop- 
kins Hospital,  in  25  either  husband  or  wife  had  been  affected  with  it  or 
had  died  of  tuberculosis.  In  response  to  a  question  as  to  contagion,  asked 
by  the  Collective  Investigation  Committee  of  the  l?ritish  Medical  Associa- 
tion, there  were  2G1  replies  in  tlie  affirmative,  among  which  were  158  cases 
of  supposed  contagion  through  marriage.  Weber's  cases  arc  of  special 
interest.  One  of  his  patients  lost  four  wives  in  succession,  one  lost  three, 
and  four  lost  two  each. 

{(I)  Infedum  by  Milk. — The  milk  of  an  animal  suffering  from  tuber- 
culosis may  contain  the  virus,  and  is  capable  of  communicating  the  dis- 
ease, as  shown  by  Gerlach,  Bang,  Bollinger,  and  others.  Striking  illustra- 
tions of  this  are  sometimes  afforded  in  the  lower  animals.  The  pigs,  for 
instance,  of  a  tuberculous  sow  have  been  shown  to  present  intestinal  tubercu- 
losis of  the  most  exquisite  form.  Of  late  years  the  experimental  proof  has 
been  entirely  conclusive.  It  was  formerly  thought  that  the  cow  must  pre- 
sent tuberculous  disease  of  the  udder,  but  Ernst  has  shown  that  the  bacilli 
may  be  present  and  the  milk  be  infective  in  a  large  proportion  of  cases  in 
which  there  is  no  tuberculous  mammitis*,  an  observation  made  also  by 
Ilirschbcrger  and  others.  This  author  states  the  interesting  fact  that  an 
owner  of  a  herd  known  to  be  tuberculous  withdrew  the  milk  from 
market  and  used  it  without  boiling  to  fatten  his  pigs,  which,  almost  with- 
out exception,  became  tuberculous,  so  that  the  whole  stock  liad  to  be 
slaughtered.  There  is  no  reason  to  believe  that  young  children  or  even 
adults  are  less  susceptible  to  the  virus  than  calves  or  pigs,  so  that  the 
danger  of  the  disease  from  this  source  is  real  and  serious.  The  great  fre- 
quency of  intestinal  and  mesenteric  tuberculosis  in  children  no  doubt 
finds  here  its  explanation.  As  noted  in  Woodhcad's  analysis  of  one  hun- 
dred and  twenty-seven  cases  of  fatal  tuberculosis  in  children,  the  mesen- 
teric glands  were  involved  in  one  hundred.       ■  '  '. 

{(■)  Infection  by  Meat. — The  meat  of  tuberculous  animals  is  not  neces- 
sarily infective.  The  results  of  experiments  with  the  flesh  of  cows  are 
not  in  accord.     This  mode  of  infection  probably  plays  a  minor  r6le  in  the 


*  Evidences  of  the  Communiciibility  of  Consumption,  London,  1890. 


•A'h<. 


•I'i 


hi 


!   I 


I  'Hi 


*'~ 


192 


SrECIFlC  INB'ECTIOUS  DISEASES. 


etiology  of  luinmii  tuberculosis,  as  usually  tlio  flosh  is  thoroughly  cooked 
before  eating.  The  possibility,  howevDr,  must  be  borne  in  mind,  and  it 
would  certuinly  be  safer  in  the  interests  of  a  community  to  confiscate  tlie 
carcasses  of  all  tuberculous  animals.  Experiments  in  Hollinger's  laboratory 
show  that  the  ilesh  of  tuberculous  subjects  is  very  infective  to  guinea-j)i<,'3. 

0.  Conditions  influencing  Infection.— (^/)  ('onstilulionnl  rcmiUarities.— 
It  was  formerly  thought  that  individuals  of  a  certain  habit  of  body,  and  of 
a  certain  physiognomy,  the  habitus  j)hthi,sicus,  were  specially  prone  to 
tuberculous  disease ;  but  few  now  regard  the  so-called  tuberculous  or 
scrofulous  diathesis  as  more  than  an  indication  of  a  certain  type  of  con- 
formation, in  which  the  tissues  arc  more  vulnerable  and  less  capable  of 
resisting  infection.  In  many  instances  Cohnheim  is  unquestionably  cor- 
rect in  stating  that  the  so-called  phthisical  habit  is  not  an  indication  of  a 
tendency  to,  but  actually  of  the  existence  of,  tuberculosis.  The  belief  in 
a  special  phthisical  frame  lias  existed  in  the  profession  from  the  days  of 
Hippocrates,  who  says,  "  The  form  of  body  peculiar  to  subjects  of  phthisi- 
cal complaints  was  the  smooth,  the  whitish,  that  resembling  the  lentil; 
the  reddish,  the  blue-eyed,  the  leuco-phlegmatic,  and  that  with  the  scapulie 
having  the  appearance  of  wings."  Galen  also  wrote  upon  this  type  of  chest 
as  specially  characteristic  of  the  disease.  Certainly  the  long,  narrow,  flat 
chest  with  depressed  sternum  is  most  commonly  seen  in  tuberculous  per- 
sons, but  how  common  it  is  also  to  meet  with  patients  who  have  well- 
formed,  well-built  chests,  with  wide  costal  angle  and  good  pulmonary  ex- 
pansion !  The  investigations  of  Beneke  with  reference  to  the  formation 
of  the  viscera  in  the  subjects  of  phthisis  are  very  interesting.  His  meas- 
urements indicate  that  the  heart  is  relatively  small,  the  arteries  arc  pro- 
portionately narrow,  and  the  pulmonary  artery  is  relatively  wider  than  the 
aorta.  This  point,  he  suggests,  would  lead  to  increase  in  the  blood-press- 
ure in  the  lungs  and  favor  catarrh.  The  lung  volume  he  found  to  be 
relatively  greater  in  those  aiTected  with  phthisis. 

Galton  and  Mahomed  made  observations  upon  the  composite  portrait- 
ure of  phthisis.  In  443  patients  they  separated  two  types  of  face;  one 
ovoid  and  narrow,  the  other  broad  and  coarse  featured.  This  corresponds 
in  an  interesting  way  to  the  diathetic  states  formerly  recognized — namely, 
the  tuberculous,  Avith  thin  skin,  bright  eyes,  oval  face,  and  long,  thin 
bones ;  and  the  scrofulous,  with  thick  lips  and  nose,  opaque  skin,  large 
thick  bones,  and  heavy  figure.  These  conditions,  on  which  so  much  stress 
was  formerly  laid,  indicate,  as  Fagge  states,  nothing  more  than  delicacy 
of  constitution,  incomplete  growth,  and  imperfect  development. 

(ft)  Influence  of  Age. — Tuberculosis  occurs  at  all  periods  of  life,  in  the 
suckling  as  well  as  in  the  octogenarian.  The  distribution  of  the  lesions 
varies  greatly  at  different  ages.  In  the  first  decade  the  lymphatic  glands, 
bones,  and  meninges  are  much  more  frequently  affected  than  at  subse- 
quent periods.  ^Meningeal  tuberculosis  is  most  common  between  the 
third  and  eighth  years. 


large 


TUBERCULOSIS. 


193 


Tlio  nipsentcric  glftiuls  arc  sijcoiully  proiio  to  bo  involved  iu  young 
cliiliiri'ii,  113  before  mentioned.  Of  127  ciwes  of  tuberculosis  in  childron, 
Wooillicad  found  these  bodies  alTected  in  100  instances,  in  1-4  of  which 
there  wore  no  tubercles  in  other  jjarts  of  the  body.  Tiie  majority  of  these 
ciiscs  occur  between  the  first  and  fifth  years.  The  bronchial  glanils  are 
still  more  frequently  involved,  and  of  15J5  cases  at  the  New  York  Found- 
ling,' llosjjital  in  every  one  were  these  structures  the  seat  of  more  or  less 
extt'iisivc  tuberculosis. 

In  adults  the  lungs  usually  contain  tubercle  when  it  is  present  in  the 
body  (Louis'  law). 

(r)  Soil  and  lovnlily  arc  held  by  many  to  have  an  important  influence 
in  tuberculosis.  The  observations  of  H.  I.  IJowditch  in  this  country,  and 
of  Hucluman  in  England,  show  that  pulmonary  tuberculosis  is  more  preva- 
lent in  damp,  ill-drained  districts ;  but  this  increased  incidence  is  most 
j)rol)ably  associated  with  a  heightened  vulnerability  duo  to  an  increased 
liubility  to  catarrhal  affections  of  all  kinds. 

((/)  Local  Conditions  injlucncing  Infection. — These  aro  doubtless  of 
the  highest  importance,  and  second  only  to  the  constitutional  vulnera- 
bility.   Among  the  more  important  may  be  mentioned  : 

Catarrhal  Inflammation. — This  probably  acts  by  lov  ering  the  resist- 
ance, or,  in  modern  imrlance,  reducing  the  activity  oi'  tl»e  phagocytes 
and  allowing  the  bacilli  to  pass  the  portals.  The  liability  of  infection 
in  the  cervical  and  bronchial  glands  in  children  is  probably  associated 
with  the  common  occurrence  of  catarrhal  processes  in  the  throat  and 
bronchi. 

The  influence  of  bronchial  catarrh  in  pulmonary  tuberculosis  is  all-im- 
portant. How  often  is  it  said  that  the  disease  has  started  in  a  neglected 
cold,  which  means,  in  other  words,  that  the  bronchial  catarrh  has  enfeebled 
the  power  of  tissue  resistance,  or  i^roduced  conditions  favorable  to  the  growth 
and  dovelopr.ient  of  the  bacilli ! 

An  important  part  in  the  etiology  of  tuberculous  processes  is  played 
by  trauma.  Surgeons  have  for  years  laid  great  stress  upon  this  associa- 
tion, but  the  relation,  though  universally  recognized,  is  by  no  means  e.asy 
of  explanation.  Bacteriological  experiments,  however,  indicate  that  in 
tissues  wliich  have  been  injured  organisms,  which  would  in  health  have 
been  readily  and  rapidly  destroyed  by  the  action  of  the  normal  juices  or 
cells,  under  these  altered  circumstances  grow  rapidly  and  develop.  Proba- 
bly in  the  case  of  tuberculosis  following  trauma  the  injured  part  is  for  a 
tune  a  locus  ininoris  resistentice,  and  if  bacilli  are  present  they  may  by  it 
receive  a  stimulus  to  growth,  or  under  the  altered  conditions  be  capable  of 
multiplying.  Not  only  in  arthritis  but  in  pulmonary  tuberculosis  trau- 
matism may  play  a  part  The  question  has  been  thoroughly  studied  by 
Mendelsolin,*  who  reports  nine  cases  in  which,  without  fracture  of  the 


1 

i 

*  Zeitschrift  f.  klin.  Medicln.  Bd.  10. 


I        '    ,   I 


■  f    .. 


194 


SPECIFIC  INFECTIOUS  DISEASES. 


rib  or  lactation  of  the  lung,  tuberculosis  developed  shortly  after  contu- 
sion  of  the  chest. 

The  production  of  general  tuberculosis  is  sometimes  favored  by  02)na- 
(ion  upon  tuberculous  lesions.  Surgeons  have  long  known  that  resection 
of  a  strumous  joint  is  occasionally  followed  by  acute  tuberculosis.  The 
question  has  been  carefully  studied  by  Wartmann,*  who  gives  statistics  of 
837  resections.  Of  these,  2:25  ended  fatally,  26  with  acute  tuberculosis, 
the  outbreak  of  which  was  directly  associated  with  operation. 

The  acute  miliary  tuberculosis  which,  as  Litten  has  shown,  occasion- 
'  ally  follows  the  aspiration  of  the  effusion  in  tuberculous  pleurisy,  may 
come  under  this  division. 

The  conctant  inhalation  of  impure  air  in  occupations  associated  with 
a  very  dusty  atmosphere  rondel's  the  lungs  less  capable  of  resisting  infec- 
tion. The  pulmonary  affection  of  stone-cutters  and  coal-miners,  though 
non-tuberculous  at  the  outset  and  often  a  simple  chronic  interstitial  pneu- 
monia, is  ultimately  in  a  large  proportion  of  the  cases  tuberculous.  In 
manufactories  metallic  seems  more  hurtful  than  mineral  dust.  Peterson  f 
quotes  the  incidence  of  pulmonary  tuberculosis  among  the  trades  as  fol- 
lows: Glass- workers,  80  per  cent;  needle-sharpeners,  70;  file-cutters,  G2; 
and  stone-cutters,  GO.  And,  lastly,  circumstances  which  temporarily  lower 
the  nutrition,  as  the  xpecific  fevers  render  the  tissues  more  susceptible.  In 
this  way  alone  can  we  explain  the  frequent  onset  of  tuberculosis  after  an 
exhausting  illness.  Fevers,  such  as  measles  and  whooping-cough,  which 
are  associated  with  bronchial  catarrh,  are  more  prone  than  others  to  be 
followed  by  tuberculosis.  This  is  often  only  the  blazing  of  a  smoulder- 
ing fire. 

General  Morbid  Anatomy  and  Histolog:y  of  Tuberculous 
LesionB. 

(1)  Distribution  of  the  Tubercles  in  the  Body.— The  organs  of  the 
body  are  variously  affected  by  tuberculosis.  In  adults,  the  lungs  may  be 
regarded  as  the  seat  of  election ;  in  children,  the  lymph-glands,  bones,  and 
joints.  In  1,000  autopsies  there  were  275  cases  with  tuberculous  lesions. 
With  but  two  or  three  exceptions  the  lungs  were  affected.  The  distribu- 
tion in  the  other  organs  was  as  follows :  Pericardium,  7  ;  peritonaeum,  3G; 
brain,  31;  spleen,  23;  liver,  12;  kidneys,  32;  intestines,  Go;  heart,  4; 
and  generative  organs,  8. 

The  tuberculosis  which  comes  under  the  care  of  the  surgeon  has  a  tlif- 
ferent  distribution,  as  shown  by  the  following  figures  from  the  Wurzburg 
clinic :  Among  8,873  patients  there  were  1,287  tuberculous,  with  the 
following  distribution  of  lesions:  Bones  and  joints,  1,037;  lymph-glands, 
19G ;  skin  and  connective  tissues,  77;  mucous  membranes,  10;  genito- 
urinary organs,  20. 


*  Deutsche  Zeitschrift  f.  Chirurgie,  Bd.  24. 
f  Medical  News,  1885. 


TUBERCULOSIS. 


195 


(2)  The  Changes  produced  by  the  Tubercle  Bacilli. 

(d)  The  Nodular  Tubercle. — The  body  which  we  term  a  "  tubercle  " 
presents  in  its  early  formation  nothing  distinctive  or  peculiar,  either  in 
its  comjwnents  or  in  their  arrangevient.  Identical  structures  are  pro- 
duced by  other  parasites,  such  as  the  actiuomyces,  and  by  the  strongylus 
in  tiie  lungs  of  sheep. 

'i'hc  researches  of  Baumgarten  have  enabled  us  to  follow  in  detail  all 
the  steps  in  the  development  of  a  tubercle. 

These  are  :  (  )  The  multiplication  of  the  fixed  cells,  especially  those  of 
connective  tissue  and  the  endothelium  of  the  capillaries,  and  the  gradual 
production  from  them  of  rounded,  cuboidal,  or  polygonal  bodies  with 
vesicular  nuclei — the  epithelioid  cells — inside  some  of  which  the  bacilli  are 
soon  seen. 

(/3)  From  the  vessels  of  the  infected  focus,  leucocytes  migrate  in 
numbers  and  form  the  lymphoid  cells  which  were  thought  to  be  so 
characteristic  of  tubercle.    They  do  not,  however,  undergo  division. 

(y)  A  reticulum  of  fibres  is  formed  by  the  fibrillation  and  rarefaction 
of  the  connective-tissue  matrix.  This  is  most  apparent,  as  a  rule,  at  the 
margins  of  the  growth. 

((J)  In  some,  but  not  all,  tubercles  gia^it  cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by 
the  fusion  of  several  cells.  The  giant  cells  seem  to  be  in  inverse  ratio  to 
the  number  and  virulence  of  the  bacilli.  In  lupus,  joint  tuberculosis, 
and  scrofulous  glands,  in  which  the  bacilli  are  scanty,  the  giant  cells  are 
numerous ;  while  in  miliary  tubercles  and  all  lesions  iu  which  the  bacilli 
are  abundant  the  giant  cells  are  few  in  number. 

The  bacilli  then  cause,  in  the  first  place,  a  proliferation  of  the  fixed 
elements,  Avith  the  production  of  epithelioid  and  giant  cells;  and,  secondly, 
an  inflammatory  reaction.,  associated  with  exudation  of  leucocytes.  How 
far  the  leucocytes  attack  and  destroy  the  bacilli  has  not  been  definitely 
settled — Metschnikoff  claiming,  l^aumgarten  denying,  an  active  phago- 
cytosis. 

Once  formed,  a  tubercle  undergoes  caseation  and  sclerosis. 
Caseation. — At  the  c(  ntral  part  of  the  growth,  owing  to  the  direct 
action  of  the  bacilli,  a  process  of  coagulation  necrosis  goes  on  in  the  cells, 
which  lose  their  outline,  become  irregular,  no  longer  take  stains,  and  are 
finally  converted  into  a  hcimogeneous,  structureless  substance.  Proceed- 
ing from  the  centre  outward,  the  tubercle  may  be  gradually  converted 
into  a  yellowish-gray  body,  in  which,  however,  the  bacilli  are  still  abundant. 
Xo  blood-^CdS  lis  are  found  in  them.  Aggregated  together  these  form  the 
cheesy  masses  bo  common  in  tuberculosis,  which  may  undergo  (a)  soften- 
ing; {h)  fibroid  limitation  (encapsulation) ;  (c)  calcification. 

Sclerosis. — With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in 
the  fibroid  elements ;  .so  that  the  tubercle  is  converted  into  a  firm,  hard 


196 


SPECIFIC  INFECTIOUS  DISEASES. 


structnro.  Often  the  change  is  rather  of  a  fibro-caseous  nature  ;  but  the 
sclerosis  predominates.  In  some  situations,  as  the  peritonaeum,  this  seems 
to  be  the  natural  transformation  of  tubercle,  and  it  is  by  no  means  rare  in 
the  lungs. 

In  all  tubercles  two  processes  go  on :  the  one — caseation — destructive 
and  dangerous ;  and  the  other — sclerosis — conservative  and  healing.  The 
ultimate  result  in  a  given  case  depends  upon  the  capabilities  of  the  body 
to  restrict  and  limit  the  growth  of  the  bacilli.  There  are  tissue-soils  in 
which  the  bacilli  are,  in  all  probability,  killed  at  once — the  seed  has  fallen 
by  the  wayside.  There  are  others  in  which  a  lodgment  is  gained  and 
more  or  less  damage  done,  but  finally  the  day  is  with  the  conservative, 
protecting  forces — the  seed  has  fallen  upon  stony  ground.  Thirdly,  there 
are  tissue-soils  in  which  tlie  bacilli  grow  luxuriantly,  caseation  and  soft- 
ening, not  limitation  and  sclerosis,  prevail,  and  the  day  is  with  the  in- 
vaders— the  seed  has  fallen  upon  good  ground. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illus- 
trates many  points  in  the  histology  and  pathology  of  tuberculosis.  If  into 
the  vein  of  a  rabbit  a  pure  culture  of  the  bacilli  is  injected,  the  microhes 
accumulate  chiefly  in  the  liver  and  spleen.  The  animal  dies  usually  with- 
in two  weeks,  and  the  organs  apparently  show  no  trace  of  tubercles. 
Microscopically,  in  both  spleen  and  liver  the  young  tubercles  in  process  of 
formation  are  very  numerous,  and  the  process  of  karyokinesis  is  seen  in 
the  liver-cells.  After  an  injection  of  a  more  dilute  culture,  or  one  whose 
virulence  has  been  mitigated  by  age,  instead  of  dying  within  a  fortnight 
the  animal  survives  for  five  or  six  weeks,  by  which  time  the  tubercles  are 
apparent  in  the  spleen  and  liver,  and  often  in  the  other  organs. 

(b)  The  Diffuse  Infiltrated  Ttibercle. — This  is  most  fi-equently  seen  in 
the  lungs.  Only  a  great  master  like  Virchow  could  have  won  the  pro- 
fession from  a  belief  in  the  iinity  of  phthisis,  which  the  genius  of  Laenncc 
had,  on  anatomical  ground,  announced.  Here  and  there  a  teacher,  as 
Wilson  Fox,  protested,  but  the  heresy  prevailed,  and  we  repeated  the  strii(- 
ing  aphorism  of  Niemeyer,  "  The  greatest  evil  which  can  happen  to  a  con- 
sumptive is  that  he  should  become  tuberculous."  It  was  thought  that  the 
products  of  any  simple  inflammation  might  become  caseous  and  that  ordi- 
nary catarrhal  pneumonia  terminated  in  phthisis.  It  was  peculiarly  fitting 
that  from  Germany,  in  which  the  dualistic  heresy  arose,  the  truth  of  Laen- 
nec's  views  should  receive  incontestable  proof,  in  the  demonstration  by 
Koch  of  the  etiological  unity  of  all  the  various  processes  known  as  tuber- 
culous and  scrofulous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  foci  of  in- 
fection— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but 
which  histologically  are  seen  to  be  composed  of  scattered  centres,  sur- 
rounded by  areas  in  which  the  air-cells  are  filled  with  the  products  of  exu- 
dation and  of  the  proliferation  of  the  alveolar  epithelium.  Under  the 
influence  of  the  bacilli,  caseation  takes  place,  usually  in  small  groups  of 


TUBERCULOSIS. 


197 


lobules,  occasionally  in  an  entire  lobe,  or  even  the  greater  part  of  a  lung. 
In  tlie  early  stage  of  the  ])rocess,  the  tissue  has  a  gray  gelatinous  appear- 
ance, the  (jray  infiltration  of  Laennec.  Tlie  alveoli  contain  a  sero-fibrinous 
fluid  with  cells,  and  the  septa  are  also  infiltrated.  These  cells  accumulate 
and  undergo  coagulation  necrosis,  forming  areas  of  caseation,  the  irifiUra- 
lion  luhcrculeuse  jaune  of  Laennec,  the  scrofulous  or  cheesy  pneumonia 
of  later  writers.  There  may  also  be  a  diffuse  infiltration  and  caseation 
witliout  any  special  foci,  a  wide-spread  tuberculous  pneumonia  induced  by 
the  bacilli. 

After  all,  the  two  process.s  are  identical.  As  Baumgarten  states: 
"there  is  no  well-marked  difference  between  miliary  tubercle  and  chronic 
caseous  pneumonia.  Speaking  histologically,  miliary  tuberculosis  is  noth- 
ing else  than  a  chronic  caseous  miliary  pneumonia,  and  chronic  caseous 
pneumonia  is  nothing  but  a  tuberculosis  of  the  lungs." 

{(')  Secondary  Inflammatory  Processes. — (1)  The  irritation  of  the 
bacilli  invariably  produces  an  inflammation  which  may,  as  has  been  de- 
scribed, be  limited  to  exudation  of  leucocytes  and  serum,  but  may  also  be 
much  more  extensive,  and  varies  Avith  varying  conditions.  We  find,  for 
example,  about  the  smaller  tubercles  in  the  lungs,  pneumonia — either 
catarrhal  or  fibrinous,  proliferation  of  the  connective-tissue  elements  in  the 
septa  (which  also  become  infiltrated  with  round  cells),  and  changes  in  the 
blood  and  lymph  vessels. 

(2)  In  processes  of  minor  intensity  the  inflammation  is  of  the  slow 
reactive  nature,  which  results  in  the  production  of  a  cicatricial  connective 
tissue  which  limits  and  restricts  the  development  of  the  tubercles  and  is 
the  essential  conservative  element  in  the  disease.  It  is  to  be  remembered 
that  in  chronic  pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is 
present  is  not  in  any  way  associated  Avith  the  action  of  the  bacilli. 

(3)  Suppuration.  Do  the  bacilli  themselves  induce  suppuration  ?  In 
so-called  cold  tuberculous  abscess  the  material  is  not  histologically  pus, 
but  a  debris  consisting  of  broken-down  cells  and  cheesy  material.  It  is 
moreover  sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The 
products  of  the  tubercle  bacilli  are  probably  able  to  induce  suppuration, 
as  in  joint  and  bone  tuberculosis  pus  is  frequently  produced,  although  this 
may  be  duo  to  a  mixed  infection.  Koch,  it  Avill  be  remembered,  states 
that  tlie  "  tuberculin  "  is  one  of  the  best  agents  for  the  production  of  ex- 
perimental suppuration.  In  tuberculosis  of  the  lungs  the  suppuration  is 
largely  the  result  of  an  infection  with  pus  organisms. 

II.  Acute  Tuberculosis. 

The  truly  infective  nature  of  tubercle  is  best  shown  in  this  affection, 
which  is  characterized  by  an  eruption  of  miliary  tubercles  in  various  parts 
ff  the  body.  The  clinical  picture  varies  with  the  general  or  localized  dis- 
tribution of  the  growths.     The  tubercles  are  found  upon  the  pleura  and 


n . 


198 


SPECIFIC   INFECTIOUS  DISEASES. 


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peritonieum ;  in  the  lungs,  liver,  kidneys,  lymph-glands,  and  spleen ;  upon 
the  membranes  of  the  brain,  occasionally  in  the  choroid  coat  of  the  eye, 
and  in  the  bone-marrow.  They  may  be  abundant  in  some  organs  and 
scaTity  in  others.  Thus,  in  the  meninges  of  the  brain  they  may  be  thickly 
set,  while  there  are  few  or  none  in  the  abdominal  viscera  or  in  the  lungs. 
On  the  other  hand,  the  lungs  may  be  stuffed  with  granulations  while  the 
meninges  of  the  brain  are  free.  In  other  cases,  again,  the  distribution  is 
uniform  in  all  the  viscera. 

The  etiology  has  been  in  part  considered,  and  the  only  additional  state- 
ment necessary  is  that  in  a  great  majority  of  all  cases  it  is  an  auto-infec- 
tion, arising  from  a  pre-existing  tuberculous  focus,  which  may  be  latent 
and  unsuspected.  The  following  are  the  most  common  sources  of  general 
infection :  Local  disease  of  the  lungs,  which  may  be  quite  limited  and  un- 
productive of  symptoms ;  tuberculous  affection  of  the  lymph-glands,  par- 
ticularly in  children ;  and  tuberculosis  of  the  bones  and  of  the  kidneys, 
Of  these  sources  perhaps  the  most  common  are  the  tracheal  and  bronchial 
lymph-glands,  which  are  so  often  tlie  seat  of  local  tuberculosis.  Weigert 
has  shown  that  in  many  cases  the  infection  results  from  the  rupture  of  a 
caseous  pulmonary  nodule  into  a  vein,  or  of  a  caseous  bronchial  gland  into 
one  of  the  pulmonary  veins.  A  general  infection  may,  as  shown  by  Pon- 
fick,  result  from  invasion  of  the  thoracic  duct  by  tubercles.  With  special 
care  the  source  of  infection  can  usually  be  discovered  at  post-mortem 
examination.  The  connection  between  tuberculous  lymph-glands  and 
veins  has  often  been  demonstrated.  In  many  instances  it  is  impossible  to 
say  what  determines  the  sudden  and  violent  onset  of  the  disease.  It  would 
seem  sometimes  as  if  general  rather  than  local  conditions  influenced  the 
outbreak.  After  certain  fevers,  particularly  measles  and  whooping-cough 
in  children — affections,  it  is  true,  which  are  associated  with  long-continued 
bronchitis — miliary  tuberculosis  is  not  uncommon.  The  prostration  and 
constitutional  weakness  which  follow  protracted  fevers  frequently  seem  iu 
the  adult  a  predisposing  cause. 

Clinical  Forms. — For  practical  purposes  the  cases  may  be  divided 
into  those  with  the  symptoms  of  acitte  general  infection  without  special 
localization ;  cases  with  marked  pulmonary  symptoms ;  and  cases  with 
cerebral  or  ccreb7'o-spinal  symptoms. 

Other  forms  have  been  recognized,  but  this  division  covers  a  large  ma- 
jority of  the  cases. 

Taking  any  series  of  cases  it  will  be  found  that  the  meningeal  form  of 
acute  tuberculosis  exceeds  in  numbers  the  cases  with  general  or  marked 
pulmonary  symptoms. 

1.  General  or  Typhoid  YoTm.—Symptoms. — The  patient  here  presents 
the  symptoms  of  an  infectious  disease  with  few  if  any  local  symptoms. 
The  cases  simulate  and  are  frequently  mistaken  for  typhoid  fever.  After 
a  period  of  failing  health,  with  loss  of  appetite,  the  patient  becomes 
feverish  and  weak.    Occasionally  the  disease  sets  in  more  abruptly,  but  in 


TUBERCULOSIS. 


199 


many  instances  the  anamnesis  closely  resembles  that  of  typhoid  fever. 
Nose-Uecding,  however,  is  rare.  The  temperature  increases,  the  pulse 
becomes  rapid  and  feeble,  the  tongue  dry ;  delirium  becomes  marked  and 
tlie  cheeks  are  flushed.  The  pulmonary  symptoms  may  be  very  slight ; 
iisuiilly  bronchitis  exists,  but  not  more  severe  than  is  common  with  typhoid 
fever.  The  pulse  is  seldom  dicrotic,  but  is  rapid  in  proportion  to  the 
pyrexia.  Perhaps  the  most  striking  feature  of  the  temperature  is  the 
irrefjiilarity ;  and  if  seen  from  the  outset  there  is  not  the  steady  ascent 
noted  in  typhoid  fever.  There  is  usually  an  evening  rise  to  103°,  some- 
times 104°,  and  a  morning  remission  of  from  two  to  three  degrees.  Some- 
times llie  pyrexia  is  intermittent,  and  the  thermometer  may  register  below 
iiorimil  during  the  early  morning  hours.  The  inverse  type  of  temperature, 
ill  whicli  the  rise  takes  place  in  the  morning,  is  held  by  some  writers  to  be 
more  frequent  in  general  tuberculosis  than  in  other  diseases.  In  rare  in- 
stances tliere  may  be  little  or  no  fever.  On  two  occasions  I  have  had  a 
patient  admitted  to  my  wards  in  a  condition  of  profound  debility,  with  a 
history  of  illness  of  from  three  to  four  weeks'  duration,  with  rapid  pulse, 
tiushed  cheeks,  dry  tongue,  and  very  slight  elevation  in  temperature,  in 
wliom  (post  mortem)  the  condition  proved  to  be  general  tuberculosis.  In 
one  instance  there  was  tolerably  extensive  disease  at  the  right  apex.  Rein- 
hold,  from  Biiumler's  clinic,  has  recently  called  attention  to  these  afebrile 
forms  of  acute  tuberculosis.  In  nine  of  fifty-two  cases  there  was  no  fever, 
or  oidy  a  transient  rise. 

In  a  considerable  number  of  these  cases  the  respirations  are  increased 
in  frequency,  particularly  in  the  early  stage,  and  there  may  be  signs  of 
diffuse  bronchitis  and  slight  cyanosis.  Cheyne-Stokes  breathing  devel- 
ops toward  the  close. 

Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dullness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
the  pulmonary  symptoms  become  more  marked ;  in  others,  meningeal  or 
cerebral  features  develop. 

Dimjnosis. — The  differential  diagnosis  between  general  miliary  tuber- 
culosis without  local  manifestations  and  typhoid  fever  is  extremely  diffi- 
cult. A  point  of  importance,  to  which  reference  has  already  been  made, 
is  the  irregularity  of  the  temperature  curve.  The  greater  frequency  of 
the  respirations  and  the  tendency  to  slight  cyanosis  is  much  more  com- 
mon in  tuberculosis.  There  are  cases,  however,  of  typhoid  fever  in  which 
the  initial  bronchitis  is  severe  and  may  lead  to  dyspna>a  and  disturbed 
oxygenation.  The  cough  may  be  slight  or  absent.  Diarrhoea  is  rare  in 
tuberculosis ;  the  bowels  are  usually  constipated ;  but  diarrhoea  may  oc- 
cur and  persist  for  days.  In  certain  cases  the  diagnosis  has  been  compli- 
rated  still  further  by  the  occurrence  of  blood  in  the  stools.  Enlargement 
of  the  spleen  occurs  in  general  tuberculosis,  but  is  neither  so  early  nor  so 
marked  as  in  typhoid  fever.  In  children,  however,  the  enlargement  may 
be  considerable.  The  urine  may  show  traces  of  albumen,  and  unfortu- 
14 


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200 


SPECIFIC  INFECTIOUS  DISEASES. 


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nately  Ehrlich's  diazo-reaction,  which  is  so  constant  in  typhoid  fevoi-,  is 
also  met  with  iu  general  tuberculosis.  The  absence  of  the  charactori.stic 
roseola  is  an  important  feature.  Occasionally  in  acute  tuberculosis  redtlisli 
spots  may  develop  and  for  a  time  cause  ditficulty,  but  they  do  not  vnma 
out  in  crops,  and  rarely  have  the  characters  of  the  true  typhoid  eruption. 
Herpes  is  perhaps  more  common  in  tuberculosis.  Toward  the  close,  pete- 
chiae  may  appear  on  the  skin,  particularly  about  the  wrists  A  rare  event 
is  jaundice,  due  possibly  to  the  eruption  of  tubercles  in  the  liver. 

In  a  few  instances  the  presence  of  tubercle  bacilli  has  been  demon- 
strated in  the  blood,  which  in  doubtful  cases  should  therefore  be  exam- 
ined. The  sploeri  has  been  punctured  and  cultivations  made  to  determine 
the  presence  or  absence  of  the  typhoid  bacilli  The  eye-grounds  should 
be  carefully  examined  for  choroidal  tubercles.  Leucocytosis  occurs  in 
acute  tuberculosis,  but  not  in  typhoid  fever. 

2.  Pulmonary  Form. — Symptoms. — From  the  outset  the  pulmonary 
symptoms  are  marked  The  patient  may  have  had  a  cough  for  months  or 
for  years  without  much  impairment  of  health,  or  he  may  be  known  to  be 
the  subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  par- 
ticularly in  children,  the  disease  follows  measles  and  whooping-cough,  and 
is  of  a  distinctly  broncho-pneumonic  type.  The  disease  begins  with  the 
symptoms  of  diffuse  bronchitis.  The  cough  is  marked,  the  expectoration 
muco-puruleut,  occasionally  rusty.  Haemoptysis  has  been  noted  in  a  few 
instances.  From  the  outset  dyspnrea  is  a  striking  feature  and  may  be  out 
of  proportion  to  the  intensity  of  the  physical  signs.  In  adults,  the  res- 
pirations may  be  as  hurried  as  in  acute  pneumonia,  reaching  from  fifty  to 
sixty ;  in  children,  as  high  as  eighty  or  more.  There  is  more  or  less  cya- 
nosis of  the  lips  and  finger-tips,  and  the  cheeks  are  suffused.  Apart  from 
emphysema  and  the  later  stages  of  severe  pneumonia  I  know  of  no  other 
pulmonary  condition  in  which  the  cyanosis  is  so  marked.  The  physical 
signs  are  those  of  bronchitis.  There  is  rarely  much  alteration  in  the  })er- 
cussion  note.  In  children  there  may  be  defective  resonance  at  the  bases, 
from  scattered  areas  of  broncho-pneumonia ;  or,  Avhat  is  equally  su<rges- 
tive,  areas  of  hyper-resonance.  Indeed,  the  percussion  note,  particularly 
in  the  front  of  the  chest,  in  some  cases  of  miliary  tuberculosis,  is  full  and 
clear,  and  it  M'ill  be  noted  (post  mortem)  that  the  lungs  are  unusually 
voluminous.  This  is  probably  the  result  of  more  or  less  wide-spread 
acute  emphysema.  On  auscultation,  the  rilles  are  either  sibilant  and 
sonorous  or  small,  fine,  and  crepitant.  There  may  be  fine  crepitation 
from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen).  In  children 
there  may  be  high-pitched  tubular  breathing  at  the  bases  or  toward  tlie 
root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and  more 
mucous.  The  temperature  rises  to  103°  or  103°,  and  may  present  the  in- 
verse type.  The  pulse  is  rapid  and  feeble.  In  the  A'ery  acute  cases  tlie 
spleen  is  always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve 
days,  or  may  be  protracted  for  weeks  or  even  months. 


^w^i 


TUBERCULOSIS. 


201 


Diofjnosis. — The  diagnosis  of  this  form  offers  less  difficulty  and  is 
nioif  Irequently  made.  There  is  often  a  history  of  previous  cough,  or  the 
patient  is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the 
Ivmiih-glands,  or  of  the  bones.  In  children  these  symptoms  following 
moasK'8  or  whooping-cough  indicate  in  the  majority  of  cases  acute  miliary 
tuberculosis,  with  or  without  broncho-pneumonia.  Occasionally  the  spu- 
tum contains  tubercle  bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may 
help  tlie  diagnosis.  More  important  in  an  adult  is  the  combination  of 
(lyspiKea  with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  in- 
stances the  occurrence  of  cerebral  symptoms  at  once  give  a  clew  to  the 
nature  of  the  trouble. 

3  Meningeal  Form  {Tuberculous  Meningitis). — This  affection,  which  is 
also  known  as  acute  hydrocephalus  or  "  water  on  the  brain,"  is  essentially 
an  acute  tuberculosis  in  which  the  membranes  of  the  brain,  sometimes  of 
tlie  cord,  bear  the  brunt  of  the  attack. 

There  are  several  special  etiological  factors  in  connection  with  this 
form.  It  is  much  more  common  in  children  than  in  atlults.  It  is  rare 
(luring  the  first  year  of  life,  more  frequent  between  the  second  and  the 
fifth  years.  In  a  majority  of  the  cases  a  focus  of  old  tuberculous  disease 
will  bo  found,  commonly  in  the  bronchial  or  mesenteric  glands.  In  a  few 
instances  the  affection  seems  to  be  primary  in  the  meninges.  It  is  very 
(litiicult,  however,  in  an  ordinary  post-mortem  to  make  an  exhaustive 
search,  and  the  lesion  may  be  in  the  bones,  sometimes  in  the  middle  ear, 
or  in  the  genito-urinary  organs.  In  those  instances  in  which  no  primary 
focus  has  been  discovered  it  has  been  suggested  that  the  bacilli  reach  the 
meninges  through  the  cribriform  plate  of  the  ethmoid  from  the  upper 
part  of  the  nostrils,  but  this  is  not  probable. 

Morbid  Anatomy. — Tuberculous  meningitis  presents  a  very  character- 
istic picture.  The  meninges  at  the  base  are  most  involved,  hence  the  term 
basilar  meningitis.  The  parts  about  the  optic  chiasm,  the  Sylvian  fissures, 
imd  tlie  interpeduncular  space  are  affected.  There  may  be  only  slight 
turbidity  and  matting  of  the  membranes,  and  a  certain  stickiness  with 
serous  infiltration ;  but  more  commonly  there  is  a  turbid  exudate,  fibrino- 
IHuulent  in  character,  which  covers  the  structures  at  the  base,  surrounds 
the  nerves,  extends  out  in  the  Sylvian  fissures,  and  appears  on  the  lateral, 
mrely  on  the  upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be 
very  apparent,  particularly  in  the  Sylvian  fissures,  appearing  as  small, 
whitish  nodules  on  the  membranes.  They  vary  much  in  number  and  size, 
iiiul  may  be  difficult  to  find.  The  amount  of  exudate  bears  no  definite  re- 
l:ition  to  the  abundance  of  tubercles.  The  arteries  of  the  anterior  and 
posterior  perforated  spaces  should  be  carefully  withdrawn  and  searched, 
as  upon  them  nodular  tubercles  may  be  found  when  not  present  elsewhere. 
Ill  doubtful  cases  the  middle  cerebral  arteries  should  be  very  carefully  re- 
moved, spread  on  a  glass  plate  with  a  black  background,  and  examined 


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202 


SPECIFIC  INFECTIOUS  DISEASES. 


with  a  low  objective.  Tiie  tubercles  arc  then  seen  as  nodular  enlarge- 
ments on  tlie  smaller  arteries.  The  lateral  ventricles  are  dilated  (uciito 
hydrocephalus)  and  contain  a  turbid  fluid;  the  ependyma  maybe  sitft- 
ened,  and  the  septum  lucidum  and  fornix  are  usually  broken  down.  Tlio 
convolutions  are  often  flattened  and  the  sulci  obliterated  owing  to  the 
increased  intra-ventricular  pressure.  Histologically  the  tubercles  are  .scon 
to  develop  in  the  perivascular  sheaths,  producing  circumscribed  aggrcirji- 
tions  of  lymphoid  and  epithelioid  cells.  The  lumen  of  the  vessel  is  nar- 
rowed and  thrombosis  may  result.  The  meninges  are  not  alone  involved, 
but  the  contiguous  cerebral  substance  is  more  or  less  edematous  and  iniil- 
trated  with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
meningo-encepUaUtis. 

There  are  instances  in  which  the  acute  process  is  associated  with 
chronic  meningeal  tuberculosis ;  cases  which  may  for  months  present  the 
clinical  picture  of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  si)iiiiil 
meninges  may  also  be  involved,  particularly  those  of  the  cervical  cord. 
There  are  cases  indeed  in  which  the  symptoms  are  chiefly  spinal.  A  sailor, 
who  had  fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to 
the  Montreal  General  Hospital.  He  presented  signs  of  meningitis,  cliielly 
spinal,  which  were  naturally  attributed  to  traumatism.  The  post-mortem 
showed  absence  of  tubercles  and  lymph  at  the  base  of  the  brain,  and  an 
extensive  eruption  of  miliary  tubercles  with  much  turbid  lymph  over  the 
entire  spinal  meninges.  There  were  small  cheesy  masses  at  the  apices  of 
the  lungs. 

Symptoms. — Tuberculous  meningitis  presents  an  extremely  complex 
clinical  picture.     It  will  be  best  to  describe  the  form  found  in  children. 

Prodromal  symptoms  are  common.  The  child  may  have  been  in  fail- 
ing health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whoop- 
ing-cough. In  many  instances  there  is  a  history  of  a  fall.  The  child 
gets  thin,  is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  dispo- 
sition may  completely  change.  Symptoms  pointing  to  the  disease  may 
then  set  in,  either  quite  suddenly  with  a  convulsion,  or  more  commonly 
with  headache,  vomiting,  and  fever,  three  essential  symptoms  of  the  onset 
which  are  rarely  absent.  The  pain  may  be  intense  and  agonizing.  The 
child  puts  its  hand  to  its  head  and  occasionally,  when  the  pain  becomes 
worse,  gives  a  short,  sudden  cry,  the  so-called  hydrocephalic  cry.  Some- 
times the  child  screams  continuously  until  utterly  exhausted.  I  saw  in 
West  Philadelphia  a  case  of  basilar  meningitis  in  a  girl  of  thirteen,  who 
for  three  days,  when  not  under  the  influence  of  a  powerful  sedative  or  of 
chloroform,  screamed  at  the  top  of  her  voice  so  as  to  be  heard  a  square  or 
more  away.  The  vomiting  is  without  apparent  cause,  and  is  independent 
of  taking  of  food.  Constipation  is  usually  present.  The  fever  is  slight, 
but  gradually  rises  to  102°  or  103".  The  pulse  is  at  first  rapid,  subse- 
quently irregular  and  slow.    The  respirations  are  rarely  altered.    During 


tongue, 
tenij)eratii 
94''.    Jn 
fever  risii 
night  to 
Tiiero 
course!. 
go(.;]  Ilea 
"lore  com 
involved, 
display 
psychical 
There 
The  ir 
stages  of  t 
('h)se,  as  t 
qiient.    Tl 
«'hich  it  d( 
It  may  he 
tliree  or  fo 


TUBERCULOSIS. 


203 


slcc])  the  child  is  restless  and  disturbed.  There  may  be  twitchings  of  the 
rmiscles,  or  sudden  starlings;  or  the  child  may  wake  up  from  sleep  in 
LMTiit  terror.  In  this  early  stage  the  pui)ilsare  usually  contracted.  These 
me  till'  t'liiof  symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of 
irnlatlon. 

Ill  the  second  period  of  the  disease  these  irritative  8ymi)toms  subside ; 
voiiiiliiig  is  no  longer  marked,  the  abdomen  becomes  retracted,  boat- 
sliaiH'd  or  earinated.  'J'he  bowels  are  obstinately  constipated,  the  child  no 
luiigi'r  cuinplains  of  headache,  but  is  dull  and  apathetic,  and  when  roused 
is  more  or  less  delirious.  The  head  is  often  retracted  and  the  child  utters 
an  occasional  cry.  The  pupils  are  dilated  or  irregular,  and  a  squint  may 
develop.  Sighing  respiration  is  common.  Convulsions  may  occur,  or 
ligklit y  of  the  muscles  of  one  side  or  of  one  limb.  The  temperature  is 
variable,  ranging  from  100°  to  lO'^-5°.  A  blotchy  erythema  is  not  uncom- 
mon on  the  skin.  If  the  finger-nail  is  drawn  across  the  skin  of  any  region 
a  red  line  comes  out  quickly,  the  so-called  idcJie  cereOrale,  which,  however, 
luus  no  diagnostic  significance. 

In  the  final  period,  or  stage  of  paralysis,  the  coma  increases  and  the 
child  cannot  be  roused.  Convulsions  are  not  infrequent,  and  there  are 
spasmodic  contractions  of  the  muscles  of  the  back  and  neck.  Spasms 
may  occur  in  the  limbs  of  one  side.  Optic  neuritis  and  paralysis  of  the 
ocular  muscles  may  be  present.  The  pupils  become  dilated,  the  eyelids 
are  only  partially  closed,  and  the  eyeballs  are  rolled  up  so  that  the  corneae 
are  only  covered  in  part  by  the  upper  eyelid.  Diarrhoea  may  develop,  the 
piilso  bocomes  rapid,  and  the  child  may  sink  into  a  typhoid  state  with  dry 
tongue,  low  delirium,  and  involuntary  passages  of  urine  and  faeces.  The 
temperature  often  becomes  subnormal,  sinking  in  rare  instances  to  93°  or 
94°.  In  some  cases  there  is  ante-mortem  elevation  of  temperature,  the 
fever  rising  to  10G°.  The  entire  duration  of  the  disease  is  froni  a  fort- 
night to  three  or  four  weeks. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
course.  They  set  in  with  great  violence,  often  in  persons  ap})arently  in 
go(i:l  health,  and  may  prove  fatal  within  a  few  days.  In  these  instances, 
more  commonly  seen  in  adults,  the  convex  surface  .of  the  brain  is  usually 
involved.  There  are  again  instances  which  are  essentially  chronic  and 
dis})lay  symptoms  of  a  limited  meningitis;  sometimes  with  pronounced 
psychical  symptoms,  and  sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  which  call  for  special  comment. 

The  irregularity  and  slowness  of  the  pulse  in  the  early  and  middle 
stages  of  the  disease  are  points  upon  which  all  authors  agree.  Toward  the 
dose,  as  the  heart's  action  becomes  weaker,  the  pulsations  are  more  fre- 
quent. The  temperature  is  usually  elevated,  but  there  are  instances  in 
which  it  does  not  rise  in  the  whole  course  of  the  disease  much  above  100°. 
It  may  he  extremely  irregular,  and  the  oscillations  are  often  as  much  as 
three  or  four  degrees  in  the  day.     Toward  the  close  the  temperature  may 


Pi' 

it  *' 

1    '<   ) 

11  i;  1 

204 


SPECIFIC  INFECTIOUS  DISEASES. 


• 


sink  to  95°,  oocasiojmlly  to  94",  or  tlicro  mny  be  liyperpyrexia.  In  ii  oaso 
or  Biiiimlor's  the  tempemtiire  rose  before  death  to  43-7°  C.  (110-7°  F.). 

The  ooiilar  symptoms  of  the  disease  are  of  special  importance.  In  tiio 
early  stages  narrowing  of  tiie  pupils  is  the  rule.  Toward  the  close,  with 
increase  in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular. 
There  niay  be  conjugate  deviation  of  the  eyes.  Of  ocular  palsies  the 
third  nerve  is  most  frequently  involved.  The  changes  in  the  eye-grnimds 
are  very  imi)ortant  Neuritis  is  the  most  common.  According  to  Gowcrs, 
the  disk  at  first  becomes  full  colored  and  has  hazy  outlines,  and  the  veins 
are  dilated.  Swelling  and  striation  become  pronoitnced,  but  the  neuritis  is 
rarely  intense.  Of  twenty-six  cases  studied  by  Garlick,  in  six  the  con- 
dition was  of  diagnostic  value.  The  tubercles  in  the  choroid  are  rare  and 
mucli  less  frequently  seen  during  life  than  post-mortem  figures  would 
indicate.  Thus  Litten  found  them  (post  mortem)  in  thirty-nine  out  of 
fifty-two  cases.  They  were  present  in  only  one  of  the  twenty-six  casus  of 
tuberculous  meningitis  examined  by  Garlick.  I  have  never  met  tlicni 
clinically,  and  have  oidy  found  two  instances  post  mortem,  lleinzel  exam- 
ined with  negative  results  forty-one  cases. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there 
are  other  changes  which  deserve  special  mention.  A  tetanic  contraction 
of  one  limb  may  persist  for  several  days,  or  a  cataleptic  condition.  Tronior 
and  athetoid  movements  are  sometimes  seen.  The  paralyses  are  eitlior 
hemiplegias  or  monoplegias.  Hemiplegia  may  result  from  disturbance  in 
the  cortical  branches  of  the  middle  cerebral  artery,  occasionally  from 
softening  in  the  internal  capsule,  due  to  involvement  of  the  central 
branches.  Of  monoplegias,  that  of  the  face  is  perhaps  most  common,  and 
if  on  the  right  side  it  may  occur  with  apluisia.  In  two  of  my  cases  in 
adults  apliasia  developed.  Brachial  monoplegia  may  be  associated  with  it. 
In  the  more  chronic  cases  the  symptoms  persist  for  months,  and  there  may 
be  a  characteristic  Jacksonian  epilepsy  when  the  tubercles  involve  tlio 
meninges  of  the  motor  cortex. 

The  proffuonis  in  this  form  of  meningitis  is  always  most  serious.  1 
have  neither  seen  a  case  which  I  regarded  as  tuberculous  recover,  nor 
have  I  seen  post-mortom  evidence  of  past  disease  of  this  nature.  Cases  of 
recovery  liave  been  reported  by  reliable  authorities,  but  they  are  extieniely 
rare,  and  there  is  always  a  reasonable  doubt  as  to  the  correctness  of  the 
diagnosis.  The  ditferential  features  will  be  considered  in  connection  with 
acute  meningitis. 

III.   TunEncuLOsrs  of  the  Lymph-glands  {Scrofula). 

Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is 
the  essential  element.  It  is  not  yet  definitely  settled  whether  the  virus 
which  produces  the  chronic  adenitis  or  scrofula  differs  from  that  which 
produces  tuberculosis  in  other  parts,  or  whether  it  is  the  local  conditions 


TUBKRCULOSIS, 


205 


in  the  glands  which  account  for  the  slow  development  and  milder  course. 
The  cxiu'iiinents  of  Arloing  would  indicate  that  the  virus  was  attenuated 
or  iiiiltU'r,  for  he  has  shown  that  the  caseous  material  of  a  lymph-gland 
killed  jriii'iea-pigs,  while  rabbits  escaped.  The  guinea-pig,  as  is  well 
known,  is  the  more  susceptible  animal  of  the  two.  The  observations  of 
Liii'Mrd  are  still  more  conclusive,  as  showing  a  variation  in  the  virulence 
of  the  tubercle  bacillus.  Guinea-pigs  inoculated  with  ordinary  tubercle 
showed  lymphatic  infection  witliin  the  first  week,  and  the  animals  died 
within  three  months;  infected  with  material  from  scrofulous  glands,  the 
Ivniphatic  onlargrment  did  not  appear  until  the  second  or  third  week,  and 
tiio  animals  survived  for  six  or  seven  months.  He  showed,  moreover,  that 
the  virulence  of  the  infection  obtained  from  the  scrofulous  glands  in- 
creased in  intensity  by  passing  through  a  series  of  guinea-pigs.  Eve's  ex- 
})oriinonts  show  that  scrofulous  material  invariably  produces  tuberculosis 
in  guinea-pigs  and  very  often  in  rabbits. 

Tuberculous  adenitis  is  met  with  at  all  ages.  It  is  more  common  in 
children  than  in  adults,  but  it  is  not  infrequent  in  the  middle  period  of 
life,  and  may  occur  in  old  age. 

'I'he  tubercle  bacillus  is  ubiquitous.  All  are  exposed  to  infection,  and 
upon  the  local  conditions,  whether  favorable  or  unfavorable,  depend  the 
fate  of  those  organisms  which  find  lodgment  in  our  bodies.  It  is  possible, 
of  course,  that  tuberculous  adenitis  may  be  congenital,  but  such  instances 
must  be  extremely  rare.  A  special  predisposing  factor  in  lymphatic  tuber- 
culosis is  catarrhal  inflammation  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  con- 
stantly recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the 
mucous  membranes  find  in  all  probability  the  gateways  less  strictly 
guarded  and  are  taken  up  by  the  lymphatics  and  passed  to  the  nearest 
glands  In  conditions  of  health  the  local  resistance,  or,  as  some  would 
l)ut  it,  the  phagocytes,  would  be  active  enough  to  deal  with  the  invaders, 
but  the  irritation  of  a  chronic  catarrh  weakens  the  resistance  of  the  lymph- 
tissue  and  the  bacilli  are  enabled  to  develop  and  gradually  to  change  a 
simple  into  a  tuberculous  adenitis.  The  frequent  association  of  tubercu- 
lous adenitis  of  the  bronchial  glands  with  whooping-cough  and  with 
niea.sles,  and  the  frequent  development  of  tubercle  in  the  mesenteric 
glands  in  children  with  intestinal  catarrh,  find  in  this  way  a  rational  ex- 
planation. After  all,  as  Virchow  pointed  out,  an  increased  vulnerability 
of  the  tissue,  however  brought  about,  is  the  important  factor  in  the  disease. 
The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis: 

(")  The  local  character  of  the  disease ;  thus,  the  glands  of  the  neck,  or 
i^t  the  bifurcation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 
involved. 

(/')  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of 
the  cases  the  battle  which  ensues  between  the  bacilli  and  the  tissue-cells  is 


II' 


I :  -i 


♦    » 


206 


SPECIFIC   INFECTIOUS   DISEASES. 


-   •; 


long;  but  tho  Intter  tiro  finiiUy  HUccesHful,  and  wo  find  in  tho  culcillcd 
rcniniinta  in  tlio  bronuliiul  and  nu'.sitnterio  lyinpii-glands  evidenccH  of  vie- 
tory.  Too  oftuii  in  tliu  broiicliial  j^lands  a  truco  only  is  duclarcd  and  lio.s. 
tilitioa  nmy  broalv  out  afri  sh  in  tho  form  of  an  acute  tuborcubjsis. 

(c)  Tho  tendency  of  tuburculous  adonitis  to  pass  on  to  suppunition, 
Tho  friKjuoncy  willi  which,  particularly  in  tiio  glanda  of  tho  neck,  wo  find 
tho  tuberculous  processes  associated  with  pus  is  a  s])ecial  feature  of  this 
form  of  adenitis.  In  nearly  all  instances  the  [ma  is  sterile.  Whether  tliu 
suppuration  is  excited  by  the  bacilli  or  by  their  products,  or  whether  it  is 
tho  result  of  a  mixed  infection  with  pus  organisms,  which  are  siibso- 
quently  destroyed,  has  not  been  settled. 

{il)  The  I  xistence  of  an  unhealed  focus  of  tuberculous  adenitis  is  u 
constant  menace  to  the  or":anism.  It  is  safe  to  sa"  tluit  in  three  foiirth-i 
of  the  instances  of  acute  tuberculosis  the  infection  is  derived  from  tiiis 
source.  On  the  other  hand,  it  has  been  urged  that  scrofula  in  chiklhoinl 
gives  a  sort  of  protection  against  tuberculosis  in  adult  life.  We  certainly 
do  meet  with  many  jjcrsons  of  exceptional  bodily  vigor  who  in  childinnMl 
had  enlargeil  glands,  but  the  evidence  which  Marfan  *  brings  forward  in 
support  of  this  view  is  not  conclusive. 

Clinical  Forms.— I.  General  Tuberculous  Lymphadenitis.— In  ex- 
ceptioiud  instances  we  find  dilTuse  tuberculosis  of  nearly  all  the  lymjiii- 
glands  of  the  body  with  little  or  no  involvement  of  other  parts.  The  most 
extreme  cases  of  it  which  I  have  seen  have  been  in  negro  patients.  Two 
well-marked  cases  occurred  at  tho  Phila(lelj)liia  Hospital.  In  one,  a 
woman,  aged  thirty-four,  was  admitted  April  4th,  with  enlarged  glands  in 
the  right  side  of  the  neck  and  irregular  fever.  The  chart  from  A!)iil, 
1888,  until  March,  1889,  showed  persistent  fever,  ranging  from  101^  to 
103°,  occasionally  rising  to  104:°.  On  December  IGtli  tho  glands  on  the 
right  side  of  the  neck  were  removed.  After  an  attack  of  erysipelas,  on 
February  17th,  she  gradually  sank  and  died  March  5tb.  The  lungs  pre- 
sented, only  one  or  two  puckered  spots  at  the  apices.  The  bronchial, 
retro-peritoneal,  and  mesenteric  glands  were  greatly  enlarged  and  caseous. 
No  intestinal,  uterine,  or  bone  disease.  The  continuous  high  fever  in 
this  case  depended  ap{)arently  upon  the  tuberculous  adenitis,  which  wis 
much  more  extensive  than  was  supposed  during  life.  In  these  instances 
the  enlargement  is  most  marked  in  the  retro  peritoneal,  bronchial,  and 
mesenteric  glands,  but  may  bo  also  present  in  the  groups  of  external 
glands.  Occurring  acutely,  it  presents  a  picture  resembling  Ilodgkin's 
disease.  In  a  case  which  died  in  the  Montreal  General  Hospital  this 
diagnosis  was  made.  The  cervical  and  axillary  glands  were  enormously 
enlarged,  and  death  was  caused  by  infiltration  of  the  larynx. 

2.  Local  Tuberculous  Adenitis. — (a)  Cervical. — This  is  the  most  com- 
mon form  met  with  in  children.     It  is  seen  particularly  among  the  \)oot 

*  Archives  generales,  1886. 


If  1 1  I  'i 


TunERcn.osis. 


2(»7 


ainl  tlioHc  who  livo  continuously  in  tlio  impure  atmosphcro  of  btidly  venti- 
l;iti(l  lotigiti;,'^.  Cliiidreii  in  foundliuj,'  liospitiils  luul  iisylums  uro  Hj)t'(!iully 
pnuK)  to  iho  (list'iisi!.  In  this  country  it  is  most  connnoti  in  thu  iu'<;ro 
nice.  As  ahvady  statod,  it  is  often  mot  vvitli  in  catarrh  of  tiio  nose  and 
tliinat,  or  chronic  enlargement  of  the  tonsils ;  or  the  ciiild  nuiy  have 
liad  e(!zcma  of  the  sculp  or  u  [)urulent  otitis. 

Tiio  sid)iiia.\illary  glands  are  lirst  invsilved,  and  are  popularly  spoken 
of  as  enlarged  {•eriicls.  They  are  usually  larger  on  one  sitle  than  on  the 
oilier.  As  they  increa.se  in  size,  the  individual  tumors  can  bo  felt;  the 
surface  is  smooth  and  the  consistence  tirm.  They  may  reimiin  isolated, 
hilt  more  coiiimoidy  they  form  large,  knotted  musses,  over  which  the 
hkiii  is,  as  a  rule,  freely  movable.  In  numy  cases  the  skin  ultimately  be- 
comes ailiiereut,  and  intlammation  and  suj)puration  occur.  An  abscess 
poiuts  and,  unless  o])eneil,  bursts,  leaving  u  sinus  which  heals  slowly. 
Tlio  disease  is  frequently  associated  with  coryza,  with  eczenuv  of  the  scalp, 
ear,  or  lips,  and  with  conjunctivitis  or  keratitis.  When  the  glands  arc 
largo  and  growing  actively,  there  is  fever.  The  subjects  are  usually  anie- 
iiiic,  particularly  if  suppuration  has  occurred.  The  })rogre.ss  of  this  form 
of  adenitis  is  slow  ami  tedious.  Death,  however,  rarely  follows,  and  many 
aggravated  cases  in  children  nltinnitely  get  well.  Not  only  the  submaxil- 
lary grouj),  but  the  glands  above  the  clavicle  and  in  the  posterior  cervical 
triangle,  may  be  involved.  In  other  instances  the  cervical  and  axillary 
glands  are  involved  together,  forming  a  continuous  chain  which  extends 
lieiieath  the  clavicle  and  the  pectoral  muscle.  With  them  the  bronchial 
glands  may  also  be  enlarged  and  caseous.  Not  infrequently  the  enlarge- 
ment of  the  supraclavicular  and  axillary  group  of  glands  on  one  side 
precedes  the  development  of  u  tuberculous  pleurisy  or  of  pulmonary 
tuberculosis. 

(h)  Jirnnrliial. — The   modiiistinal   lymph-glands  constitute  filters  in 
wliieli  ludgo  the  various  foreign  i)articles  which  escape  the  normal  phago- 
cytes of  bronchi  and  lungs.     Among  these  foreign  particles,  and  probably 
attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find  tuber- 
cles and  caseous  matter  Avitli  great  frequency  in  the  mediastinal  glands, 
pjuticularly  those  about  the  bronchi.     It  is  stated  that  this  process  is 
always  secondary  to  a  focus,  however  small,  in  the  lungs,  but  my  exj)cri- 
once  does  tujt  bear  out  such  a  statement.     As  already  mentioned,  North- 
nip  found  thorn  involved  in  every  one  of  a  hundred  and  twenty-seven 
fasos  at  the  New  York  Foundling  Hospital.     This  tuberculous  adenitis 
iiiiiy,  in  the  bronchial  glands,  attain  the  dimensions  of  a  tumor  of  large 
.*ize.    But  even  when  this  occurs  there  may  be  no  pressure  symptoms. 
In  children  the  bronchial  adenitis  is  apt  to  be  associated  with  suppuration. 
A  more  serious  danger  in  tuberculous  disease  of  the  bronchial  glands 
IS  sy>;teinic  infection,  which  takes  place  through  the  vessels.     Local  in- 
foction  of  the  lungs  may  also  occur.     In  the  tuberculous  broncho-pneu- 
monia of  children  it  is  usual  to  find  the  bronchial  glands  enormously  en- 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


1   M 


larged,  passing  deeply  into  the  hilus,  adjoining,  and  in  some  instuuces 
even  merging  with,  areas  of  caseation  of  the  pulmonary  tissue  itself. 

There  is  a  special  danger  of  infection  of  the  pericardium  by  tubercu- 
lous lymph-glands  in  the  anterior  mediastinum. 

(c)  Mesenteric  ;  Tabes  mesentcrica. — In  this  affection,  the  abdominal 
scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritonanim 
become  enlarged  and  caseate ;  more  rarely  they  suppurate  or  calcify.  A 
slight  tuberculous  adenitis  is  extr  mely  common  in  children,  and  is  often 
accidentally  found  (post  mortem)  when  the  children  have  died  of  other 
diseases.  It  may  be  a  primary  lesion  associated  with  intestinal  catarrh,  or 
it  may  be  secondary  to  tuberculous  disease  of  the  intestiiies. 

The  primary  cases  are  very  common  in  children,  as  may  be  gathercJ 
from  Woodhead's  figures.  The  general  involvement  of  the  glands  inter- 
feres seriously  with  nutrition,  and  the  patients  are  puny,  wasted,  and  aniv- 
mic.  The  abdomen  is  enlarged  and  tympanitic ;  diarrhcoa  is  a  constsnit 
feature ;  the  stools  are  thin  and  offensive.  There  is  moderate  fevoi-,  hut 
the  general  wasting  and  debility  are  the  most  characteristic  features.  1'lie 
enlarged  glands  cannot  often  be  felt,  owing  to  the  distended  condition  of 
the  bowels.  These  cases  are  often  spoken  of  as  consumption  of  the 
bowels,  but  in  a  majority  of  them  the  intestines  do  not  present  tuber- 
culous lesions.  In  a  considerable  number  of  the  cases  of  tabes  nicsen- 
terica  the  peritoneum  is  also  involved,  and  in  such  the  abdomen  is  large 
and  hard,  and  nodules  may  be  felt.  The  condition  is  one  to  which  the 
French  have  given  the  name  carreau. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  as  a 
primary  affection,  or  in  association  with  pulmonary  disease.  Gairdner* 
gives  a  remarkable  instance  of  tlie  kind  in  a  man  aged  twenty-one.  In- 
stances of  this  sort  are  not  uncommon  in  the  literature.  Large  tumors 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  any  other 
parts. 

The  diagnosis  of  local  and  general  tuberculous  adenitis  from  lyin- 
phiidenonui  will  be  subsequently  considered. 


IV.  Pulmonary  Tuuekculosis  {Phthisis,  Consumption). 

Three  clinical  groups  may  be  conveniently  recognized:  (1)  tubcrcnk- 
pneninonic phthisis — acute  phthisis;  {'Z)  chronic  ulcerative 2)hthisis ;  and 
{[i)  Jihroid  phthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  of 
lesions : 

(a)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels,  the 
primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in  the  capil- 
lary vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective-tissue 


*  Lectures  to  Practitioners,  Gairdner  and  Coats,  1888. 


TUBERCULOSIS. 


209 


framework  of  the  septa.  The  process  of  cell  division  proceeds  as  already 
described  in  the  general  histology  of  tubercle.  The  irritation  of  the 
bacilli  produces,  within  a  few  days,  the  small,  gray  miliary  nodules,  involv- 
iiitr  several  alveoli  and  consisting  largely  of  round,  cuboidal,  uninuclear 
cijitholioid  cells.  Depending  upon  the  number  of  bacilli  which  reach  the 
luiij(  in  this  way,  either  a  localized  or  a  general  tuberculosis  is  excited. 
The  tubercles  may  be  uniformly  scattered  througii  both  lungs  and  form 
a  part  of  a  general  miliary  tuberculosis,  or  they  may  be  confined  to  the 
lungs,  or  even  in  great  part  to  one  lung.  The  changes  which  the  tuber- 
cles undergo  have  already  been  referred  to.  The  further  changes  may  be : 
(1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the  tubercle, 
and  ultimately  complete  fibroid  transformation.  (2)  Caseation  of  the 
centre  of  the  tubercle,  extension  at  the  periphery  by  proliferation  of  the 
epitlu;Iioid  and  lymphoid  cells,  so  that  the  individual  tubercles  or  small 
groups  become  confluent  and  form  diffuse  areas  which  undergo  caseation 
and  softening.  (3)  Occasionally  as  a  result  of  intense  infection  of  a 
localized  region  through  the  blood-vessels  the  tubercles  are  thickly  set. 
The  intervening  tissue  becomes  acutely  inflamed,  the  air-cells  are  filled 
with  the  products  of  a  desquamative  pneumonia,  and  many  lobules  are 
involved. 

{b)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation 
tuberculosis — the  picture  differs.  The  smaller  bronchi  and  bronchioles 
are  more  extensively  affected  ;  the  process  is  not  confined  to  single  groups 
of  alveoli,  but  has  a  more  lobular  arrangement,  and  the  tuberculous  masses 
from  the  outset  are  larger,  more  diffuse,  and  may  in  some  cases  involve 
an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in  this  mode  of  infection 
that  we  see  the  characteristic  peri-bronchial  granulations  and  the  areas 
of  the  so-called  nodular  broncho-pneumonia.  These  broncho-pneumonic 
areas,  with  on  ihe  one  hand  caseation,  ulceration,  and  cavity  formation, 
ami  on  the  other  sclerosis  and  limitation,  make  up  the  essential  ele- 
ments in  the  anatomical  picture  of  tuberculous  phthisis. 

1.  Acute  Pneumonic  Phthisis. 

This  form,  known  also  by  the  name  of  gallo])ing  consumption,  is  met 
with  Ijoth  in  children  and  adults.  In  the  former  many  of  the  casos  are 
mistaken  for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  iho pneumonic  and  hroncho-])ncumonic. 

(")  In  the  pneumonic  farm  one  lobe  may  be  involved,  or  in  some  in- 
staiu'cs  an  entire  lung.  The  organ  is  heavy,  the  affected  portion  airless, 
the  [ili'iini  usually  covered  with  thin  exudation,  and  on  section  the  picture 
resemlilis  cl.isoly  that  of  ordinary  hepatization.  The  following  is  an  extract 
from  the  jiost-mortem  report  of  a  case  in  which  death  occurred  twenty-nine 
days  after  the  onset  of  the  illness,  having  all  the  characters  of  an  acute 
pneumonia :  "  Left  lung  weighs  1,500  grammes  (double  the  weight  of  the 


3S--  '■  m 


:i 


210 


SPECIFIC  INFECTIOUS  DISEASES. 


i:5M 


other  organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  mar- 
gins Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  about 
which  are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part 
of  the  lung  presents  a  grayish-white  appearance  due  to  the  aggregation 
of  tubercles  which  in  some  places  have  a  continuous,  uniform  appearance, 
in  others  are  surrounded  by  an  injected  and  consolidated  lung-tissue. 
Toward  the  margins  of  the  lower  lobe  strands  of  this  firm  reddish  tissue 
separate  ana'mic,  dry  areas.  There  are  in  the  right  lung  three  or  four 
small  groiTps  of  tubercles  but  no  caseous  masses.  The  bronchial  glands 
are  not  tuberculous."  Here  the  intense  local  infection  was  due  to  the 
small  focus  at  the  apex  of  the  lung,  probably  an  aspiration  process. 

Only  the  most  careful  inspection  may  reveal  the  presence  of  miliary 
tubercles,  or  tlio  attention  may  be  arrested  by  the  detection  of  tubercles  in 
the  other  lung  or  in  the  bronchial  glands.  The  process  may  involve  only 
one  lobe.  There  may  be  older  areas  which  are  of  a  peculiarly  yellowish- 
white  color  and  distinctly  caseous.  The  most  remarkable  picture  is  pre- 
sented by  cases  of  this  kind  in  which  the  disease  lasts  for  some  months. 
A  lobe  or  an  entire  lung  may  be  enlarged,  firm,  aiiless  throughout,  and 
converted  into  a  dry,  yellowish-white,  cheesy  substance.  Cases  are  met 
with  in  which  the  entire  lung  from  apex  to  base  is  in  this  condition,  with 
perhaps  only  a  small,  narrow  area  of  air-containing  tissue  on  the  margin. 
More  commonly,  if  tlie  case  has  lasted  for  two  or  three  months,  rapid 
softening  has  taken  place  at  the  apex.  The  following  brief  extract  gives 
the  actual  condition  of  the  lung  in  a  case  in  which  death  occurred  in  the 
eleventh  week :  "  Left  lung  is  solid  and  heavy,  weighing  1,490  grammes, 
and  is  nowhere  cro})itant.  Tlie  upper  third  of  the  upper  lobe  is  occuiiied 
by  a  cavity,  containing  blood  and  pus,  the  walls  of  which  are  formed  by 
ragged  caseous  masses.  ^Phe  rest  of  the  lung  is  firm  and  solid,  ami  on 
section  presents  a  uniform  opaque  white  color.  The  surface  is  dry,  and 
all  parts  present  the  same  cheesy  appearance." 

Symptoms. — The  attack  sots  in  abruptly  with  a  chill,  usually  in  an 
individual  who  has  enjoyed  good  health,  altiiough  in  many  cases  the  onset 
has  been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating 
circumstaiuH's.  The  temperature  rises  rapidly  after  the  chill,  theie  are 
pain  in  the  side,  and  cough,  with  at  first  mucoid,  subsequently  rusty- 
colored  expectoration.  The  dyspuwa  may  become  extreme  an<1  the 
patient  iiiay  have  suffocative  attacks.  Tlie  physical  examination  shows 
involvement  of  one  lobe  or  of  one  lung,  with  signs  of  consolidation,  diil- 
ness,  increased  fremitus,  at  first  feeble  or  suppressed  vc^sicular  murnuir, 
ami  subsequently  well-marked  bronchial  breathing.  The  upper  or  h)\ver 
lobe  may  be  involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  ininu  of  the  practitioner 
that  the  case  is  anything  but  one  of  frank  lobar  pneumonia.  Occasion- 
ally there  may  be  suspicious  circumstances  in  the  history  of  the  patient 
or  in  his  family;  but,  as  a  rule,  no  stress  is  laid  upon  them  in  comparison 


!'f 


TUBERCULOSIS. 


211 


witli  the  intense  and  characteristic  mode  of  onset.  Between  the  eighth 
ami  tenth  day,  instead  of  tlie  expected  crisis,  the  condition  becomes 
a<Tt'iavated,  the  temperature  is  irregular,  and  the  pulse  more  rapid. 
TluTo  may  be  sweating,  and  the  expectoration  becomes  muco-purulent. 
Kvtii  in  the  second  or  third  week,  with  the  persistence  of  these  symptoms, 
the  physician  tries  to  console  himself  with  the  idea  that  the  case  is  one  of 
unresolved  pneumonia,  and  that  all  will  yet  be  well.  Gradually,  however, 
the  severity  of  the  symptoms,  ilio  presence  of  physical  signs  indicating 
softening,  the  existence  of  elastic  tissue  and  tubercle  bacilli  in  the  sputa 
jjixvseiit  the  mournful  propfs  that  the  case  is  one  of  acute  pneumonic 
phthisis.  Death  may  occur  before  softening  takes  place,  even  in  the 
second  or  third  week.  In  other  cases  there  is  extensive  destruction  at 
the  apex,  with  rapid  formation  of  cavity,  and  the  case  may  drag  on  for 
two  or  three  months. 

Diagnosis. — It  is  by  no  means  widely  recognized  in  the  profession 
that  there  is  a  form  of  ac\ite  phthisis  which  may  closely  simulate  ordinary,^ 
pi  eiui'onia.  Waters,  of  Liverpool,  gave  an  admirable  description  of  these 
■usi  ,  ^•^  called  attention  to  the  difficulty  in  distinguishing  them  from 
M'cLi.i.}  pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion 
whatever.  A  healthy,  robust-looking  young  Irishman,  a  cab-driver,  who 
had  bci'U  kept  Avaiting  on  a  cold,  blustering  night  until  three  in  the  morn- 
ing, was  seized  the  next  afternoon  with  a  violent  chill,  and  the  following 
day  was  admitted  to  my  wards  at  the  University  Hospital,  Philadelphia. 
He  was  made  the  subject  of  a  clinical  lecture  on  the  fifth  day,  when  there 
was  absent  no  single  feature  in  history,  symptoms,  or  physical  signs  of 
arute  lobar  pneumonia  of  the  right  upper  lobe.  It  was  not  until  ten  days 
later,  when  bacilli  were  found  in  his  expectoratioii.  that  we  were  made 
aware  of  tlie  true  nature  of  the  case.  I  know  of  no  criterion  by  which 
eases  of  this  kind  can  be  distinguished  in  the  early  stage.  The  tubercle 
i)a(illi  arc  not  present  at  first.  A  i)oint  to  which  Traube  called  attention, 
ami  wliieh  is  luiv  referred  to  as  important  by  Ilerard  and  Cornil,  is  the 
absence  of  I  -  >'''  fi-n.ids  in  the  consolidated  region;  but  this,  I  am  sure, 
does  not  b  .1  :  'Ci  'i  all  cases.  The  tubular  breathing  may  be  intense 
and  marked  as  cw'y  as  the  fourth  day;  and  again,  l»ow  common  it  is  to 
liavc,  as  one  of  the  K-aniest  and  most  suggestive  symptoms  of  lobar  pneu- 
monia, suppression  or  enfeebleracnt  of  the  vesicular  murmur !  In  many 
eases,  h  ,wever,  there  are  =iis]iiciou8  circumstances  in  the  onset;  the  pa- 
tient has  been  in  bad  healLii,or  may  have  had  previous  pulmonary  trouble, 
or  there  are  recurring  chills.  Careful  examination  of  the  sputa  and  a 
study  of  the  physical  signs  from  day  to  day  can  alone  determine  the  true 
nature  of  'be  case.  A  point  of  some  moment  is  the  character  of  the  fever, 
pneumonia  is  more  continuous,  particularly  in  severe  cases, 
■s  'oira  of  tuberculosis  remissions  of  1"5°  or  2°  are  not  in- 


w'.iirli  j; 


whereas  n, 
frpquenl. 

(/')  Arute  tnbei'culous  broiiclio-juicitnwiiia  is  more  common,  particu 


i-; 


i  ^^:■»■ 


\ 

1 

1 
i] 

•S'' 

1 

1- 

« 

m: 

■^ 

■  r  ' 

' 

■ 

4  -"- 

f   ■ 

1 

t 

f 

«t:-  ■ 

212 


SPECIFIC  INFECTIOUS  DISEASES. 


larly  in  children,  and  forms  a  majority  of  the  cases  of  pMhisis  florida  or 
"galloping  consumption."  It  is  an  acute  caseous  broncho-pneumoiiiti, 
starting  in  the  snialler  tubes,  which  become  blocked  with  a  cheesy  sub- 
stance, while  the  air-cells  of  the  lobule  are  filled  with  the  products  of  a 
catarrhal  pneumonia.  In  the  early  stage  the  areas  have  a  grayish-red,  later 
an  opaque-white,  caseous  appearance.  By  the  fusion  of  contiguous  masses 
an  entire  lobe  may  be  rendered  nearly  solid,  but  there  can  usually  be  seen 
between  the  groups  areas  of  crepitant  air  tissue.  This  is  not  an  uncom- 
mon picture  in  the  acute  phthisis  of  adults,  but  it  is  still  more  frequent  in 
children.  The  following  is  an  extract  from  the  post-mortem  of  a  case  on 
a  child  aged  four  months,  which  died  in  the  sixth  week  of  illness :  "  The 
upper  lobe  of  the  right  lung  is  scarcely  anywhere  crepitant  except  at  tlie 
anterior  edge.  The  middle  and  lower  lobes  are  heavy  and  slightly  crepi- 
tant; the  visceral  pleura  is  beset  with  tubercles  which  have  grown  into  it 
from  the  lung.  On  section  the  right  upper  lobe  is  occupied  with  caseous 
masses  from  five  to  twelve  i.  ,''  •*  es  in  diameter,  separated  from  each 
other  by  an  intervening  tissue  o  ep-red  color.     The  bronchi  are  filled 

with  cheesy  substance  The  midd^.  and  lower  lobes  are  stuffed  with  tuber- 
cles, many  of  which  are  becoming  caseous.  Toward  the  diaphragnuitic  sur- 
face of  the  lower  lobe  there  is  a  small  cavity,  the  size  of  a  marble.  The  left 
lung  is  more  crepitant  and  uniformly  studded  with  tubercles  of  all  sizes, 
some  as  large  as  peas.  There  is  an  acute  tuberculous  bronchitis  in  the 
smaller  and  larger  branches,  and  extending  into  the  trachea.  The  bron- 
chial glands  are  very  large,  and  one  contains  a  tuberculous  abscess." 

In  children  the  enlarged  bronchial  glands  usually  surround  the  root  of 
the  lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are 
often  involved  by  direct  contact.* 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both  a}U(;es, 
forming  areas  from  one  to  three  centimetres  in  diameter.  The  size  of  the 
mass  depends  largely  upon  that  of  the  bronchus  involved.  There  are  cases 
wliich  probably  should  come  in  this  category,  in  which,  with  a  history  of 
an  acute  illness  of  from  four  to  eight  weeks,  the  lungs  are  extensively  stud- 
ded with  large  gray  tubercles,  ranging  in  size  from  five  to  ten  millimetres. 
In  some  instances  there  are  cheesy  masses  the  size  of  a  cherry.  All  of 
these  are  grayish-white  in  color,  distinctly  cheesy,  and  between  the  adja- 
cent ones,  particularly  in  the  lower  lobe,  there  may  be  recent  pneumonia, 
or  the  condition  of  lung  which  has  been  termed  splenization.  In  a  case  of 
this  kind  at  the  Philadelphia  Hospital  death  took  place  about  the  ei,;:lith 
week  from  the  abrupt  onset  of  the  illness  with  haemorrhage.  There  were 
no  extensive  areas  of  consolidation,  but  the  cheesy  nodules  were  uniformly 
scattered  throughout  both  lungs.     No  softening  had  taken  place. 


*  Vide  the  dniwings  illustrating  Northrup's  article;  New  York  Medical  Jourual, 
February  21,  1«91. 


TUBERCULOSIS. 


213 


Symptoms. — The  symptoms  of  acuto  broncho-pneumonic  phthisio 
are  very  variable.  In  adults  the  disease  may  attack  persons  in  good  health, 
but  wiin  are  overworked  or  "  run  down  "  from  any  cause.  Iliemorrhage 
initiates  the  attack  in  a  few  cases.  There  maybe  repeated  chills;  the 
temperature  is  high,  the  i)ulse  raj)id,  and  the  respirations  are  increased. 
The  loss  of  flesh  and  strength  is  very  striking. 

Tlie  physical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  impaired  resonance,  usually  at  the  apices ;  the  breath- 
souiuls  arc  harsh  and  tubular,  with  numerous  riiles.  The  sputa  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  patient  may  be  in  a  marked  typhoid  state,  with  delirium,  dry 
tongue,  and  high  fever.  Death  may  occur  within  three  weeks.  In  other 
cases  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  and  strength, 
and  signs  of  extensive  unilateral  or  bilateral  disease.  Softening  takes 
place;  there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the 
features  of  phthisis  Jiorida.  Six  or  eight  weeks  or  later  the  patient  may 
begin  to  improve,  the  fever  lessens,  the  general  symptoms  mitigate,  and  a 
case  Avhicli  looked  as  if  it  would  certainly  terminate  fatally  within  a  few 
weeks  drags  on  and  becomes  chronic. 

In  children  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping-cough.*  The  profession  is  gradually 
recognizing  the  fact  that  a  majority  of  all  such  cases  are  tuberculous. 
At  least  three  groups  of  these  cases  of  tuberculous  broncho-pneumonia 
may  he  recognized.  In  the  Jirsi  the  child  is  taken  ill  suddenly  while 
teething  or  during  convalescence  from  fever;  the  temperature  rises  rapidly, 
the  cough  is  severe,  and  there  may  be  signs  of  consolidation  at  one  or  both 
apices  with  rales.  Death  may  occur  within  a  few  days,  and  the  lung  shows 
areas  of  broncho-pneumonia,  '.vith  perhaps  here  and  there  scattered  opaque 
grayish-yellow  nodules.  Macroscopically  the  affection  does  not  look  tuber- 
culous, but  histologically  miliary  granulations  and  bacilli  may  be  found. f 
Tuliercles  are  usually  present  in  the  bronchial  glands,  but  the  appearance 
of  the  broncho-pneumonia  may  be  exceedingly  deceptive,  and  it  may  re- 
quire careful  microscopical  examination  to  determine  its  tuberculous  char- 
acter. The  second  group  is  represented  by  the  case  of  the  child  previously 
quoted,  which  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
broncho-])neumonia.  And  the  third  (jronp  is  that  in  which,  during  the 
eonvaleseence  from  an  infectious  disease,  the  child  is  taken  ill  with  fever, 
cough,  and  shortness  of  breath.  The  severity  of  the  symptoms  miti- 
gates witliiii  the  first  fortnight;  but  there  is  loss  of  flesh,  the  general 
condition  is  bad,  and  the  physical  examination  shows  the  presence  of 
scattered  rales  throughout  the  lungs,  and  here  and  there  areas  of  de- 
fective resonance.     The  child  has  sweats,  the  fever  becomes  hectic  in 


*  "Tussis  convulsiva  vestibuhnn  tabis"  (Willis), 
f  Coriiil  and  Babes,  Les  Bacteries,  tome  ii,  1890. 


214 


SPECIFIC  INFECTIOUS  DISEASES. 


«!<- 


character,   and  in   many  cases  the  clinical  picture  gradually  dovelopa 
into  that  of  chronic  phthisis. 

2.  Chronic  Ulcerative  Phthisis. 

Under  this  heading  may  be  grouped  the  great  majority  of  cases  of  pul- 
monary tuberculosis,  in  which  the  lesions  proceed  to  ulceration  and  soften- 
ing, and  ultimately  produce  the  well-known  picture  of  chronic  phthisis. 
At  first  a  strictly  tuberculous  affection,  it  ultimately  becomes,  in  a  majority 
of  cases,  a  mixed  disease,  many  of  the  most  prominent  symptoms  of  whicii 
are  due  to  septic  infection  from  purulent  foci  and  cavities. 

Morbid  Anatomy. — Inspection  of  the  lungs  in  a  case  of  clironic 
phthisis  shows  a  remarkable  variety  of  lesions,  comprising  nodular  ttibcr- 
cles,  diffuse  tuberculous  infiltration,  caseous  masses,  pneumonic  areas, 
cavities  of  various  size,  with  changes  in  the  pleura,  bronchi,  and  broncliial 
glands. 

1.  The  Distribution  of  the  Lesions.— For  years  it  has  been  recognized 
that  the  most  advaiu-ed  lesions  are  at  the  apices,  and  that  the  disease 
progresses  downward,  usually  more  rapidly  in  one  of  the  lungs.  Tiiis 
general  statement,  which  has  passed  current  in  the  text-books  ever  since 
the  masterly  description  of  Laennec,  has  recently  been  carefully  elabo- 
rated by  Kingston  Fowler,  who  finds  that  the  disease  in  its  onward  pro- 
gress through  the  luTigs  follows,  in  a  majority  of  the  cases,  distinct  routes. 
In  the  upper  lobe  the  primary  lesion  is  not,  as  a  rule,  at  the  extreme 
apex,  but  from  an  inch  to  an  inch  and  a  half  below  the  summit  of  the 
lung,  and  nearer  to  the  posterior  and  external  borders.  The  lesion  liere 
tends  to  spread  downward,  probably  from  inhalation  of  the  virus,  and 
this  accounts  for  the  frequent  r/'rcumstance  that  examination  behind,  in 
the  supraspinus  fossa,  will  give  indications  of  disease  before  any  evidences 
exist  at  the  apex  in  front.  Anteriorly  this  initial  focus  corresponds  to  a 
spot  just  below  the  centre  of  the  clavicle,  and  the  direction  of  extension 
in  front  is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line  run- 
ning about  an  inch  and  a  half  from  the  inner  ends  of  the  first,  second, 
and  third  interspaces.  A  second  less  common  site  of  the  primary  lesion 
in  the  apex  "corresponds  on  the  chest  wall  with  the  first  and  second 
interspaces  below  the  outer  third  of  the  clavicle."  The  extension  is  down- 
ward, so  that  the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  the 
upper  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe  the 
first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  l)elo\v 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest 
importance  clinically,  as  "  in  the  great  majority  of  cases,  when  the  j)hysi- 
cal  signs  of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  tlie 
diagnosia  of  phthisis  being  made,  the  lower  lobe  is  already  affected."    £x- 


U'.J       *« 


TUBERCULOSIS. 


215 


limitation,  therefore,  should  be  mude  carefully  of  this  posterior  apex  in 
Jill  suspicious  cases.  In  this  situation  the  lesion  spreads  downward  and 
hilenilly  along  the  line  of  the  interlobular  septa,  a  line  which  is  marked 
l)y  the  vertubral  border  of  the  scapula,  when  the  hand  is  placed  on  the 
o[)posite  scapula  and  the  elbow  raised  above  the  level  of  the  shoulder. 
Once  present  in  an  apex,  the  disease  usually  extends  in  time  to  the  oppo- 
site upper  lobe ;  but  not,  as  a  rule,  until  the  apex  of  the  lower  lobe  of  the 
lung  first  affected  has  been  attacked. 

Of  427  cases  above  mentioned,  the  right  apex  was  involved  in  173,  tho 
left  in  130,  both  in  111. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy  Kidd 
makes  the  proportion  of  basic  to  apicic  phthisis  one  to  five  hundred,  a 
smaller  number  than  existed  in  my  series.  In  very  chronic  cases  there 
may  be  arrested  lesions  at  the  apex  and  more  recent  lesions  at  the  base. 

2.  Summary  of  the  Lesions  in  Chronic  Ulcerative  Phthisis.— (^f)  Mili- 
ary Tubercles, — These  may  not  be  evident  on  microscopical  examination, 
or  there  may  be  a  few  colonies,  "  the  secondary  crop  "  of  Laennec,  about 
the  caseous  areas.  In  other  instances,  with  old  lesions  at  the  apex,  there 
lire,  throughout  the  lower  lobes,  scattered  groups  of  miliary  tubercles 
which  luive  undergone  fibroid  and  pigmentary  changes.  Sometimes,  in 
ciisi'S  with  cavity  formation  at  the  apex,  the  greater  part  of  the  lower  lobes 
present  many  groups  of  firm,  sclerotic,  miliary  tubercles,  which  may  in- 
deed form  the  distinguishing  anatomical  feature — a  chronic  miliary  tuber- 
culosis. 

{())  Tuberculous  Broncho-pneuvionia. — In  a  large  proportion  of  the 
cases  of  chronic  phthisis  the  terminal  bronchiole  is  the  point  of  origin  of 
the  process,  consequently  we  find  the  smaller  bronchi  and  their  alveolar 
territories  blocked  with  the  accumulated  products  of  inflammation  in  all 
stages  of  caseation.  At  an  early  period  a  cross-section  of  an  area  of  tuber- 
culous broncho-pneumonia  gives  the  most  characteristic  appearance.  The 
central  bronchiole  is  seen  as  a  small  orifice,  or  it  is  plugged  witii  cheesy  con- 
tents, while  surrounding  it  is  a  caseous  nodule,  the  so-called  peribronchial 
tuherele.  The  longitudinal  section  has  a  somewhat  dendritic  or  foliaceous 
appearance.  The  condition  of  the  picture  depends  much  upon  the  slow- 
ness or  rapidity  with  which  the  process  has  advanced.  The  following 
changes  may  occur  : 

Ukcrafion.  —  When  the  caseation  takes  place  rapidly  or  ulceration 
occurs  in  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small 
cavity. 

SrJerosis. — In  other  instances  the  process  is  more  chronic.  Fibroid 
changes  gradually  produce  a  sclerosis  of  the  aifccted  area,  a  condition 
«hich  is  sometimes  called  cirvJiosis  nodosa  tuberculosa.  The  sclei'osis  may 
be  couliiied  to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within 
which  is  a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
Jepositod.  This  represents  the  healing  of  one  of  these  areas  of  caseous 
15     . 


in 


216 


SPECIFIC  INFECTIOUS  DISEASES. 


broncho-pneumonia.  It  is  only,  liowever,  when  ooinplete  fibroid  trans- 
formation or  calcification  has  occurred  that  we  can  really  speak  of  healing. 
In  many  instances  the  colonies  of  miliary  tubercles  about  these  musses 
show  that  the  virus  is  still  active  in  them.  Subsequently,  in  ulcerative 
processes,  these  calcareous  bodies  —  lung-stones,  as  they  are  sometinu's 
called — may  be  expectorated. 

(6-)  Pneumonia. — An  important  though  secondary  place  is  occupied 
by  inflammation  of  the  alveoli  surrounding  tlie  tubercles,  which  become 
filled  with  epithelioid  cells.  The  consolidation  may  extend  for  some  dis- 
tance about  the  tuberculous  foci  and  unite  them  into  areas  of  uniform  con- 
solidation. Although  in  some  instances  this  inflammatory  process  may  be 
simple,  in  others  it  is  undoubtedly  specific.  It  is  excited  by  the  tubercle 
bacilli  aiul  is  a  manifestation  of  their  action.  It  may  present  a  very  varied 
appearance;  in  some  instances  resembling  closely  ordinary  red  heptitiza- 
tion,  in  others  more  homogeneous  and  infiltrated,  the  so-called  infiltral'mii 
tubercuh'use  of  Laennec.  In  other  cases  the  contents  of  the  alveoli  un- 
dergo fatty  degeneration,  and  appear  on  the  cut  surface  as  opaque  white 
or  yellowish-white  bodies.  In  early  phthisis  much  of  the  consolidation  i^ 
due  to  this  pneumonic  infiltration,  which  may  surround  for  some  distance 
the  smaller  tuberculous  foci. 

{d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by 
necrosis  and  ulceration.  It  differs  materially  from  the  bronchioctatic 
form.  The  process  usually  begins  in  the  wall  of  the  bronchus  in  a  tuljer- 
culous  area.  Dilatation  is  produced  by  retained  secretion,  and  necro.sis  and 
ulceration  of  the  wall  occur  with  gradual  destruction  of  the  contiguous 
tissues.  By  extension  of  the  necrosis  and  ulceration  the  cavity  increa.ses, 
contiguous  ones  unite,  and  in  an  affected  region  there  may  be  a  series  of 
small  excavations  communicating  with  a  bronchus.  In  nearly  all  instances 
the  process  extends  from  the  bronchi,  though  it  is  possible  for  necrosis 
and  softening  to  take  place  in  the  centre  of  a  caseous  area  without  pri- 
mary involvement  of  the  bronchial  wall.  Three  forms  of  cavities  may  be 
recognized : 

The  fresh  ulcerative,  seen  in  acute  phthisis,  in  which  there  is  no 
limiting  membrane,  but  the  walls  are  made  up  of  softened,  necrotic,  and 
caseous  masses.  Small  vomicas  of  this  sort,  situated  just  beneath  the 
pleura,  may  rupture  and  cause  pneumothorax.  In  cases  of  acute  tuber- 
culo-pneumonic  phthisis  they  may  be  large,  occupying  the  greater  portion 
of  the  upper  lobe.  In  the  chronic  ulcerative  phthisis,  cavities  of  this  sort 
are  invariably  present  in  those  portions  of  the  lung  in  which  the  disease  is 
advancing.  At  the  apex  there  may  be  a  large  old  cavity  with  well-defined 
walls,  while  at  the  anterior  margin  of  the  upper  lobes,  or  in  the  apices  of 
the  lower  lobe,  there  are  recent  ulcerating  cavities  communicating  with 
the  bronchi. 

Cavities  with  well-defined  walls. — A  majority  of  the  cavities  in  the 
chronic  form  of  phthisis  have  a  well-defined  limiting  membrane,  the 


TUBERCULOSIS. 


217 


iniK^r  surface  of  which  constantly  produces  pus.  The  walls  are  crossed 
liv  tniliecuhe  which  represent  remnants  of  bronchi  and  blood-vessels. 
hvi'ii  tiie  vomica}  with  the  well-defined  walls  extend  gradually  by  a  slow 
necrosis  and  destruction  of  the  contiguous  lung  tissue.  The  contents  are 
usually  purulent,  similar  in  cliaracter  to  tiie  grayish  numnnilar  sjtuta 
(Miii,i,du'd  up  by  phthisical  patients.  Not  infrequently  the  membrane  is 
viisLiilar  or  it  nuiy  be  luemorrhagic.  Occasionally,  when  gangrene  has 
OLinirrcd  in  tlie  wall,  the  contents  are  horribly  foetid.  These  cavities  may 
occupy  the  greater  portion  of  the  a])ex,  forming  an  irregular  series  which 
eomniunicate  with  each  other  and  with  the  bronchi,  or  the  entire  upper 
lobe  except  the  anterior  margin  may  be  excavated,  forming  a  thin-walled 
cavity.  In  rare  instances  the  process  has  proceeded  to  total  excavation  of 
the  lung,  not  a  remnant  of  which  remains,  except  perhaps  a  narrow  strip 
at  the  anterior  margin.  In  a  case  of  this  kind,  in  a  young  girl,  the  cavity 
held  forty  iluidouuces. 

(Jiiic.sceni  Cavities. — When  quite  small  and  surrounded  by  dense  cica- 
tricial tissue  communicating  with  the  bronchi  'ney  form  the  cicatrices 
Jistiikuses  of  Laennec.  Occasionally  one  ai)ex  may  be  represented  by  a 
series  of  these  small  cavities,  surrounded  by  c  onse  fibrous  tissue.  The 
lining  membrane  of  these  old  cavities  may  be  quite  smooth,  almost  like 
a  nuK.'ous  membrane.     Cavities  of  any  size  do  not  heal  completely. 

Cases  are  often  seen  in  which  it  has  been  supr)osed  that  a  cavity  has 
healed;  but  the  signs  of  excavation  are  notoriously  uncertain,  and  there 
niiiy  be  pectoriloquy  and  cavernous  sounds  witii  gurgling,  resonant  rslles 
ill  an  area  of  consolidation  close  to  a  large  bronchus. 

In  the  formation  of  vomicae  the  blood-vessels  gradually  become  closed 
by  an  obliterating  inflammation.  They  are  the  last  structures  to  yield 
iuid  may  be  completely  exposed  in  a  cavity,  even  when  the  circulation  is 
still  jjfoing  on  in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which 
liiis  not  yet  been  obliterated  is  by  no  means  infrequent,  and  causes  profuse 
and  often  fatal  haemorrhage.  Another  common  event  is  the  development 
of  aneurisms  on  the  arteries  running  in  the  walls  of  cavities.  These  may 
be  small,  bunch-like  dilatations,  or  they  may  form  cavities  the  size  of  a 
wiilnut  or  even  larger.  Ra?mussen,  Douglas  Powell  and  others  have 
called  attention  to  their  importance  in  haemoptysis,  under  which  section 
they  are  dealt  with  more  fully. 

And  finally,  about  cavities  of  all  sorts,  the  connective  tissue  develops 
ami  tends  to  limit  the  extent.  The  thickening  is  particularly  marked 
lieneath  the  pleura,  and  in  chronic  cases  an  entire  apex  may  be  converted 
into  a  mass  of  fibrous  tissue,  enclosing  a  few  small  cavities. 

(<')  Pleura. — Practically,  in  all  cases  of  chronic  phthisis  the  pleura  is 
involved.  Adhesions  take  place  which  may  be  thin  and  readily  torn,  or 
'lense  and  firm,  uniting  layers  of  from  two  to  five  millimetres  in  thickness. 
Hiis  pleurisy  may  be  simple,  but  in  many  cases  it  is  tuberculous,  and  mili- 
ary tubercles  or  caseons  masses  are  seen  in  the  thickened  pleural  mem- 


l|'!,i' 


;» 


218 


SPECIFIC   INFECTIOUS  DISEASES. 


brane.     Pleural  effusion  is  not  at  all  infrequent,  either  serous,  purulent, 
or  haemorrhagic.     Pneumothorax  is  a  common  accident. 

(/)  Changes  in  the  smaller  bronchi  control  the  situation  in  the  oaily 
stages  of  tub(!rculous  phthisis,  and  play  an  important  role  throughout  tlio 
disease.  The  process  very  often  begins  in  the  walls  of  the  smaller  tultcs 
and  leads  to  caseation,  distention  with  products  of  intlammation,  and 
broncho-pneumonia  of  the  lobules.  In  many  cases  the  visible  implication 
of  the  bronchus  is  an  extension  upward  of  a  process  which  has  begun  in 
the  smallest  bronchiole.  'J'his  involvement  weakens  the  wall,  leading  to 
bronchiectasis,  not  an  uncommon  event  in  phthisis.  The  mucous  mem- 
brane of  the  larger  bronchi,  which  is  usually  involved  in  a  chronic  catarrh, 
is  more  or  less  swollen,  and  in  some  instances  ulcerated. 

{(j)  The  bronchial  glands,  in  the  more  acute  cases,  are  swollen  and 
cedematous.  Miliary  tubercles  and  caseous  foci  are  usually  present.  In 
cases  of  chronic  phthisis  the  cjiseous  areas  are  common,  calcification  may 
occur,  and  not  infrequently  purulent  softening. 

(A)  C'ha)if/cs  in  the  other  Orffctns. — Of  these,  tuberculosis  is  the  most 
common.  In  my  series  of  autopsies  the  brain  presented  tuberculous 
lesions  in  31,  the  spleen  in  33,  the  liver  in  12,  the  kidneys  in  33,  the  intes- 
tines in  G5,  and  the  perica'"dium  in  7.  Otlior  groups  of  lymphatic  glands 
besides  the  bronchial  may  be  affected— -the  cervical,  the  mediastinal,  and 
the  retro-peritoneal. 

Certain  degenerations  nre  com;non.  Amyloid  change  is  frequent  in 
the  liver,  spleen^  kidneys,  and  mucous  membrf.ne  of  the  intestines.  Tho 
liver  is  often  tl  3  seat  of  extensive  fatty  infiltration,  which  may  cause 
marked  enlargen.ont.  The  intestinal  t.iberculosis _  occurs  in  ad'Mncod 
oases  and  is  responsible  in  great  part  for  the  troublesome  diarrhoea. 

Endocarditis  is  not  very  uncommon,  and  was  present  in  13  of  my 
post-mortems  and  in  27  of  Percy  Kidd's  500  cases.  Tubercles  may  be 
present  on  the  endocardium,  particularly  of  the  right  ventricle.  As 
pointed  out  by  Norman  Chevers  and  confirmed  by  subsequent  writers,  tlie 
subjects  of  congenital  stenosis  of  the  pulmonary  orifice  very  frequently 
have  phthisis. 

The  larynx  is  frequently  involved,  and  ulceration  of  the  vocal  cords 
and  destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset. — We  have  already  seen  that  tuberculosis  of  tlie 
lungs  may  occur  as  the  chief  part  of  a  general  infection,  or  may  set  in 
with  symptoms  which  closely  simulate  acute  pneumonia.  In  the  onlinary 
type  of  pulmonary  tuberculosis  the  invasion  is  gradual  and  less  striking, 
but  presents  an  extraordinarily  diverse  picture,  so  that  the  practitioner  is 
often  led  into  error.  Among  the  most  characteristic  of  these  types  of  on- 
set are  the  following :  (a)  With  dyspeptic  and  anceniic  symptoms,  forming 
a  large  and  important  group.  The  patients  may  naturally  have  had  feeble 
digestion.  They  begin  to  show  marked  signs  of  dyspepsia  and  become 
pale,  lose  flesh,  and  look  chlorotic  before  any  pulmonary  symptoms  are 


TUBKKCUr.OSIS. 


210 


nlllIli^^^t.  {/>)  With  chills  (tnd  fvrvr.  This  mode  of  onset  is  particuliirlv 
iiii|ii)rtiiiit  in  jnalariiil  regions,  ji.s  tiio  diiignosiH  of  ordinary  intermittent 
fever  is  often  made,  and  the  nature  of  the  disease  entirely  overlooked. 
ill  l'hil!i(k'lj)hia  it  was  very  common  to  have  patients  sent  to  hospital 
Slip,  Dsi'd  to  be  sutTcring  with  malaria,  who  had  well-developed  signs  of 
|)iihnnnary  tuberculosis,  {r)  Hronchilit'.  on^d.  These  are  the  instances 
wliicli  arise  in  what  the  patient  calls  a  neglected  cold.  The  patient  has 
pcrliaps  been  subject  to  naso-pharyngeal  catarrh,  and  has  been  liable  to 
take  cold  readily;  then  a  bronchial  cough  develops,  which  j)roves  intrac- 
tiililc.  Sometimes  the  bronchitic  symptoms  are  associated  with  wheezing, 
like  mild  asthma.  The  development  in  these  instances  may  be  extremely 
iiisiilious  and,  without  any  special  aggravation  of  the  general  symptoms 
or  iiH^rease  in  the  fever,  the  tuberculous  nature  of  the  trouble  may  bo 
(liscoverotl  accidentally  by  the  examination  of  the  sputum,  [d)  Onset 
ici/h  hii'iiiopti/sis.  The  relation  of  haemoptysis  to  pulmomiry  tuberculosis 
will  be  discussed  elsewhere.  The  lutmopfysis  nuiy  come  on  ir;  a  con- 
dition of  robust  health,  and  it  occasionally,  though  rarely,  happens  that 
tlic  pulmonary  symptoms  follow  rapidly.  In  other  cases  a  long  interval 
olapscs.  Undoubtedly  these  are  cases  in  which  there  has  been  a  small 
localized  lesion  in  the  lung  which  has  not  produced  cori'-^itutional  dis- 
turbance, (e)  Pleuritic  onset.  This  may  be  a  dry  pleurisy,  developing  at 
the  apex  or  in  a  sca])ular  region,  or  in  some  instances  extending  generally. 
It  may  be  acute  pleurisy  with  etfusion,  or  the  elfusion  may  have  come  on 
iusiiliously  without  any  acute  manifestations.  Phthisis  develojied  in  a 
third  of  ninety  cases  of  pleurisy  with  effusion,  the  subsequent  history  of 
which  was  followed  by  Bowditch.  (/)  With  laryiiijefd  synqjtonis.  In  rare 
instances  huskiness  and  loss  of  voice  are  the  symptoms  for  which  the  j)a- 
ticnt  seeks  advice,  and  the  epiglottis  or  cords  may  be  involved  in  a  well- 
cliaractorized  tuberculosis  before  the  physical  signs  in  the  lungs  are  at  all 
cloar.  It  is  in  these  instances  that  the  examination  of  the  sputa  is  of  the 
greatest  value. 

These  rei)resent  the  nsual  modes  of  onset  of  the  ordinary  chronic 
phtliisis.  It  occasionally  happens  that  in  an  instance  with  an  acute  ]meu- 
nioiiic  onset  the  severity  of  the  symptoms  subsides,  and,  instead  of  termi- 
nating as  a  majority  of  these  cases  do  within  ten  or  twelve  weeks,  the  case 
draufs  on  and  becomes  chronic. 

Symptoms. — In  discussing  the  symptoms  it  is  usual  to  divide  the 
tliscaso  into  three  periods :  the  first  embracing  the  time  of  the  growth  and 
•ipvclopinent  of  the  tubercles ;  the  second,  in  which  they  soften ;  and  the 
third,  in  which  there  is  a  formation  of  cavities.  Unfortunately,  these  ana- 
tomioal  stages  can  not  be  satisfactorily  correlated  with  corresponding  clini- 
«'al  poiiods,  and  we  often  find  that  a  patient  in  the  third  stage  with  well- 
marked  cavity  is  in  a  far  better  condition  and  has  greater  prospects  of  re- 
covery than  a  patient  in  the  first  stage  with  diffuse  consolidation.  It  is 
therefore  better  perhaps  to  disregard  them  altogether. 


m 


I  :!i 


fi; 


220 


SPRCIFr   INFECTIOUS   DISEASES. 


1.  Local  Symptoms. — Pain  in  the  choHt  may  bo  curly  and  troublesonio 
or  absent  throughout.  It  is  u.snully  asHociuted  witli  pleurisy,  nnd  may  lio 
sharp  and  stabbing  in  character,  and  either  constant  or  felt  only  during' 
coughing.  Perhaps  the  commonest  situation  is  in  the  lower  thorai  ic 
zone,  though  in  some  instances  it  is  beneath  the  8(!ai)ida  or  referred  to  tho 
apex.  The  attacks  may  recur  at  long  intervals.  Intercostal  neuralgia 
occasionally  develops  in  tho  course  of  ordinary  phthisis. 

Cough  is  one  of  the  earliest  symptoms,  and  is  present  in  the  majority 
of  cases  from  beginning  to  end.  There  is  nothing  peculiar  or  distinctive 
about  it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the 
attention  of  tlio  ])atient,  it  subsequently  becomes  looser,  more  constant, 
and  associated  with  a  glairy,  muco-purulcnt  expectoration.  In  tho  curly 
stages  of  tho  disease  tho  cough  is  bronchial  in  its  origin.  When  cavities 
have  formed  it  becomes  more  paroxysmal,  and  is  most  marked  in  the 
morning  or  after  a  sleep.  Cough  is  not  a  constant  symptom,  however, 
and  a  patient  may  present  himself  with  well-n»arked  excavation  at  one 
apex  who  will  declare  that  he  has  had  little  or  no  cough.  So,  too,  there 
may  be  well-marked  physical  signs,  dulness  and  moist  sounds,  without 
either  expectoration  or  cough.  In  well-established  cases  the  nocturnal 
paroxysms  are  most  distressing  and  j)rcvent  sleep.  Tho  cough  nuiy  be  of 
such  persistence  and  severity  as  to  cause  vomiting,  and  the  patient  becomes 
ra[)idly  emaciated  from  loss  of  food. 

tiputum. — This  varies  greatly  in  amount  and  character  at  the  difi'ereiit 
stages  of  ordinary  phthisis.  There  are  cases  with  well-marked  local  Ki<rns 
at  one  apex,  with  slight  cough  and  moderately  high  fever,  without  from 
day  to  day  a  trace  of  expectoration.  So,  also,  there  are  instances  with  the 
most  extensive  consolidation  (caseous  pneumonia),  with  high  fever,  and,  as 
in  a  recent  instance  under  observation  for  several  months,  without  eiioiigli 
expectoration  to  enable  an  examination  for  bacilli  to  be  made.  In  the 
early  stage  of  pulmonary  tuberculosis  the  sputum  is  chiefly  catarrhal  and 
has  a  glairy,  sago-like  appearance,  due  to  the  presence  of  alveolar  cells 
which  have  undergone  the  myelin  degeneration.  There  is  nothing  dis- 
tinctive or  peculiar  in  this  form  of  expectoration,  which  may  persist  for 
months  without  indicating  serious  trouble.  The  earliest  trace  of  churac- 
teristic  sputum  is  se«n  in  the  presence  of  small  grayish  or  greenish-gray 
purulent  masses.  These,  when  coughed  up,  are  always  suggestive  and 
should  be  the  portions  picked  out  for  microscopical  examination.  As 
softening  comes  on,  the  expectoration  becomes  more  profuse  and  i)uru- 
lent,  but  may  still  contain  a  considerable  quantity  of  alveolar  epithelium. 
Finally,  when  cavities  exist,  the  sputa  assume  the  so-called  numnnilar 
form ;  each  mass  is  isolated,  flattened,  greenish-gray  in  color,  quite  airless, 
dnd  sinks  to  the  bottom  when  spat  into  water. 

By  the  microscopical  examination  of  the  sputum  we  determine  whether 
the  process  is  tuberculous,  and  wliether  softening  has  occurred.  For  tu- 
bercle bacilli  the  Ehrlich-Weigert  method  is  the  best.     Eleven  centimetres 


TUBKRCULOSIS. 


221 


of  a  saturated  solution  of  fuchsin  in  absolute  alcohol  is  added  to  one  hun- 
(iriMl  ci'iitiMietres  of  the  saturated  solution  of  commercial  aniline  oil  (made 
by  shaking  up  the  oil  in  water  and  then  tilterini,').  'I'his  should  ho  made 
frcsli  every  third  or  fourth  day.  A  small  bit  of  the  sputum  is  ])icked  out 
(111  a  needle  or  |)latinum  wire  and  spread  thin  on  the  top-cover  so  as  to 
make  a  uniforndy  thin  layer.  The  top-cover  is  slowly  dried  about  a  foot 
above  a  Hansen  burner.  SuHicient  of  the  staining  lluid  is  then  dropped 
u|i(m  the  top-cover,  which  is  held  at  a  little  distance  above  the  llamo  un- 
til tlic  lluid  boils.  The  staining  lluid  is  then  washed  olT  in  distilled  water 
or  put  under  the  tap,  decolorized  in  thirty  per  cent  nitric-acid  lluid,  again 
waslied  otT  in  water,  and  mounted  on  the  slide.  In  doubtful  cases  the 
long  process  is  used,  the  cover-slips  remaining  twenty-four  hours  in  the 
.stain.  The  bacilli  are  seen  as  elongated,  slightly  curved,  red  rods,  some- 
tiinos  presenting  a  beaded  aj)pearance.  They  are  frequently  in  groups  of 
three  or  four,  but  the  number  varies  considerably.  Only  one  or  two  may 
be  found  in  a  preparation,  or,  in  some  instances,  they  are  so  abundant 
that  tlie  entire  field  is  occupied. 

The  presence  of  these  baciUi  in  the  sputum  is  an  infallible  itidicntion 
of  the  existence  of  tiiherculosis. 

Sometimes  they  are  found  only  after  repeated  examination.  They 
may  be  abundant  early  in  the  disease  and  are  usually  numeroiM  in  the 
nuniiiudar  sputum  of  the  later  stages. 

'■Uastic  tissue  may  be  derived  from  the  bronchi,  the  alveoli,  or  from 
•terial  coats ;  and  naturally  the  appearance  of  the  tissue  will  vary 
witti  the  locality  from  which  it  comes.  In  the  examination  for  this  it  is 
not  necessary  to  boil  the  sputum  with  caustic  potash.  For  years  I  have 
used  a  simple  plan  which  was  shown  to  mo  at  the  London  Hospital  by 
.Sir  Andrew  Clark.  This  method  depends  upon  the  fact  that  in  almost 
all  instances  if  the  sputum  is  spread  in  a  sufficiently  thin  layer  the  frag- 
ments of  elastic  tissue  can  be  seen  with  the  naked  eye.  The  thick,  puru- 
lent portions  are  placed  upon  a  glass  plate  fifteen  by  fifteen  centimetres 
and  flattened  into  a  thin  layer  by  a  second  glass  plate  ten  by  ten  centi- 
metres. In  this  compressed  grayish  layer  between  the  glass  slips  any 
fragments  of  elastic  tissue  show  on  a  black  background  as  grayish-yellow 
spots  and  can  either  be  examined  at  once  under  a  low  power  or  the  upper- 
most piece  of  glass  is  slid  along  until  the  fragment  is  exposed,  when  it  is 
picked  out  and  placed  upon  the  ordinary  microscopic  slide.  Fragments 
of  bread  and  collections  of  milk-globules  may  also  present  an  opaque 
wliite  appearance,  but  with  a  little  practice  they  can  readily  be  recog- 
nized. Fragments  of  epithelium  from  the  tongue,  infiltrated  with  micro- 
cocci, are  still  more  deceptive,  but  the  microscope  at  once  shows  the  dif- 
ference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or 
three  long,  narrow  fibres  are  found  close  together.  From  the  blood-ves- 
sels a  somewhat  similar  form  may  be  seen  and  occasionally  a  distinct 


i  " 


222 


SPECIFIC  INFECTIOUS  DISEASES. 


;ij^^^- 


»■- 


sheeting  is  found  as  if  it  had  come  from  the  intima  of  a  good-S'zed  ar- 
tery.    The  elastic  tissue  of  tlie  alvcohir  wall  is  quite  distinctive;  the  fibres 
are  branched  and  often  show  the  outline  of  the  arrangonient  of  the  air 
cells.     The  elastic   tissue  from  bronchus  or  alveoli   indicates  extensivu 
erosion  of  a  tube  and  softening  of  the  lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  may  be 
present  as  the  chief  constituent  of  the  expectoration  in  hemoptysis  or 
nuiy  simply  tinge  the  sputum.  In  chronic  cases  witli  large  cavities,  in 
addition  to  bacteria,  various  forms  of  fungi  may  develop,  of  which  tlie 
aspergillus  is  the  most  important.     Sarcinai  may  also  occur. 

The  daily  amoun*^^  of  expectoration  varies.  In  rapidly  advancin;,' 
cases,  with  much  cough,  it  may  reach  as  high  as  five  hundred  cubic  centi- 
metres in  the  day.  In  cases  with  large  cavities  the  chief  amount  {.•^ 
brought  up  in  the  morning.  The  expectoration  of  tuberculous  patients 
usually  has  a  heavy,  sweetish  odor,  and  occasionally  it  is  fetid,  owing  to 
decomposition  in  the  cavities. 

lIiaiHoptiisis. — Ila^noptysis  is  met  with  cither  early  in  the  disease,  bo- 
fore  there  are  physical  signs,  or  during  the  course  of  the  alTection  wlieii 
there  is  softening  or  excavation.  A  majority  of  the  lia^morrhages  believed 
to  be  precursory  are  really  due  to  already  existing  disease  of  the  lung,  and 
there  is  no  ground  whatever  for  the  opinion,  so  long  lield,  that  phthisis 
can  originate  directly  from  liamoptysis.  The  blood  nuiy  be  either  ])ure 
or  mixed  with  s])utum.  A  distinction  should  be  made  between  these  two 
forms.  AVhen  the  sputa  are  simply  tinged  or  tlie  blood  is  admixed,  it 
comes,  in  all  probability,  from  hyperamiic  bronchial  mucosa  or  locally 
congested  areas  of  lung-tissue ;  hut  the  brisk  hamiorrhage  in  which  the 
blood  comes  up  in  nu)uthfnls  is  always  due  to  erosion'  of  vessels,  small  or 
large,  i  the  })rocess  of  softening,  or,  in  the  later  stages  of  the  disease, 
comes  from  the  erosion  of  a  branch  of  the  i)ulmoiuiry  artery  or  from  a 
ruptured  aneurism  of  the  pulmomiry  artery  in  a  cavity.  This  latter  is  the 
most  frequent  cause  of  the  fatal  hannorrhage  in  consumptioii. 

Dyspiuea  is  not  a  common  accompaniment  of  ordinary  i)hthisis.  The 
greater  part  of  one  lung  may  bo  diseased  and  local  trouble  exist  at  the 
other  apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of 
very  high  fever  the  respirations  may  not  be  much  incn'ased.  Kapid  ad- 
vance, as  of  a  broncho-pneumonic  process,  or  the  development  of  miliarv 
tubercles  throughout  the  lung,  causes  great  increase  in  the  number  of 
respirations.  A  degree  of  dysjiniea  leading  to  cyanosis  is  almost  unknown, 
apart  from  extensive  invasion  of  the  sound  portions  hy  miliary  tubercles. 
One  reason  why  there  is  so  little  shortness  of  breath  in  j)hthisis  is  that 
there  is  always  a  moderate  grade  of  amemia,  and  the  diminished  lung- 
space  is  sufficient  to  sui)ply  oxygen  to  the  reduced  number  of  blood-eor- 
puscles. 

2.  General  Symptoms, — Fet'cr. — To  get  a  correct  idea  of  tlie  tempera- 
ture range  in  jmlmonary  tuberculosis  it  is  necessary,  as  Uinger  pointed 


TUBERCULOSIS. 


223 


out,  to  make  tolerably  frequent  observations.  The  usual  8  A.  m.  and  8  p.  M. 
record  is,  in  a  majority  of  the  cases,  very  deceptive,  giving  no'ther  the 
miuiiiniin  nor  maximum.  The  former  usually  occurs  between  2  und  G  A.  M. 
and  the  latter  between  2  and  6  r.  M. 

A  recognition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of 
ulceration,  and  of  absorption,  emphasizes  the  anatomical  stages  of  growth, 
softening  and  cavity  formation ;  but  practically  P'ich  a  division  is  of  little 
use,  as  in  a  majority  of  cases  these  processes  are  going  on  together. 

Fever  is  the  most  important  initial  symptom  and  throughout  the  entire 
course  the  thermometer  is  the  most  trustworthy  guide  as  to  the  progress 
of  tlie  atfection.  With  pyrexia  a  patient  loses  in  Avcight  and  strengtli, 
ami  tlie  local  disease  usually  progresses.  The  periods  of  apyrexia  are 
those  of  gain  in  weight  and  strength  and  in  limitation  of  the  local  lesion. 
It  by  no  means  necessarily  follows  tiiat  a  patient  with  tuberculosis  has 
jiyrexia.  There  nuiy  be  quite  extensive  disease  without  coexisting  fever. 
At  the  moment  of  writing,  I  have  eighteen  instances  of  chronic  phthisis 
under  observation,  of  whom  ten  are  practically  free  from  fever  ;  but  in  the 
early  stage,  when  tubercles  arc  developing  and  caseous  areas  are  in  pro- 
cess of  formation  and  when  softening  is  in  progress,  fever  is  a  constant 
symptom.  It  was  jjresent  in  one  hundred  consecutive  cases  at  my  dis- 
jieiisury  service. 

Two  types  of  fever  are  seen — the  remittent  and  the  intermittent. 
'I'lu'se  may  occur  indilTe.cntly  in  the  early  or  in  the  late  stages  of  the 
disease  or  may  alternate  with  each  other,  a  variability  which  depends  upon 
the  fact  that  ])hthisis  is  .i  jn'ogressivo  disease  and  that  all  stages  of  lesions 
may  bo  found  in  a  single  lung.  Special  stress  should  be  laid  upon  the 
fact,  particularly  in  malarial  regions,  that  tuberculosis  may  set  in  with  a 
fever  typically  intermittent  in  character — a  daily  chill,  with  subsequent 
ftver  and  sweat.  In  Jfontreal,  where  malaria  is  practically  unknown, 
this  was  always  regarded  as  a  suggestive  symptom;  but  in  Philadelphia 
iiiul  Baltimore,  where  ague  prevails,  it  is  no  exaggeration  to  .say  that  yearly 
w'ores  of  cases  of  early  tuberculosis  arc  treated  for  ague.  These  are  often 
cases  that  })ursue  a  rapid  course.  The  fever  of  onset — tuberculization — 
nifiy  1)0  almost  continuous,  with  slight  daily  exacerbations;  and  at  any 
time  (luring  the  course  of  chronic  phthisis,  if  there  is  rapid  extension, 
the  remissions  become  less  marked. 

A  remittent  fccr,  in  wliieh  the  temperature  is  constantly  ibove 
normal  but  drops  wo  or  three  degrees  toward  morning,  is  not  une^unmon 
i'l  the  middle  ar  d  later  stages  and  is  usually  assoitiated  with  softening 
"r  extension  of  the  disease.  Here,  too,  a  simple  morning  and  evening 
'•"lister  may  g;.e  an  entirely  erroneous  idea  as  to  the  range  of  the  fever. 
\\ith  lireaking  down  of  the  lung-tissue  and  formation  of  cavities,  associ- 
iitcd  as  thise  processes  always  are  with  Buppuration  and  with  more  or  IcBS 
^vstemio  contamination,  the  fever  assumes  a  characteristically  intermittent 
"f  hectic  type.    For  a  largo  part  of  the  day  the  patient  is  not  only  afebrile. 


m 


m 


ite  i'l? 


224 


SPECIFIC   INFECTIOUS  DISEASES. 


but  the  temperature  is  subnormal.  In  the  annexed  two-hourly  chart, 
from  a  case  of  chronic  tuberculosis  of  the  lungs,  it  will  be  seen  that  from 
10  P.  M.  to  8  or  12  A.  M.,  the  temperature  continuously  fell  and  reached 
as  low  as  95°.  A  slow  rise  then  took  place  through  the  late  morning  and 
early  afternoon  hours  and  reached  its  maximum  between  G  and  10  p.  m. 
As  shown  in  the  chart  there  were  in  the  three  <lays  about  forty-three 
hours  of  pyrexia  and  twenty-uiue  hours  of  apyrexia.     The  rapid  fall  of 


Chart  XIII. — Three  days.    Chronic  tuberculosis. 


the  temperature  in  the  early  morning  hours  is  usually  associated  with 
sweating.  This  hectic,  as  it  is  called,  which  is  a  typical  fever  of  septic 
infection,  is  met  with  when  the  process  of  cavity  formation  and  softoniii? 
is  advanced  and  extending. 

A  continuous  fever  with  remissions  of  not  more  than  a  degree,  develop- 
ing in  tlie  course  of  pulmonary  tuberculosis,  is  suggestive  of  acute  pneu- 
monia. When  a  two-hourly  chart  is  made,  the  remissions  even  in  acute 
tuberculous  pneumonia  are  usually  well  marked.     A  continued  fever,  such 


TUBERCULOSIS. 


225 


as  is  seen  in  the  first  week  of  typhoid,  or  in  some  cases  of  inflammation 
of  the  king,  is  rare  in  tuberculosis. 

Sweating. — Drenching  perspirations  are  common  in  phthisis  and  con- 
stitute one  of  the  most  distressing  features  of  the  disease.  Tliey  occur 
usually  at  night,  or  at  any  time  in  the  day  when  tlic  i)atiriit  sleeps.  They 
iiiav  come  on  early  in  the  disease,  but  are  more  persistent  and  frequent 
after  cavities  have  formed.     Some  patients  escape  alttjgether. 

'I'he  pulse  is  increased  in  frequency,  especially  when  the  fever  is  high. 
It  is  often  remarkably  full,  though  soft  and  compressible.  Pulsation  may 
sometimes  be  seen  in  the  capillaries  and  in  the  veins  on  the  back  of  the 
hand. 

Emarintion  is  a  pronounced  feature.  The  loss  of  weight  is  gradual 
but,  if  the  disease  is  extending,  progressive.  The  scales  give  one  of  the 
best  indications  of  tlie  progress  of  the  case. 

3.  Physical  Signs. — («)  Inspection. — The  shape  of  the  chest  is  often 
suggestive,  though  it  is  to  be  remembered  that  pulmonary  tuberculosis 
may  be  met  with  in  chests  of  any  build.  Practically,  however,  in  a  con- 
siJoiable  proportion  of  cases  the  thorax  is  long  and  narrow,  with  very 
wide  intercostal  spaces,  the  ribs  more  vertical  in  direction  and  the  costal 
angle  very  narrow.  The  scapulae  are  "  winged,"  a  point  noted  by  Hip- 
poerates.  Another  type  of  chest  which  is  very  common  is  that  which  is 
llattened  in  the  antero-posterior  diameter.  The  costal  cartilages  may  be 
prominent  and  the  sternum  depressed.  Occasionally  the  lower  sternum 
forms  a  deep  concavity,  the  so-called  funnel  breast  {Tricliter-Iirxixt).  In- 
spection gives  valuable  information  in  all  stages  of  the  disease.  Spooial 
examination  should  be  made  of  the  clavicular  regions  to  see  if  one  clavitile 
stands  out  more  distinctly  than  the  other,  or  if  the  spaces  alx'  ■•  or  below 
it  are  more  marked.  Defective  expansion  at  one  apex  is  an  t  :ind  im- 
portant sign.  The  condition  of  expansion  of  the  lower  zone  of  tJie  tl)(»rax 
may  be  well  estimated  by  inspection.  The  condition  of  the  praecordia 
siiould  also  be  noted,  as  a  wide  area  of  impulse,  particularly  in  the  second, 
third,  and  fourth  interspaces,  often  results  from  disease  of  the  left  apex. 
From  a  point  behind  the  patient,  looking  over  the  slioulders,  one  can 
often  better  estimate  the  relative  expansion  of  the  apices. 

(/')  Puliation. — Deficiency  in  expansion  at  the  apices  or  bases  is  per- 
haps host  ganged  by  placing  the  hands  in  the  subclavicular  spaces  and 

en  in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw 
slowly  a  full  breath.  Standing  behind  tlie  patient  and  placing  tlie 
thumbs  in  the  supraclavicular  and  the  fingers  in  the  infraclavicular 
ppaces  one  can  judge  accurately  as  to  the  relative  mobility  of  the  two 
sides.  Disease  at  an  apex,  though  early  and  before  dulness  is  at  all 
marked,  may  be  indicated  by  deficient  expansion.  On  asking  the  patient 
to  count,  the  tactile  fremitus  is  increased  wherever  there  is  local  growth  of 
tuhorele  or  extensive  caseation.  In  comparing  the  apices  it  is  important 
to  bear  in  mind  that  normally  the  fremitus  is  strongei  at  the  right  than 


:ll^ 


226 


SPECIFIC   INFECTIOUS  DISEASES. 


at  the  left.  So  too  at  the  base,  when  there  is  consolidation  of  the  lung, 
the  fremitus  is  increased  ;  whereas,  if  there  is  pleural  effusion,  it  is 
diminished  or  absent.  In  the  later  stages,  when  cavities  form,  the  tuctile 
fremitus  is  usually  much  exaggerated  over  them.  When  the  pleura  is 
greatly  thickened  the  fremitus  may  be  somewhat  diminished. 

(r.)  Percussion. — Tubercles,  inflammatory  products,  fibroid  chaugos, 
and  cavities  prodr.ce  important  changes  in  the  pulmonary  resonance. 
There  mav  bo  localized  disease,  even  of  some  extent,  without  inducinir 
much  alteration ;  as  when  the  tubercles  are  scattered  and  have  air-con- 
taining  tissue  between  them.  One  of  the  earliest  and  most  valuable  signs 
is  defective  resonance  ui)on  and  above  a  clavicle.  In  a  considerable  pro- 
portion of  all  cases  of  plithisis  the  dulncss  is  first  noted  in  these  regions. 
Tiie  comparison  between  the  two  sides  should  be  made  also  when  tiie 
breath  is  held  after  a  full  iiispiration,  as  the  defective  resonance  may  then 
be  more  clearly  marked.  In  the  early  stages  the  percussion  note  is  usually 
higiier  in  pitch  and  may  require  an  experienced  ear  to  detect  the  differ- 
ence. In  recent  consolidation  from  caseous  pneumonia  the  percussion 
note  often  has  a  tubular  or  tympanitic  quality.  A  wooden  duliiess  is 
rarely  heard  except  in  old  cases  with  extensive  fibroid  change  at  the  upex 
or  base.  Over  large,  thin- walled  cavities  at  the  apex  the  so-called  cracked- 
pot  sound  may  be  obtained.  In  thin  subjects  the  percussion  should  bo 
carefully  practised  in  the  supraspinous  fossa?  and  the  interscapular  space, 
as  they  correspond  to  very  important  areas  early  involved  in  the  disease. 
In  cases  with  numerous  separated  cavities  at  the  apex,  without  luucli 
fibroid  tissue  Oi  thickening  of  the  pleura,  the  percussion  note  may  show 
little  change,  ;iud  the  contrast  between  the  signs  obtained  on  auscullation 
and  percussion  is  most  marked. 

(d)  Aifsru(/(t(io)i. — Feeble  breath-souiuls  are  among  the  most  charac- 
teristic early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of 
the  atfectcd  area.  It  is  well  at  first  always  to  compare  carefully  tlie  cor- 
responding points  on  the  two  sides  of  the  chest  without  asking  the  patient 
cither  to  draw  a  deep  breath  or  to  cough.  With  early  apical  disease  tlie 
inspiration  on  quiet  breathing  may  be  scarcely  audible.  Expiration  is 
usually  prolonged.  On  the  other  hand  there  are  cases  in  which  the  earliest 
sign  is  a  harsh,  rude,  respiratory  murmur.  -  On  deep  breathing  it  is  fre- 
quently to  be  noted  that  inspiration  is  jerking  or  wavy,  the  so-called  "cog- 
wheel "  rhythm  ;  which,  however,  is  by  no  means  confined  to  tuberculosis. 
With  extension  of  the  disease  the  inspiratory  murmur  is  harsh,  and,  when 
consolidation  occurs,  whiffing  and  bronchial.  With  these  changes  in  the 
character  of  the  murmur  there  are  rales,  due  to  the  accompanying  hron- 
chitis.  They  may  be  heard  only  on  deep  inspiration  or  on  coughing,  aii'l 
early  in  the  disease  are  often  crackling  in  character.  When  soflcniiig 
occurs  they  are  louder  and  have  a  bubbling,  sometimes  a  caaracieristie 
clicking  quality.  These  "moist  sounds,"  as  they  are  called,  when  asso- 
ciated with  change  in  the  percussion  resonance  are  extremely  suggestive. 


TUBERCULOSIS. 


22( 


When  cavities  form,  the  rdles  are  louder,  more  gurgling,  and  resonant  in 

(iiiality.     When  there  is  consolidation  of  any  extent  the  hreath-sounds  are 

tiilmlar,  and  in  the  large  excavations  loud  and  cavernous,  or  have  an  am- 

nliuiic  quality.    In  the  unaffected  portions  of  the  lobe  and  in  the  opposite 

lung  the  breath-sounds  may  be  harsh  and  even  puerile.    The  vocal  reso- 

luuKH!  is  usually  increased  in  all  stages  of  the  process,  and  bronchophony 

iiiul  pi'ctoriloquy  are  met  with  in  the  regions  of  consolidation  and  over 

ciivitios.    Pleuritic  friction  may  be  present  at  any  stage  and,  as  mentioned 

before,  occurs  very  early.     There  are  cases  in  which  it  is  a  marked  feature 

tliroughout.     When  the  lappet  of  lung  over  the  heart  is  involved  there 

iiiiiy  be  a  pleuro-pericardial  friction,  and  when  this  area  is  consolidated 

there  niiiy  be  curious  clicking  rAles  synchronous  with  the  heart-beat,  due 

to  the  compression  by  the  heart  of,  and  the  expulsion  of  air  from,  this 

portion.   An  interesting  auscultatory  sign,  met  most  commonly  in  phthisis, 

is  the  so-ciilled  cardio-respiratory  murmur,  a  whiffing  systolic  bruit  due  to 

the  pro})ulriion  of  air  out  of  the  tubes  by  the  impulse  of  the  heart.     It  is 

best  heard  during  inspiration  and  in  the  antcro-lateral  regions  of  the  chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on 

either  side,  the  pulsation  of  which  may  be  very  visible.     The  murmur  is 

ill  nil  ])robability  due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

(,'()  Wlien  there  is  not  much  thickening  of  the  pleura  or  condensation 

of  the  surrounding  lung-tissue,  the  percussion  sound  may  be  full  and 

I  leur,  resembling  the  normal  note.     More  commonly  there  is  defective 

resonance  or  a  tympanitic  quality  which  may  at  times  be  purely  amphoric. 

The  pitcli  of  the  percussion  note  changes  over  a  cavity  when  the  mouth 

is  opened  or  closed  (Wintrich's  sign),  or  it  may  be  brought  out  more 

chnu'ly  on  change  of  position.     The  cracked-pot  sound  is  only  obtainable 

over  tolerably  large  cavities  with  thin  walls.     It  is  best  elicited  by  a  firm, 

quii'k  stroke,  the  patient  at  the  time  having  the  mouth  open.     In  those 

rare  instances  of  almost  total  excavation  of  one  lung  the  percussion  note 

may  he  amphoric  in  quality.     (/;)  On  auscultation  the  so-called  cavernous 

souiuls  are  heard  :  (1)  Various  grades  of  modified  breathing — blowing  or 

tuljuhir,  cavernous  or  amphoric.     There  may  be  a  curiously  sharp  hissing 

souiul,  as  if  the  air  was  passing  from  a  narrow  opening  into  a  wide  space. 

In  very  large  cavities  both  inspiration  and  expiration  may  be  typically 

amphoric.     (2)  There  are  coarse  bubbling  rales  which  have  a  resonant 

qnahty,  and  on  coughing  may  have  a  metallic  or  ringing  character.     On 

ooiiirhiiig  they  are  often  loud  and  gurgling.     In  very  large  thin-walled 

eavities,  and  more  rarely  in  medium-sized  cavities,  surrounded  by  recent 

consolidation,  the  rales  may  have  a  distinctly  amphoric  echo,  simulating 

those  of  pneumothorax.     There  are  dry  cavities  in  which  no  rales  are 

heard.     (;])  The   vocal   resonance   is  greatly  intensified   and   whispered 

pectoriloquy  is  clearly  heard.     In  large  apical  cavities  the  heart-sounds 

ire  well  heard,  and  occasionally  there  may  be  an  intense  systolic  murmur, 


228 


SPECIFIC  INFECTIOUS  DISEASES. 


probably  always  transmitted  to,  and  not  produced,  as  has  been  supposed, 
in  the  cavity  itself. 

Pseudo-cavernous  signs  may  be  caused  by  an  area  of  consolidation 
near  a  large  bronchus.  The  condition  may  be  most  deceptive — the  lii;,'h. 
pitched  or  tympanic  percussion  note,  the  tubular  or  cavernous  breaihiii", 
and  the  resotumt  rules,  simulate  closely  those  of  cavity. 

4.  Symptoms  referable  to  other  Organs.— («)  Cardio-vascular.—'Uhn 
retraction  of  the  left  upper  lobe  exposes  a  large  area  of  the  heart.  In 
thin-chested  subjects  there  may  be  pulsation  in  the  second,  third,  and 
fourth  interspaces  close  to  the  sternum.  Sometimes  with  much  retraction 
of  the  left  upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the 
pulmonary  area  is  common  in  all  stages  of  phthisis.  Apical  murmurs  are 
also  not  infrequent  and  may  be  extremely  rough  and  harsh  without  iicces- 
sarily  indicating  that  endocarditis  is  present.  The  association  of  heart- 
disease  with  phthisis  is  not,  however,  very  uncommon.  As  already  men- 
tioned, there  were  twelve  instances  of  endocarditis  in  21G  autopsies.  Tlie 
arterial  tension  is  usually  low  in  phthisis  and  the  capillary  resistance  les- 
sened so  that  the  pulse  is  often  full  and  soft  even  in  the  later  stages  of 
the  disease.  The  capillary  pulse  is  not  infrequently  met  with,  and  jjiilsa- 
tion  of  the  veins  in  the  back  of  the  hand  is  occasionally  to  be  seen. 

(b)  Blood  Glandular  System.  —  The  early  anaemia  has  already  been 
noted.  It  is  often  more  apparent  than  real,  a  chloro-an«mia,  and  the 
blood-count  rarely  sinks  below  two  million  per  cubic  millimetre. 

The  blood-plates  are,  as  a  rule,  enormously  increased  and  are  seen  in 
the  Avithdrawn  blood  as  the  so-called  Schultze's  granule  masses. 

(c)  Gastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A 
red  line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was 
paid  as  a  special  feature  of  phthisis,  occurs  in  other  cachectic  states.  Ex- 
tensive tuberculous  disease  of  the  pharynx,  associated  with  similar  aflec- 
tion  of  the  larynx,  may  interfere  seriously  with  deglutition  and  prove  a 
very  distressing  and  intractable  symptom. 

Of  late,  special  attention  has  been  paid  to  the  gastric  symptoms  of  this 
affection.  Tuberculous  disease  is  rare.  I  have  seen  but  one  undoubted 
specimen  from  a  case  which  Zinsser  has  reported.*  Ulceration  may  oecur 
as  an  acciilontal  complication  and  multiple  catarrhal  ulcers  are  not  uiieoni- 
mon.  Interstitial  and  parenchymatous  changes  in  the  mucosa  are  com- 
mon (possibly  associated  with  the  venous  stasis)  and  lead  to  atrophy,  but 
these  cannot  always  be  connoted  with  the  symptoms,  and  they  may  be 
found  when  not  expected.  On  the  other  hand,  when  the  gastric  symp- 
toms have  been  most  persistent,  the  mucosa  may  show  very  little  cliaiige. 
It  is  impossible  always  to  refer  the  anorexia,  nausea,  aiul  vomiting  of  con- 
sumption to  local  conditions.     The  hectic  fever  and  the  neurotic  influ- 


*  Philadelphia  Hospital  Reports,  vol.  i,  1800. 


TUBERCU1.0SIS. 


229 


ences,  upon  which  Immermann  lays  much  stress,  must  bo  takcu  into  ac- 
count, us  they  phiy  an  important  role.  The  organ  is  often  dihited,  and  to 
muscular  insufficiency  alone  may  be  due  some  of  the  cases  of  dyspepsia. 
Tlio  condition  of  the  gastric  secretion  is  not  constant,  and  the  reports  are 
(iiscdrdiint.  In  the  early  stages  there  may  be  hyperacidity ;  later,  a  de- 
licioucy  of  acid. 

Anorexia  is  often  a  marked  symptom  at  the  onset ;  there  may  be  positive 
loathing  of  food,  and  even  small  quantities  cause  nausea.  Sometimes  with- 
out iuiy  nausea  or  distress  after  eating  the  feeding  of  the  patient  is  a  daily 
batik'.  When  practicable,  Debove's  forced  alimentation  is  of  great  benefi 
in  such  cases.  Nausea  and  vomiting,  though  occasionally  troublesome  at 
an  early  period,  are  more  marked  in  the  later  stages.  The  latter  may  be 
caused  by  the  severe  attacks  of  coughing.  S.  II.  llabershon  refers  to  four 
tlillerent  causes  the  vomiting  in  phthisis:  (1)  central,  as  from  tuberculous 
meningitis ;  (2)  pressure  on  the  vagi  by  caseous  glands ;  (3)  stimulation 
from  the  peri])heral  branches  of  the  vagus,  either  pulmonary,  pharyngeal, 
or  gastric ;  and  (4)  mechanical  causes. 

Of  the  intestinal  symptoms  diarrhoea  is  the  most  serious.  It  may 
come  on  early,  but  is  more  usually  a  symptom  of  the  later  stages,  and 
is  associated  with  ulceration,  particularly  of  the  large  bowel.  Extensive 
ulceration  of  the  ileum  may  exist  without  any  diarrhoea.  The  associated 
catarrhal  condition  may  account  in  part  for  it,  and  in  some  instances  the 
amyloid  degeneration  of  the  mucous  membrane. 

{(I)  XervoHS  System. — (1)  Focal  lesions  due  to  the  development  of 
coarse  tubercles  and  areas  of  tuberculous  meningo-encephalitis.  Aphasia, 
for  instance,  may  result  from  the  growth  of  meningeal  tubercles  in  the 
fissure  of  Sylvius,  or  even  hemiplegia  may  develop.  The  solitary  tuber- 
cles are  more  common  in  the  chrotiic  phthisis  of  children.  {'I)  Basilar 
ineninfritis  is  an  occasional  comi)lication.  It  may  be  confined  to  the 
brain,  though  more  commonly  it  is  a  (3)  cerebro-spinal  meningitis,  which 
may  como  on  in  persons  without  well-developed  local  signs  in  the  chest. 
Twice  have  I  known  strong,  robust  men  brought  into  hospital  with  signs 
of  cereljro-spinal  meningitis,  in  whom  the  existence  of  pulmonary  disease 
was  not  discovered  until  the  post-mortem.  (4)  Peripheral  neuritis.  This 
is  not  frequent,  and  has  occurred  but  five  times  in  the  large  number  of 
consum])tives  who  have  come  under  my  observation  during  the  past  seven 
years.  It  is  nearly  always  an  extensor  paralysis  of  the  arm  or  leg,  more 
commonly  the  latter,  causing  foot-drop.  It  is  usually  a  late  manifes- 
tation. (,"»)  Mental  symptoms.  It  was  noted,  oven  by  the  older  writers, 
that  consumptives  had  a  peculiarly  hopeful  temperament,  and  the  spes 
phlliisicd  forms  a  curious  characteristic  of  the  disease.  Patients  with  ex- 
tensive cavities,  high  fever,  and  too  weak  to  move  will  often  make  plans 
f'>r  the  future  and  confidently  expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic 
phthisis  a  form  of  insanity  not  unlike  that  which  develops  in  the  conva- 


§. 


,J 


'h. 


<i!ll| 


•-  i  t 


'J  V 

n  \ 

"  A ' 

III . 


230 


SPECIFIC  INFECTIOUS  DISEASPJS. 


lescenco  from  acute  affections.  The  whole  question  of  the  mutual  relations 
of  insanity  and  phthisis  is  dealt  with  at  length  in  Mickle's  Gulstonian 
lectures. 

(e)  A  remarkable  hypertrophy  of  the  mammary  gland  may  occur  in 
pulmonary  tuberculosis,*  most  commonly  in  males.  It  may  only  be  on  tho 
affected  side.  Two  cases  came  under  my  notice  at  the  University  lIosi)itjil, 
Philadelphia,  both  in  young  males.  It  is  a  chronic  interstitial,  non-tubor- 
culous  mammitis  (Allot). 

(/*)  Gcnito-ttrinary  System. — The  urine  presents  no  special  peculiari- 
ties in  amount  or  constituents.  Fever,  however,  has  a  marked  inlluence 
upon  it.  Albumen  is  met  with  frequently  and  may  be  associated  with 
the  fever,  or  is  the  result  of  definite  changes  in  the  kidneys.  In  the  latter 
case  it  is  more  abundant  and  more  curd-like.  Amyloid  disease  of  the 
kidneys  is  not  uncommon.  Its  presence  is  shown  by  albumen  and  tube- 
casts  in  the  urine,  and  sometimes  by  a  great  increase  in  the  amount  of 
urine.  In  other  instances  there  is  dropsy,  and  the  patients  have  all  the 
characteristic  features  of  chronic  Bright's  disease. 

Pus  in  the  urine  may  be  due  to  disease  of  the  bladder  or  of  the 
pelves  of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  in- 
volved. In  pulmonary  phthisis,  however,  extensive  tuberculous  disease  is 
rarely  found  in  the  urinary  organs.  Bacilli  may  occasionally  be  detected 
in  the  pus.  Ilaematuria  is  not  a  very  common  symptom.  It  may  occur 
occasionally  as  a  result  of  congestion  of  the  kidneys,  which  passes  off  and 
leaves  the  urine  albuminous.  In  other  instances  it  results  from  disease  of 
the  pelvis  or  of  the  bladder,  and  is  associated  either  with  early  tubercu- 
losis of  the  mucous  membranes  or  more  commonly  with  ulceration. 

{g)  Cutaneous  System. — The  skin  is  often  dry  and  harsh.  Local 
tubercles  occasionally  develop  on  the  hands.  There  may  be  pigmentary 
staining,  the  chloasma  phthmcorum,  which  is  more  common  when  the 
peritonaeum  is  involved.  Upon  the  chest  and  back  the  brown  stains  of 
the  pityriasis  versicolor  are  very  frequent.  The  hair  of  the  head  and 
beard  may  become  dry  and  lanky.  The  terminal  phalanges,  in  chronic 
cases,  become  clubbed  and  the  nails  incurvated — the  Hippocratic  flngers.t 
A  remarkable  and  unusual  complication  is  general  emphysema,  which  may 
result  from  ulceration  of  an  adherent  lung  or  jjerforation  of  the  larynx. 

Diagnosis. — When  well  advanced  there  is  rarely  any  doubt  as  to  the 
existence  of  tuberculous  phthisis,  for  the  sputum  gives  positive  informa- 
tion, and  the  physical  signs  of  local  disease  are  well  marked.  The  bacilli 
give  an  infallible  indication  of  the  existence  of  tuberculosis  and  iiiay  be 
found  in  the  sputum  before  the  physical  signs  are  at  all  definite.  On  the 
other  hand,  it  must  be  remembered  that  there  are  cases  in  which,  even 


*  Allot,  Paris  Thesis,  1887. 

f  "  Morbo  progrediente,  corpus  macrescit  praeter 
pedes,  et  ungues  conlorquentur"  (Hippocrates). 


crura:  hicc  autem  tument  et 


TUBERCULOSIS. 


231 


with  tolerably  well-defined  physical  signs,  the  sputum  is  extremely  scanty 
luid  many  examinations  may  bo  required  to  detect  tubercle  bacilli.  So 
csscntiiil  is  the  examination  of  the  sputum  in  the  early  diagnosis  of  phthi- 
sis that  I  would  earnestly  insist  upon  the  more  frequent  employment  of 
this  method.  There  is  no  excuse  now  for  its  omission,  since,  if  the  prac- 
titioner has  not  command  of  the  necessary  technique,  there  are  labora- 
tories in  many  parts  of  the  country  at  which  the  examination  can  be  made. 
Karhj  detection  is  of  vital  importance,  as  successful  treatment  depends 
upon  the  measures  taken  before  the  lung  is  extensively  involved. 

The  presence  of  elastic  fibres  in  the  sputum  is  an  indication  of  destruc- 
tion of  the  lung-tissue.  In  a  large  proportion  of  cases  it  is  indicative,  too, 
of  tuberculous  disease.  It  also  may  be  found  early,  before  the  physical 
signs  are  well  marked.  Its  detection  is  easy  by  the  above-mentioned 
method,  not  vequiring  high  powers  of  the  microscope.  In  cases  of  early 
liivinoptysis,  before  there  is  marked  constitutional  disturbance,  or  even 
local  signs,  it  is  very  important  to  make  a  thorougli  examination  of  the 
sputum,  from  which  mucoid  and  purulent  portions  may  be  picked  out  for 
examination.  With  localized  and  persistent  signs  in  one  lung,  cough, 
fever,  and  loss  of  flesh,  the  diagnosis  is  rarely  dubious.  It  is  remarkable, 
however,  to  what  an  extent  the  local  process  may  sometimes  proceed  with- 
out  disturbance  of  health  sufficient  to  excite  the  alarm  of  the  physician  or 
friends.  There  are  puzzling  cases  with  localized  physical  signs  at  one  apex, 
chiefly  moist  rales,  rarely  any  percussion  changes,  perhaps  slight  fever,  and 
ii  glairy  expectoration  containing  numerous  alveolar  cells.  I  have  seen 
several  cases  of  this  kind  whicli  have  been  for  a  time  very  obscure,  and  in 
wliich  repeated  examinations  failed  to  detect  either  bacilli  or  elastic  tissue. 
They  seem  to  bo  instances  of  local  catarrhal  trouble  in  the  smaller  tubes, 
some  of  which  clear  in  a  few  weeks. 

3.  Fibroid  Phthisis. 

In  the  section  on  diseases  of  the  lungs  wo  shall  refer  to  the  chronic  in- 
terstitial pneumonia,  or  cirrhosis  of  the  lung,  which  may  be  a  sequence  of 
acute  lobar  pneumonia,  or  follow  a  chronic  pleurisy,  or  is  due  to  inhala- 
tion of  dust,  as  in  anthracosis.  From  these  causes  a  condition  of  sclerosis 
or  induration  of  the  lung  may  be  produced  with  gradual  shrinkage.  An 
identical  condition  is  present  in  certain  cases  of  chronic  pulmonary 
tuberculosis,  and  to  this  it  is  best  perhaps  to  limit  the  term  fbroid  phthi- 
>i<.  This  form  may  come  on  gradually  as  a  sequence  of  a  chronic  tuber- 
culous broncho-pneumonia,  or  follow  a  chronic  tuberculous  pleurisy.  In 
f'tlier  instances  the  process  supervenes  upon  an  ordinary  ulcerative  phthi- 
sis. The  disease  becomes  limited  to  one  apex,  the  cavity  is  surrounded  by 
layers  of  dense  fibrous  tissue,  the  pleura  is  thickened,  and  the  lower  lobe 
IS  gradually  invaded  by  the  sclerotic  change.  Ultimately  a  picture  is 
produced  little  if  at  all  different  from  the  other  forms  of  cirrhoaia  of  the 
16 


\i 


i! 

!i 


232 


SPECIFIC  INFECTIOUS  DISEASES. 


lungs.  It  may  even  be  diflicult  to  suy  that  tlic  process  is  tuberculous,  but 
in  udvanced  cases  the  bacilli  are  usually  present  in  the  walls  of  the  cavity 
at  the  apex,  or  old,  encapsulated  caseous  areas  exist  in  the  lung,  or  there 
may  be  tubercles  at  the  apex  of  the  other  lung  and  in  the  bronchial 
glands.  Dilatation  of  the  bronchi  is  present ;  the  right  ventricle,  soiuu- 
times  the  entire  heart,  is  hypertrophied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years,  dur- 
ing which  time  the  patient  may  have  fair  health. 

The  chief  symptoms  are  cough,  which  is  often  paroxysmal  in  character 
and  most  marked  in  the  morning.  The  expectoration  is  purulent,  and 
in  some  instances,  when  the  bronchiectasis  is  extensive,  fcotid.  There  is 
dyspnoea  on  exertion,  but  little  or  no  fever. 

The  physical  signs  are  very  characteristic.  The  chest  is  sunken  and 
the  shoulder  lower  on  the  affected  side ;  the  heart  is  often  drawn  over  and 
displaced.  If  the  left  lung  is  involved  there  may  be  an  unusually  largo 
area  of  cardiac  pulsation  in  the  third,  fourth,  and  fifth  interspaces.  Heart- 
murmurs  arc  common.  There  is  dulness  over  the  affected  side  and  dufi- 
Cient  tactile  fremitus.  At  the  apex  there  may  be  well-marked  cavernous 
sounds;  at  the  base,  distant  bronchial  breathing.  The  condition  may 
persist  indefinitely.  In  some  cases  the  other  lung  becomes  involved,  or 
the  patient  has  repeated  attacks  of  haemoptysis,  in  one  of  which  he  dies. 
As  a  result  of  the  chronic  suppuration,  amyloid  degeneration  of  the  liver, 
spleen,  and  intestines  may  take  place ;  dropsy  frequently  supervenes  from 
failure  of  the  right  heart. 

A  more  detailed  account  is  found  under  Cirrhosis  of  the  Lung,  with 
which  this  form  is  clinically  identical. 

Diseases  associated  with  Pulmonary  Tuhercvlosis. 

Lobar  2^>ieu7nonia  is  not  an  uncommon  cause  of  death.  It  is  met  with 
most  frequently,  indeed,  as  a  terminal  event  in  the  chronic  cases.  It 
may,  however,  occur  early,  and  be  difficult  to  distinguish  from  an  acute 
caseous  pneumonia.  The  sputa  in  the  latter  are  rarely  rusty,  while  the 
fever  in  the  former  is  more  continuous  and  higher,  but  in  many  cases  it 
is  impossible  to  differentiate  between  the  two  conditions. 

Typhoid  fever  is  rare  in  phthisis,  but  cases  unquestionably  occur.  In 
Case  8  of  my  series  of  post-mortems  in  this  disease,  a  girl,  aged  eighteen, 
had  peritoneal  adhesions,  local  disease  at  both  apices,  and  perfectly  char- 
acteristic enteric  lesions.  In  Case  34,  a  male,  aged  twenty-five,  with  tuber- 
culous cavities,  had  a  very  acute  attack.  The  Peyer's  glands  were  greatly 
swollen  with  adherent  sloughs.  The  spleen  weighed  533  grammes.  The 
characters  of  the  ulceration  are  usually  distinctive. 

Erysipelas  not  infrequently  attacks  old  poitrinaires  in  hospital  wards 
and  almshouses.  There  are  insfances  in  which  the  attack  seems  to  be 
beneficial,  as  the  cough  lessens  and  the  symptoms  ameliorate.  It  may, 
however,  prove  fatal,  as  in  a  recent  case  admitted  to  my  wards. 


TUBERCULOSIS. 


•233 


The  eruptive  fd'ertt,  particularly  measles,  frequently  precede,  but  rarely 
(IcvcUtp  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination 
of  a  tuberculous  subject  the  vesicles  run  a  normal  course. 

Fistula  in  aiio  is  associated  with  jjlithisis  in  an  interesting  manner. 
In  ;i  majority  of  such  cases  it  is  a  tuberculous  process.  The  general  affec- 
tion may  i)rogress  rapidly  after  an  operation.  The  question  is  considered 
in  tuberculosis  of  the  alimentary  caiuil. 

Ill  chronic  and  arrested  phtliisis  arteriosclerosis  is  not  uncommon. 
Orniirod  noted  thirty  cases  of  chronic  renal  disease  in  one  hundred  post 
mortems. 

The  association  of  tuberculosis  with  chronic  arthritis^  upon  which 
certain  writers  lay  stress,  iinds  its  explanation  in  the  lowered  resistance  of 
those  patients,  and  the  greater  liability  to  infection  in  the  iustitutioDB  in 
wiiieh  so  many  of  them  live. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes  of  Life. 

{(i)  Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in  the 
aged,  particularly  in  institutions.  McLachlan  noted  a  hundred  and  forty- 
live  cases  in  which  tuberculosis  was  the  cause  of  death  in  old  persons  in 
Clielsoa  Hospital.  All  were  over  sixty  years  of  age.  The  experience  at 
Siilpi'tricre  is  the  same.  Laennec  met  with  a  case  in  a  person  over  ninety- 
nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over 
from  the  almshouse  it  was  extremely  common  to  find  either  old  or  recent 
tuborculosis.  A  patient  died  under  my  care  at  the  age  of  eighty-two  with 
extensive  peritoneal  tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is 
usiuilly  latent  and  runs  a  slow  course.  The  physical  signs  are  often  masked 
by  (impliysema  and  by  the  coexisting  chronic  bronchitis.  The  diagnosis 
may  di-pend  entirely  upon  the  discovery  of  the  bacilli  and  elastic  tissue. 
Contrary  to  the  opinion  which  was  held  some  years  ago,  tuberculosis  is  by 
no  means  uncommon  with  senile  emphysema.  Some  of  the  cases  of  tuber- 
culosis in  the  aged  are  instances  of  quiescent  disease  which  may  have 
dated  from  an  early  period. 

(//)  Infai  ts. — The  occurrence  of  acute  tuberculosis  in  children  has  al- 
ready been  mentioned,  and  also  the  fact  that  the  disease  is  occasionally 
congenital.  Recent  studies,  particularly  of  French  writers,  have  shown 
that  it  is  a  frequent  affection  in  children  under  two  years  of  age.  Leroux 
has  analyzed  the  statistics  of  the  late  Prof.  Parrot,  embracing  219  cases  in 
children  under  three  years.  Of  these  there  were  from  one  day  to  three 
months,  23 ;  from  three  to  six  months,  35 ;  from  six  to  twelve  months, 
53  (a  total  of  111  under  one  year) ;  and  from  one  to  two  years,  108.  Pul- 
monary cavities  were  present  in  57  of  the  cases,  and  in  only  60  was  the 
piilmoiiary  lesion  the  sole  manifestation.  At  the  St.  Petersburg  Found- 
ling Asylum,  in  the  ten  years  ending  1884,  there  were  416  cases  of  tuber- 
culosis in  16,581  autopsies.    The  observations  of  Northrup,  at  the  New 


11 


234 


SPECIFIC  INFECTIOUS  DISEASES. 


■li 


• 


York  Foundling  Hospital,  are  of  special  interest  in  conncctien  with  tho 
mode  of  infection.  Of  l:i5  cases  of  tuberculosis  on  the  records  of  this  iti- 
stitution,  in  34  tho  ravages  were  extensive,  the  scat  of  tho  primary  atTec- 
tion  was  not  clear,  and  tho  bronchial  glands  were  large  and  cheesy.  In 
20  cases  of  general  tuberculosis  there  were  cheesy  nuisses  in  the  bronchial 
glands  and  in  tho  lungs.  In  42  cases  of  general  tuberculosis  the  only 
cheesy  masses  were  in  the  bronchial  lymph-glands.  In  0  cases  tho  tuber- 
cles were  limited  to  tho  bronchial  nodes  and  tho  lungs ;  tho  latter  contain- 
ing only  discrete  miliary  bodies,  while  tho  bronchial  glands  were  in  ad- 
vanced caseation.  In  13  cases  there  was  tuberculosis  of  the  bronchial 
nodes  only.  In  most  of  these  cases  tho  patients  died  of  infectious  dis- 
eases. These  figures  are  very  suggestive,  and  point,  as  already  noted,  to 
infection  through  the  bronchial  pas.sages  as  the  most  common  metho.l, 
even  in  children.  Of  5(»()  autopsies  in  children  at  the  Munich  Pathologi- 
cal Institute,  in  150  (thirty  per  cent)  tuberculosis  was  present  and  in  over 
ninety-two  per  cent  the  lungs  were  involved  (Miiller). 

Moden  of  Death  in  Pitlmonary  Tuberculosis. 

{a)  By  asthenia^  a  gradual  failure  of  the  strength.  Tho  end  is  usu- 
ally peaceable  and  quiet,*  occasionally  disturbed  by  paroxysms  of  cough. 
Consciousness  is  often  retained  until  near  the  close. 

(b)  By  asphyxia.,  as  in  some  cases  of  acute  miliary  tuberculosis  and 
in  acute  pneumonic  phthisis.  In  chronic  phthisis  it  is  rarely  seen,  even 
when  pneumothorax  develops. 

{c)  By  syncope.  This  is  not  common.  I  have  known  it  to  luippeii 
once  or  twice  in  patients  who  insisted  upon  going  about  when  in  the  ad- 
vanced stages  of  the  disease.  There  may  be,  but  not  necessarily,  fatty  de- 
generation of  the  heart.  A  rapidly  developing  syncope  may  follow  hcenior- 
rhage  or  may  be  due  to  thrombosis  or  embolism  of  the  pulmonary  artery, 
or  to  pneumothorax. 

{d)  From  hcemorrhaye.  The  fatal  bleeding  in  chronic  phthisis  i.s  due 
to  erosion  of  a  largo  vessel  or  rupture  of  an  aneurism  in  the  pulmonary 
cavity,  most  commonly  tho  latter.  Of  twenty-six  analyzed  by  S.  West,  in 
eleven  cases  tho  fatal  hajmoptysis  was  due  to  aneurism,  and  of  thirty-tivo 
cases  collected  by  Percy  Kidd,  aneurism  was  present  in  thirty.  In  a  case 
of  Curtin's,  at  the  Philadelphia  Hospital,  the  bleeding  proved  fatal  before 
haemoptysis  occurred,  as  tho  eroded  vessel  opened  into  a  capacious 
cavity. 

(e)  With  cerebral  symptoms.  Coma  may  be  due  to  meningitis,  less 
often  to  uraemia.  Death  in  convulsions  is  rare.  The  hoemorrliagio  pachy- 
meningitis which  develops  in  some  cases  of  phthisis  occasionally  cause:* 
loss  of  consciousness,  but  is  rarely  a  direct  cause  of  death.     In  one  of  my 

*  As  is  so  well  described  by  Sir  Thomas  Browne,  whose  Letter  to  a  Friend  gives 
a  unique  account  of  the  Ir.st  illness  of  n  consumptive.  Hood's  Death-bed  is  true  of 
phthisis  more  frequently  than  of  any  other  disease. 


TUBERCULOSIS. 


235 


oascH,  death  resulted  from  thrombosis  of  the  cerebral  sinuses  with  symp- 
toms of  meningitis. 

\'.    TlHEUClLOSIS   OF   THE   SeUOIS   MeMIIUANES. 

Goneral  Pleuro-peritoneal  Tuberculosis.— Tl't'o  are  interesting  cases 
in  wiiifi!  tiie  lesions  are  confined  almost  entirely  to  the  serous  sacs — 
ilio  iilouni,  pericardium,  and  peritonieum.  1  do  not  here  refer  to  instances 
(if  chronic  pulmonary  tuberculosis,  in  which  the  })leu)'u  and  the  perito- 
iiaiini  may  bi  involved,  but  to  the  primitive  form,  in  which  these  serous 
nieinbiaiu'S  are  involved  in  either  (a)  an  acute  miUari/  inflammation  ;  {t>) 
It  i/inmic  iilccrntive  tuberculoxiti ;  or  (r)  a  chronic  Jibruid  tubciritlu.sis. 
ii  i«  sulUcient  to  indicate  here  the  fact  that  cases  occur  involving  pri- 
marily the  pleura  and  jJcritonaDum  alone,  sometimes  with  the  jjcricardium, 
ami  to  pass  on  to  the  consideration  of  the  aifections  of  the  individual  sacs. 

Tube'' miosis  of  the  Pleura. — This  may  be  primary  or  secondary. 

I'liinanj  tuberculosis  of  the  jjlcura  occurs  as  an  actite  proccas  asso- 
cialed  with  a  sero-iibrinous  or  ha^morrhagic  exudate.  Unquestionably 
many  of  the  cases  regarded  as  pleurisy  from  cold  arc  of  this  nature.  It 
may  be  truly  primary,  but  in  many  instances  local  tuberculous  disease 
exists  in  lung  or  lymph-glands.  There  is  a  primary  chronic  tuberculosis 
of  the  jilouia.  This  produces  great  thickening  and  caseation  of  both 
lajirs,  which  are  separated  from  each  other  by  a  thin  infiltrated  connect- 
ive tissue,  in  which  miliary  granulations  may  sometimes  be  seen.  The 
jilenrul  l:'ver=:  together  may  have  a  thickness  of  from  five  to  ten  millime- 
tres. It  IS  a  comparatively  rare  affection.  I  found  one  of  the  most 
striking  illustrations  of  the  kind  in  a  young,  remarkably  healthy-looking 
Iri.sli  girl,  who  died  under  my  care  of  malignant  scarlet  fever.  There 
were  no  other  tuberculous  lesions  in  the  body.  The  condition  may  be 
unilateral  or  bilateral. 

Scnmdary  tuberculous  pleurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  pulmonary  tuberculosis.  Adhesions  usually  form  and 
a  clironic  pleurisy  results,  which  may  be  simple,  but  usually  tubercles  are 
sratterod  through  the  adhesions.  An  acute  tuberculous  pleurisy  may  re- 
Milt  from  direct  extension.  The  fluid  may  be  sero-fibrinous  or  haemor- 
rliagic,  or  may  become  purulent.  And,  lastly,  a  very  common  event  in 
jmlmonary  tuberculosis  is  the  perforation  of  a  superficial  spot  of  softening, 
and  the  production  oi pyo-pnenmothorax. 

The  general  symptomatology  of  these  forms  will  be  considered  under 
diseases  of  the  pleura. 

Tuberculosis  of  the  Pericardium. — Miliary  tubercles  may  occur  as 
a  part  of  a  general  infection,  but  the  term  is  properly  limited  to  those 
cases  in  which,  either  as  a  primary  or  secondary  process,  there  is  extensive 
disease  of  the  membrane.  Tuberculosis  is  not  so  common  in  the  peri- 
cardium as  in  the  pleura  and  peritonaeum,  but  it  is  certainly  more  com- 


236 


SPECIFIC  INFECTIOUS   DISEASES 


mon  than  the  literature  would  lead  us  to  suppose.  Only  thirty  references 
are  noted  in  the  Index  Catalogue  of  the  Surgeon-General's  Office.  It 
occurs  in  two  forms — chronic  and  acute. 

(rt)  Chronic  Tuberculous  Pericarditis. — This  may  occur  as  a  primary 
affection  associated  only  with  the  caseation  of  the  bronchial  or  particu- 
larly the  anterior  mediastinal  lymj)h-glands.  Llore  commonly  there  u 
tuberculous  disease  elsewhere,  either  of  the  })leura  or  of  the  lungs,  some- 
times of  thoijeritonjvum.  In  a  number  of  cases  th*>  pericarditis  is  only  a 
part  of  a  general  infection  of  the  serous  membranes.  The  instances  are 
very  rare  in  which  the  process  is  confined  to  the  pericardium.  In  one  of 
my  cases,  a  man  aged  seventy-two,  who  died  of  pneumonic  In  the  Phila- 
delphuv  Hospital,  the  pericardium  was  thickened,  both  leaves  were  adher- 
ent and  presented  cheesy  masses  and  gray  nodules.  The  heart  weigliud 
r).)^  grammes ;  the  bronchial  glands  »vere  calcified  ;  there  were  no  tubtr- 
clos  in  the  other  organs.  The  disease  occurs  at  all  ages.  My  young- 
est case  was  in  a  child,  aged  five,  in  whom  both  layers  of  the  pericardium 
were  greatly  thickened  and  cheesy.  In  nearly  every  instance  the  bron- 
chial ^r  mediastinal  glands  are  tuberculous.  Occasionally  it  is  due  to 
extension  from  tuberculous  disease  of  the  sternum  or  of  the  spine ;  occa- 
sionally to  extension  from  the  lungs.  In  one  case,  a  m.an,  aged  fifty,  who 
died  in  the  Philadelphia  Hospital,  the  outer  layer  of  the  pericardium  was 
alone  involved  and  thickened,  in  connection  with  a  tuberculous  abscess  in 
the  anterior  mediastinum.  The  condition  is  usually  unsuspected.  Thu 
physical  signs  are  those  of  hypertrophy  of  the  heart.  In  a  recent  case  the 
organ  weighed  000  grammes,  and  the  clinical  symptoms  were  those  of 
hyi)ertroj)hy  and  dilatation. 

The  physical  signs  are  somewhat  uncertain,  since  they  arc  those  of  ad- 
herent pericardium.  The  dulress  may  reach  high  along  the  left  ster'..»I 
margii',  and  in  one  ca.so,  in  which  it  »va8  as  high  as  the  middle  of  Hie 
manubrium,  the  thickened  pericardial  layers  forined  a  solid  cheesy  ui.iss 
which  surrounded  the  aorta. 

{b)  Acufe  Tuberculous  Pcricardilis. — This  may  occur  as  a  secoii  iary 
infection  from  tubercle  in  other  parts,  or  it  may  arise  by  direct  extension 
from  the  lungs,  or  more  commonly  by  invasion  from  mediastinal  lymph- 
glands.  The  exudation  may  be  limited  in  amount  and  chiefly  fibriinius, 
or  it  may  be  serous,  and  in  many  cases  is  ha»morrhagic.  Unless  carefully 
sought  for,  the  tubercles  may  be  overlookou.  Lastly,  some  of  tlie  cases  of 
purulent  pericarditis  are  tubercnlou-t.  The  mo;nbrancs  ^nuy  be  nuich 
thickened  and  no  trace  of  tubercles  apparent.  The  nature  o'  the  case 
may,  then,  be  gathc/ed  chiefly  from  the  existence  of  tuberculous  bronchial 
or  mediastinal  glaiuls,  or  the  existence  of  tuberculous  foci  in  other  re- 
gions. The  effusion  in  these  cases  may  bo  enormous,  as  in  one  reported 
by  Musser,  i  -  which  the  sac  contained  sixty-four  ounces  of  fluid. 

The  symptoms  and  physical  signs  of  this  condition  will  be  considered 
with  those  of  ordinary  pericarditis  with  ofTusion. 


TUBERCULOSIS. 


237 


(d)  Tuberculosis  of  the  PeritontBiim. — In  connection  with  miliary  and 
cliniiiic  pulniontiry  tuberculosis  it  i8  not  uncommon  to  find  the  peritonamm 
stiidilod  with  small  gray  granulations.  They  aro  constantly  present  on 
till!  serous  surface  of  tuberculous  ulcers  of  tho  intestines.  Apart  from 
these  conditions  the  membrane  is  often  the  seat  of  extensive  tuberculous 
disease,  which  occurs  in  the  following  forms  : 

(1)  Acute  miliary  tuhcrculosis  with  sero-librinous  or  bloody  cxuda- 
tidii. 

[•i)  Chronic  tubercnlonift,  characterized  by  larger  growths,  which  tend 
to  cascate  and  ulcerate.  It  may  lead  to  perforation  of  the  intestiiuil  coils. 
Tlio  exudate  is  purulent  or  sero-purulent,  and  is  often  sacculated. 

(3)  C hronir fibroid  itibcrculosis,  which  may  be  subacute  from  the  on- 
set, or  which  may  represent  the  fiiuil  stage  of  an  acute  miliary  eruption. 
The  tubercles  are  hard  and  jjigmentcd.  Therr  is  little  or  no  exudation, 
aud  the  serous  surfaces  aro  nuitted  together  by  adhesions. 

The  process  may  be  prinuiry  and  local,  which  was  tho  case  in  five  of 
r.iy  seventeen  post-mortems.  In  children  the  infection  appears  to  pass 
from  the  intestines,  and  in  adults  this  is  the  source  in  the  cases  as.sociated 
with  chronic  phthisis.  In  women  the  disease  extends  commonly  from 
tiie  Fallopian  tubes.  In  at  least  [\0  or  40  per  cent  of  the  instances  of 
liijuuotomy  in  this  affection  reported  by  gynaecologists  tho  infection  was 
from  them.  The  prostate  or  the  seminal  vesicles  may  be  tho  starting- 
point.  In  many  cases  the  peritonamm  is  involved  with  the  pleura  and 
pericardium,  particularly  >vith  the  former  membrar:\ 

It  is  generally  stated  that  males  are  attacked  oftener  than  females. 
In  my  own  series  of  '^l  erses,  15  were  males,  Tho  recent  laparotomies, 
however,  whicdi  have  been  performed  in  this  disease  have  been  chiefly  in 
females ;  so  that  in  the  collected  statistics  I  find  the  cases  to  be  twice  as 
numeroin  :n  females  as  in  males ;  in  the  ratio,  indeed,  of  131  to  00. 

Tuberculous  peritonitis  occurs  at  all  ages.  It  is  common  in  children 
assiK'iated  with  intestinal  and  mesenteric  disease.  The  incidence  is  most 
freiiue.it  between  the  ages  of  twenty  and  forty.  It  may  occur  in  advanced 
life.  Ill  one  of  my  cases  the  patient  was  eighty-two  years  of  age.  Of 
357  eases  collected  from  the  literature,*  there  were  under  ten  years,  27 ; 
between  ten  and  twenty,  75;  from  twenty  to  thirty,  87;  between  thirty 
and  forty,  71  ;  from  forty  to  Hfty,  (51 ;  ;rom  fiffy  to  sixty,  19  ;  from  sixty 
to  .seventy,  4 ;  above  seventy,  2.  In  An.erica  it  is  more  common  in  the 
negro  than  in  tho  white  race. 

Symptoms. — In  certain  special  features  the  tubercilous  varies  con- 
sideraljly  from  other  forms  of  peritonitis.  It  presents  a  synipfom-complcx 
of  extraordinary  diversity. 

In  il.c  first  place,  the  process  may  be  InletU  and  not  cause  a  single 
symptom.    Such  aro  tho  cusos  met  with  accidentally  in.  tJio  operation  for 


*  Johns  Hopkins  Hoopital  Reports,  voLU*. 


238 


SPECIFIC   INFECTIOUS  DISEASES. 


hernia  or  for  ovarian  tumor.  In  direct  contrast  are  the  instances  in  which 
the  onset  i.s  so  sudden  and  violent  that  the  diagnosis  of  enteritis  ox  hernia 
is  made.  The  ojjcration  for  stranguhited  hernia  lias,  indecti,  been  per- 
formed. Many  cases  set  in  acutely  with  fever,  abdominal  tenderness,  and 
the  symptoms  of  ordinary  acute  peritonitis.  C'ases  with  a  slow  onset, 
abdominal  tenderness,  tympanites,  and  low  continuous  fever  resemble 
typhoid  fever  very  closely,  and  may  lead  to  error  in  diagnosis. 

Jsrifes  is  frequent,  but  the  effusion  is  rarely  large.  It  is  somotinies 
ha'morrhagic.  It  may  simulate  the  eilusion  in  cirrhosis  of  the  liver,  of 
which  disease  it  is  to  be  noted  that  tuberculous  peritonitis  is  often  a  final 
complication.  I'l/ni/xntitcs  may  be  present  in  the  very  acute  cases,  when 
it  is  due  to  loss  of  tone  in  the  intestines,  owing  to  inflammatory  inllUrn- 
tion ;  or  it  may  occur  in  the  old,  long-standing  cases  when  univeri^al 
adhesion  has  taken  place  l)etween  the  parietal  and  visceral  layers,  /'cm- 
is  a  marked  symptom  in  the  acute  cases,  and  the  temperature  may  reach 
103°  or  104°,  In  many  instances  the  fever  is  slight.  In  the  more  chmnic 
cases  subnormal  temperatures  are  common,  and  for  days  the  temperatiiie 
may  not  rise  above  9T°,  and  the  morning  temperature  may  bo  as  low  an 
l>5*5°.  An  occasional  symptom  is  pigmentation  of  the  skin,  which  in 
some  cases  has  led  to  the  diagnosis  of  Addison's  disease.  A  striking 
peculiarity  of  tuberculous  peritonitis  is  the  frequency  with  which  citlier 
the  condition  simulates  or  is  associated  with  tumor.     These  may  be : 

(a)  Omental,  due  to  puckering  and  rolling  of  tliis  membrane  until  it 
forms  an  elongated  firm  mass,  attached  to  the  transverse  colon  and  lying 
athwart  the  ujiper  part  of  the  abdomen.  'IMiis  cord-like  structure  is  found 
also  with  cancerous  peritonitis,  but  is  much  more. common  in  tubercu- 
losis. (Jairdner  has  called  special  attention  to  this  form  of  tumor,  and  in 
children  has  seen  it  undergo  gradual  resolution.  .\  resonant  percussion 
note  may  sometimes  be  elicited  above  the  mass.  Though  usually  situated 
in  the  umbilical  region,  the  omental  mass  may  form  a  prominent  tumor 
in  the  right  iliac  region. 

{!))  Sacculated  exudation,  in  which  the  ciTusion  is  limited  and  confuicd 
l)y  adhesions  between  the  coils,  the  parietal  peritonieum,  the  mesentery, 
and  the  abdominal  or  pelvic  organs.  This  encysted  exudate  is  most 
common  in  the  middle  zone,  and  has  freqtuMitly  been  mistaken  for  ovarian 
tumor.  It  may  occupy  the  entire  anterior  portion  of  the  peritonanitii,  or 
tliere  may  bo  a  more  limited  sacc^ular  exiulate  on  one  side  or  the  otlur. 
It  may  lie  comj)leteIy  within  the  pelvis  proper,  associated  with  tuberculous 
disease  of  the  Fallopian  tubes. 

(r)  In  rare  cases  the  tumor  formatioTis  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.  The  snudl  intestine  is  found  short- 
ened, the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  finii 
knot  close  against  the  spine,  giving  on  examination  the  idea  of  a  solid 
mass.  Not  the  small  intestine  only,  but  the  entire  bowel  from  the  iliiode- 
num  to  the  rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 


TUBERCULOSIS. 


239 


{(l)  Mesenteric  glands,  which  occasionally  form  very  largo,  tumor-Iiko 
masses,  more  commouly  found  in  children  than  in  adults.  Tiiis  condition 
may  bo  confined  to  the  abdominal  glands.  Ascites  may  coexist.  The 
condition  must  be  distinguished  from  that  in  children,  in  which,  with  as- 
cites or  tympanites — sometimes  both — there  can  be  felt  irregular  nodular 
musses,  due  to  large  caseous  formations  between  the  intestinal  coils.  No 
doubt  in  a  considerable  number  of  cases  of  the  so-call'jd  tabes  mesentcrica, 
particularly  in  those  Mith  ciilargement  and  hardness  of  the  abdomen — 
the  condition  which  the  French  call  carreau — there  is  involvement  also  of 
the  jieritona'um. 

The  (U(t(jnosis  of  those  peritoneal  tumors  is  sometimes  very  difficult. 
The  omental  tumor  is  a  less  frequent  source  of  error  than  any  other ;  but, 
as  already  mentioned,  a  similar  condition  may  occur  in  cancer.  The  most 
important  problem  is  the  diagnosis  of  the  saccular  exudation  from  ovarian 
tumor.  In  fully  one  third  of  the  recorded  cases  of  laparotomy  in  tuber- 
culous peritonitis,  the  diagnc.sis  of  cystic  ovarian  disease  had  been  made. 
The  most  suggestive  point.-;  for  consideration  are  the  history  of  the  patient 
aiul  the  evidence  of  old  tuberculous  lesions.  The  physical  condition  is 
not  of  much  moment,  as  in  many  instances  the  patients  have  been  robust 
and  well  nourished.  Irregular  febrile  attacks,  gastro-intestinal  disturb- 
ance, and  pains  arc  more  common  in  tuberculous  disease.  Unless  in- 
llamcd  there  is  usually  not  much  fever  with  ovarian  cysts.  The  local 
signs  are  very  deceptive,  and  in  certain  cases  have  conformed  in  every 
particular  to  those  of  cystic  disease.  The  outlines  in  saccular  exudation 
are  rarely  so  well  defined.  The  position  and  form  may  be  variable,  owing 
to  alterations  in  the  size  of  the  coils  of  which  in  parts  the  walls  are  com- 
posed. Nodular  cheesy  masses  may  sometimes  be  felt  at  the  periphery. 
Depression  of  the  vaginal  wall  is  mentioned  as  occurring  in  encysted  peri- 
tonitis; but  it  is  also  found  in  ovarian  tumor.  Lastly,  the  condition  of 
tlio  Fallopian  tubes,  of  the  lungs  and  of  the  pleuroe,  should  be  thoroughly 
examined.  The  association  of  salpingitis  with  an  ill-defined  anomalous 
mass  iu  the  abdomen  should  arouse  suspicion,  as  should  also  involvement 
of  tlie  pleura,  the  apex  of  one  lung,  or  a  testis  in  the  male. 

VI.  TrnEiicuLosis  of  the  Alimentauv  Caxal. 

(")  Lips. — Tuberculosis  of  the  lip  is  ^ory  rare.  It  occurs  occasion- 
ally in  the  form  of  an  ulcer,  either  alone  or  more  commonly  in  association 
with  laryngeal  or  pulmonary  disea.se.  Two  cases  arc  reported  and  the 
literature  analyzed  in  Verneuil's  Etudes.*  The  ulcer  is  usually  very  sensi- 
tive and  may  be  mistaken  for  a  chancre  or  an  epithelioma.  Tiie  diagnosis 
may  he  made  in  cases  of  doubt  by  inoculation  or  the  cxamitmtion  of  a  por- 
tion for  tubercle  bacilli. 

♦  Tome  iii,  Fas.  1. 


210 


SPECIFIC  INFECTIOUS  DISEASES. 


1  i!     ' 


ftttp^m  < 


(b)  Towjue. — Tlie  disease  begins  by  an  aggregation  of  small  granular 
bodies  on  the  edge  or  dorsum.  Ulceration  proceeds,  leaving  an  irregular 
sore  with  a  distinct  but  uneven  margin,  and  a  rough,  often  caseous  base. 
The  disease  extends  slowly  and  may  form  an  ulcer  of  considerable  size. 
I  have  known  it  to  be  mistaken  for  epithelioma  and  the  tongue  to  be 
excised.  It  is  rarely  met  with  except  when  other  organs  are  involved. 
The  glands  of  the  angle  of  the  jaw  are  not  enlarged  and  the  sore  docs  not 
yield  to  iodide  of  potassium,  which  are  points  of  distinction  between  the 
tuberculous  and  the  syphilitic  ulcer.  In  doubtful  cases  the  inoculation 
test  should  be  made,  or  a  portion  excised  for  microscopical  examination. 

(c)  Tubercles  may  develop  on  the  hard  or  soft  palate.  In  a  recent 
case  under  the  care  of  my  colleague  Ilalsted  there  was  a  rough,  irregular 
patch  on  the  roof  of  the  mouth,  grayish  in  spots,  and  fissured. 

{(l)  Tuberculosis  of  the  tonnil  has  been  recorded  in  a  few  cases,  either 
in  the  form  of  the  miliary  granules  or  as  caseous  foci.  Ulceration  may 
occur.     In  the  acute  cases  the  submaxillary  glands  may  be  enlarged. 

(f)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of 
miliary  granules  on  the  posterior  wall  of  the  pharynx  is  not  very  uncom- 
mon. In  chronic  phthisis  an  ulcerative  pharyngitis,  due  to  extension  of 
the  disease  from  the  epiglottis  and  larynx,  is  one  of  the  most  distressing 
of  complication.s,  rendering  deglutition  acutely  painful. 

(/)  A  few  instances  occur  in  literature  of  tuberculosis  of  the  (esopha- 
gus. The  condition  is  a  pathological  curiosity,  except  in  the  slight  exten- 
sion from  the  larynx,  which  is  not  infrequent. 

(</)  Stomach. — Many  cases  are  reported  which  are  doubtful.  Primary 
disease  is  unknown.  Marfan*  was  able  to  collect  only  about  a  dozen 
authentic  cases.  Perforation  of  stomach  occurred  six  times,  thrice  by  a 
tuberculous  gland.  In  Oppolzer's  case  an  ulcer  of  the  colon  perforated 
the  organ.  In  Musser's  case  there  was  a  large  tuberculous  ulcer  three  by 
one  and  a  half  inches  in  extent. 

(//)  Intestines. — The  tubercles  may  be  (1)  primary  in  the  mucous 
membrane,  or  more  commonly  (•^)  secondary  to  disease  of  the  lungs,  or  in 
rare  cases  the  affection  nuiy  (3)  pass  from  the  peritoneum. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  child ren, 
in  whom  it  may  be  associated  with  enlargement  and  caseation  of  the 
mesenteric  glands,  or  with  peritimitis.  It  may  be  difTicult  to  say  at  the 
time  of  the  autopsy  whether  the  primary  lesion  has  been  intestinal  or 
peritoneal.  I  have  already  referred  to  Wood  head's  statistics  showing  the 
remarkable  fre(juency  of  infection  through  the  bowel.  In  adults  primary 
intestinal  tuberculosis  is  rare ;  but  now  and  then  cases  occur  in  which  the 
disease  sets  in  with  irregular  diarrhcx?a,  moderate  fever,  and  colicky  pains. 
In  a  few  cases  lucmorrhage  has  been  the  initial  symjitom.  Regarded  at 
first  as  a  chronic  catarrh,  it  is  not  until  the  emaciation  becomes  marked  or 

*  Pftris  Thesis,  1887. 


TUBERCULOSIS. 


241 


tlie  signs  of  disease  appear  in  tlie  lungs  that  the  true  nature  is  apparent. 
.Slill  more  deceptive  are  tlie  cases  in  which  the  tuberculosis  begins  in  the 
ciecnni  and  there  are  symptoms  of  typhlitis — tenderness  in  the  right  iliac 
fossa,  constipation,  or  an  irregular  diarrhoia  and  fever.  These  signs  may 
1,'riultiully  disappear,  to  recur  again  in  a  few  weeks,  and  still  further  com- 
jiliiiitc  the  diagnosis.  Perforation  may  occur  with  the  formation  of  a 
jicriL'a'cul  abscess,  or  perforation  into  the  peritonivum  may  take  place,  or 
in  very  rare  instances  there  is  partial  healing  with  great  thickening  of  the 
walls  and  narrowing  of  the  lumen. 

{•i)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
pulmonary  tuberculosis.  The  lesions  are  chietly  in  the  ileum,  cnecum,  and 
c<jlon.  The  affection  begins  in  the  solitary  and  agminated  glands  or  on 
the  surface  of  or  within  the  mucosa.  The  caseation  and  necrosis  lead  to 
ulroiation,  which  may  be  very  extensive  and  involve  the  greater  portion  of 
the  mucosa  of  the  largo  and  small  bowels.  In  the  ileum  the  Peyer's 
patches  are  chiefly  involved  and  the  ulcer  may  bo  ovoid,  but  in  the 
jtjiinum  and  colon  the  ulcers  are  usually  round  or  transverse  to  the 
loDg  axil).  The  tuberculous  ulcer  has  the  following  characters  :  (ii)  It  is 
irifffular,  rarely  ovoid  or  in  the  long  axis,  more  frequently  girdling  the 
bowel,  {b)  The  edges  and  base  are  infiltrated,  often  caseous,  (r)  The 
subimicosa  and  muscularis  are  usually  involved ;  and  (</)  on  the  serosa 
may  be  seen  colonies  of  young  tubercles  or  a  well-marked  tuberculous 
lymphangitis.  Perforation  and  peritonitis  are  not  uncommon  events  in 
the  secondary  ulceration.  Stenosis  of  the  bowel  from  cicatrization  may 
occur;  the  strictures  may  be  multiple. 

Tuberculosis  of  the  rectntn  has  a  special  interest  in  connection  wi_th 
Ji-<tiila  ill  ano,  which,  according  to  Spillman's  statistics,  occurs  in  about 
'■>■■>  per  cent  of  cases  of  pulmonary  disease.  In  many  instances  the 
lesion  has  been  shown  to  be  tuberculous.  It  is  very  rarely  primary,  but 
if  the  tissue  on  removal  contains  bacilli  and  is  infective  the  lungs  are 
almost  invariably  found  to  be  involved.  It  is  a  common  opinion  that  the 
pulinouary  symptoms  may  develop  rapidly  after  the  fistula  is  cut.  This 
iiuiy  have  some  basis  if  the  operation  consists  in  laying  the  tract  oi)en, 
and  not  in  a  free  excision. 

('■])  Extension  from  the  perltonicum  may  excite  tuberculous  disease  in 
the  bowels.  The  affection  may  be  primary  in  the  peritonaeum  or  extend 
from  the  tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils 
of  intestines  become  matted  together,  caseous  and  suppurating  foci  de- 
velop between  the  folds,  and  perforation  may  take  place  between  the  coils 
ut  several  different  places. 


1  ] 


,    s  (I  f  1  I  J 


t    ■' 


242 


SPECIFIC  INFECTIOUS  DISEASES. 


VII.  Tuberculosis  of  the  Liver. 


Tins  organ  is  very  constiintly  involved  in  («)  general  tuberculosis. 
The  miliary  granulation  may  be  very  small  and  in  acute  cases  scarcelv 
perceptible.     Tlie  liver  is  pale  and  often  fatty. 

(/>)  A  remarkable  condition  of  the  organ  is  produced  by  the  devoloj). 
ment  of  the  tubercles  in  the  finer  bile-vessels.  They  may  attain  a  con- 
siderable size  and  are  almost  always  softened  in  the  centre,  resembling 
small  abscesses.  The  contents  are  always  bile-stained.  The  organ  itwv 
be  honeycombed  with  these  tuberculous  abscesses. 

(c)  Large,  coarse  caseous  masses  are  occasionally  found,  sometimes  in 
association  with  perihepatitis  or  tuberculous  peritonitis.  They  may  attain 
the  size  of  an  orange  or  larger. 

{(I)  Tuberculous  cirrhosis.  With  the  eruption  of  miliary  tubcrck's 
there  may  be  slight  increase  in  the  connective  tissue,  which  is  over- 
shadowed by  the  fatty  change.  In  all  the  chronic  forms  of  tubercle  in 
this  organ  there  may  be  fibrous  overgrowth.  Ilanot,  who  has  described 
several  varieties,  states  that  the  condition  may  be  primary.  Practically  it 
is  very  rare,  exce})t  in  connection  with  chronic  tuberculous  peritonitis  and 
perihepatitis,  when  the  organ  may  be  much  deformed  by  a  sclerosis  in- 
volving the  portal  canals. 

In  this  last  group  there  may  be  symptoms  of  ascites;  as  a  rule,  tuber- 
culosis of  the  liver  has  a  purely  anatomical  interest. 

VIII.  Tuberculosis  of  the  Brain  and  Cord. 

Tuberculosis  of  the  brain  occurs  as  (a)  an  acutemiliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus;  (b)  as  a  chronic  meningo-en- 
ccpiialitis,  usually  localized,  and  containing  small  nodular  tubercles;  and 
(c)  as  the  so-called  solitary  tubercle.  Between  the  last  two  forms  tliore 
are  all  gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The 
acute  variety  has  already  been  considered.  I  shall  here  consider  the 
chronic  form,  which  develops  slowly  and  has  the  clinical  characters  of  a 
tumor. 

It  is  most  common  in  tho  young.  Of  148  cases  collected  by  Pribram 
118  were  under  (if teen  years  of  age.  Other  organs  are  usually  involved, 
particularly  the  lungs,  the  broncliial  glands,  or  the  bones.  In  rare  in- 
stances no  tubercles  are  found  elsewhere.  They  occur  most  frequently  in 
the  cerebellum ;  next  in  the  cerebrum  and  then  in  the  pons.  The  growths 
are  often  multiple,  in  100  out  of  183  cases  (Gowers).  They  range  in  size 
from  a  pea  to  a  walnut;  larger  tumors  occasionally  occur,  and  sonu'tinir? 
an  entire  lobe  of  the  cerebellum  is  affected.  On  section  the  tubercle  pre- 
sents a  grayish-yellow,  caseous  appearance,  usually  firm  and  hard,  ami  en- 
circled by  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  be 
semi-diffluent.     As  in  other  localities  the  tubercle  may  calcify.    Tlie  tu- 


If '^  ■ 


TUBERCULOSIS. 


243 


mors  are  as  a  rule  attached  to  the  mejiinges,  often  to  the  pia  at  tlio  bottom 
of  a  sul-^us  so  that  they  look  imbedilod  in  the  brain-subatanco.  About  the 
lon^Mtudinal  fissure  there  may  be  an  aggregation  of  the  growths,  with 
oomi)rossion  of  the  sinus,  and  the  formation  of  a  thrombus.  The  tuber- 
culous tumor  not  infrequently  excites  acute  meningitis.  In  localized 
nieiiiugo-cnccphalitis  the  pia  is  thickened,  tubercles  are  adherent  to  the 
uiuler  surface  and  grow  about  the  arteries.  It  is  often  combined  with 
ecre])ral  softening  from  interference  with  the  circulation.  Several  of  the 
most  characteristic  instances  which  I  have  seen  were  on  the  meninges 
covering  the  insula.  This  form  may  develop  in  pulmonary  tuberculosis, 
causing  hemiplegia  or  aphasia  which  may  persist  for  months. 

Tlie  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 

In  the  spinal  cord  the  .same  forms  are  found.  The  acute  tuberculous 
meningitis  has  been  considered  and  is  almost  always  cerebro-spinal.  The 
solitary  tubercle  of  the  cord  is  rare.  Herter  has  reported  three  cases  and 
collected  twenty-four  instances  from  the  literature.  It  was  secondary  in 
all  save  one  case.    The  symptoms  are  those  of  spinal  tumor  or  meningitis. 


IX.   TUIIEUCL'LOSIS   OF   TilR   G  ENITO-UUINAUY    SYSTEM. 

('/)  Tuberculosis  of  the  Kidneys  {Phthisis  renum). — In  general  tuber- 
culosis the  kidneys  frequently  present  scattered  miliary  tubercles.    In  pul- 
monary tuberculosis  it  is  common  to  find  a  few  nodules  in  the  substance 
of  tiie  organ,  or  there  may  be  pyelitis.     Primary  tuberculosis  of  the  kid- 
neys is  not  very  rare.     In  a  majority  of  the  cases  the  process  involves  the 
pelvis  and  the  ureter  as  well,  sometimes  the  bladder  and  prostate.    In  only 
one  of  eight  cases  was  the  prostate  involved.     It  may  be  difficult  to  say  in 
advaneed  cases  whether  the  disease  has  started  in  the  bladder,  prostate,  or 
vesicles,  and  crept  up  the  ureters,  or  whether  it  started  in  the  kidneys  and 
proceeded  downward.     In  a  majority  of  oases  it  is,  I  believe,  the  latter, 
ivnd  tlie  infection  is  through  the  blood.     One  kidney  alone  may  be  in- 
volved, and  the  disease  creeps  down  the  ureter  and  may  only  extend  a 
few  millimetres  on  the  vesical  mucosa.     In  a  recent  instance  a  man  with 
aortic  insufficiency,  who  had  no  lesions  in  the  lungs,  presented  a  localized 
patch  in  tl)o  pelvis,  involving  a  pyramid,  while  the  ureter,  five  centimetres 
from  the  bladder  and  at  its  orifice,  was  thickened  and  tuberculous.     The 
prostate  showed  an  area  of  caseation.     It  is  most  common  in  the  middle 
period  of  life,  but  it  may  occur  at  the  extremes  of  age.     It  is  more  fre- 
quent in  men  than  in  women.     In  the  earliest  stage,  which  nuiy  be  met 
with  accidentally,  the  disease  is  seen  to  begin  in  the  pyramids  and  calyces. 
Nerrosis  and  caseation  proceed  rapidly,  and  the  colonies  of  tubercles  start 
tlirougliout  the  pyramids  and  extend  upon  the  mucous  membrane  of  the 
pelvis.    As  a  rule,  from  the  outset,  it  is  a  tuberculous  pyo-nephrosis.     The 
disease  may  be  confined  to  one  kidney,  or  progress  more  extensively  io 


2U 


SPECIFIC   INFECTIOUS  DISEASES. 


4*' 


■::  i  '■ 


flit- 


one  than  in  tho  other.  At  autopsy  both  organs  are  usually  found  enlarged. 
Ono  organ  may  be  completely  destroyed  and  converted  into  a  series  of  cysts 
containing  cheesy  substance;  a  form  of  kidney  which  the  older  writers 
called  scrofulous.  In  the  putty-like  contents  of  these  cysts  lime  salts  may 
be  deposited.  In  other  instances  the  walls  of  tho  pelvis  are  thickened  and 
cheesy,  the  pyramids  eroded,  and  caseous  nodules  are  scattered  through 
the  organ,  even  to  the  capsule,  which  may  be  thickened  and  adhorout. 
The  other  organ  is  usually  less  affected,  and  shows  only  pyelitis  or  a  super- 
ficial necrosis  of  one  or  two  pyramids.  Tho  ureters  arc  usually  thickened 
and  the  mucous  membrane  ulcerated  and  caseous.  Involvement  of  the 
bladder,  vcsiculae  scminalcs,  and  testes  is  not  uncommon  in  males. 

The  symptoms  are  those  of  pyelitis.  Tho  urine  may  bo  purulent  for 
years,  and  there  may  be  little  or  no  distress.  AVhen  the  bladder  becomes 
involved  micturition  is  frequent,  and  many  instances  are  mistaken  for  cys- 
titis. The  condition  is  for  many  years  compatible  with  fair  health.  The 
curability  is  shown  by  the  accidental  discovery  of  the  so-called  scrofulous 
kidney,  converted  into  cysts  containing  a  putty-like  substance.  In  cases 
in  which  the  disease  becomes  advanced  and  both  organs  are  affected,  con- 
stitutional symptoms  are  more  marked.  There  is  irregular  fever,  witli 
chills,  and  loss  of  weight  and  strength.  General  tuberculosis  is  common. 
In  only  one  of  my  cases  M'cre  tho  lungs  uninvolved.  In  a  case  at  tlie 
Montreal  General  Hospital  a  cyst  perforated  and  caused  fatal  peritonitis. 

Physical  examination  may  detect  special  tenderness  on  one  side,  or  the 
kidney  may  be  palpable  in  front  on  deep  pressure ;  but  tuberculous  pyelo- 
nephritis seldom  causes  a  large  tumor.  Occasionally  the  pelvis  becomes 
enormously  distended ;  but  this  is  rare  in  comparison  with  calculous 
pyelitis.  The  urine  presents  changes  similar  to  those  of  ordinary  calcu- 
lous pyelitis  —  pus-cells,  epithelium,  and  occasionally  definite  caseous 
masses.  Albumen  is,  of  course,  present.  Tubercle  bacilli  may  be  demon- 
strated by  the  ordinary  methods.     Tube-casts  are  not  often  seen. 

To  distinguish  the  condition  from  calculous  pyelitis  is  often  diflficult. 
Haemorrhage  may  be  present  in  both,  though  not  nearly  so  frequently  in 
the  tuberculous  disease.  Careful  examination  of  the  pus  for  tubercle 
bacilli  gives  most  important  information.  The  lungs  or  other  organs  may 
be  tuberculous. 

The  incidence  of  renal  in  uro-genital  tuberculosis  may  be  gathered 
from  Orth's  Gcittingen  material,  analyzed  by  Oppenheim.  Of  GO  cases 
there  were  34  in  which  the  kidneys  were  involved. 

(b)  Tuberculosis  of  the  Ureters  and  Bladder.— This  rarely  occurs  as 
a  primary  affection,  but  is  nearly  always  secondary  to  involvement  of  other 
parts,  particularly  the  pelvis  of  the  kidney.  In  tho  case  of  uro-genital 
tuberculosis,  above  mentioned,  in  a  patient  who  died  of  heart  disease,  the 
ureter,  just  where  it  enters  tho  bladder,  showed  a  fresh  patch  of  tuber- 
culosis. 

Protracted  cystitis,  which  has  come  on  without  apparent  cause,  is 


!;i'5 


■ '  ■'  < 


TUBERCULOSIS. 


245 


always  suggestive  of  tuberculosis.  The  renal  regions,  the  testes,  and  tlie 
prostate  should  be  examined  with  care.  It  may  follow  a  pyelo-nephritis 
or  bo  associated  with  primary  disease  of  the  prostate  or  vesicula)  semi- 
nales. 

(r)  Tuberculosis  of  the  Prostate  and  Vesiculo  Seminales.— The  pros- 
tate is  frequently  involved  in  tuberculosis  of  the  uro-gonital  tract.  In 
Krzyincki's  cases,  of  15  males  the  prostate  was  involved  in  14  and  the  ve- 
sicula) seminales  in  11.  In  Orth's  cases  the  prostate  M'as  involved  in  18 
of  the  37  cases  in  males.  These  parts  are  much  more  frequently  involved 
than  ordinary  post-mortem  statistics  indicate. 

(d)  Tuberculosis  of  the  Testes. — This  somewhat  common  affection 
may  bo  primary,  or,  more  frequently,  is  secondary  to  tuberculous  disease 
elsewhere.  Many  cases  occur  before  the  second  year,  and  it  is  stated  to 
have  been  met  with  in  the  foetus.  In  infants  it  is  serious  and  usually 
associated  with  tuberculous  disease  in  other  parts.  In  nine  cases  recently 
reported  by  Ilutinel  and  Deschamps  *  in  every  one  there  was  a  general 
allection.  In  20  cases  reported  by  Jullien  f  G  were  under  one  year,  and  6 
between  one  and  two  years  old.  In  five  of  the  cases  both  testicles  were 
ailcctcd.  Koplik  holds  that  most  of  the  cases  of  this  kind  are  congenital, 
in  Baiungarten's  sense.  In  the  adult  the  tubercles  begin  within  the  sub- 
stance of  the  gland,  but  in  children  the  tunica  albuginea  is  first  affected. 
Tlie  tubercle  does  not  always  undergo  caseation,  but  it  may  present  a 
number  of  embryonic  cells,  not  unlike  a  sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  syphilis. 
In  the  hitter  the  body  of  the  organ  is  most  often  affected,  there  is  less 
pain,  and  the  outlines  of  the  growth  are  more  nodular  and  irregular.  In 
obscure  peritoneal  disease  the  detection  of  tubercle  in  a  testis  has  not 
infref|uently  led  to  a  correct  diagnosis.  The  association  of  the  two  con- 
ditions is  not  uncommon.  The  lesion  in  the  testis  may  heal  completely, 
or  the  disease  may  become  generalized.  General  infection  has  followed 
operation. 

{f)  Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus.— The 
special  attention  which  has  been  paid  to  local  affections  of  these  parts  by 
gynecologists  has  taught  us  that  primary  tuberculosis  of  the  tubes  is  not 
at  all  uncommon.  Within  a  year  my  colleague,  Kelly,  has  oi)erated  upon 
five  or  six  cases.  The  disease  may  bo  primary  and  produce  a  most  char- 
acteristic form  of  salpingitis,  in  which  the  tubes  are  enlarged,  the  walls 
thickened  and  infiltrated,  and  the  contents  cheesy.  Adhesion  takes  place 
between  the  fimbrisB  and  the  ovaries,  or  the  uterus  may  be  invaded.  The 
condition  is  usually  bilateral.  It  may  occur  in  young  children.  Although, 
as  a  rule,  very  evident  to  the  naked  eye,  there  are  specimens  resembling 
ordiiiury  salpingitis,  which  show  on  microscopical  examination  numerous 
miliary  tubercles  (Welch  and  Williams).     Tuberculous  salpingitis  may 


■f 

1  , 


•  Archives  G6n6rales  do  MoJecine,  1891. 


t  Ibid.,  1890. 


240 


SPECIFIC  INFECTIOUS  DISEASES. 


cttuso  serious  local  disease  with  abscess  forinution,  and  it  may  bo  the 
starting-point  of  peritonitis. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  three  examplcH  Imvo 
come  under  my  observation,  all  in  connection  with  pulmonary  phthi>i.s. 
It  may  be  primary.  The  mucosa  of  the  fundus  is  thickened  and  caseous, 
and  tubercles  nuiy  be  seen  in  the  muscular  tissue.  Occasionally  the  pro- 
cess extends  to  the  vagina. 

X.    AUTEKIEa. 

Primary  tuberculosis  of  the  larger  blood-vessels  is  unknown.  The  dis- 
ease nuiy,  however,  occur  in  a  large  artery  and  not  result  from  external 
invasion.  In  a  case  of  chronic  phthisis  from  my  ward  Councilman  found 
a  fresh  tuberculous  growth  in  the  aorta,  which  had  no  connection  with 
cheesy  masses  outside  the  vessel. 

In  the  lungs  and  other  organs  attacked  by  tuberculosis  the  arteries  arc 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or 
tubercles  may  develop  in  the  walls  and  proceed  to  caseation  and  softening 
frequently  with  the  result  of  hemorrhage.  By  extension  into  vessels, 
particularly  veins,  the  bacilli  are  widely  distributed.  In  meningitis  tuber- 
culosis of  the  arteries  plays  an  important  role. 

XI.  The  Pnooxo.sis  in  TuBERccLObis. 

Not  all  persons  in  whoso  bodi(>s  the  bacilli  gain  a  foothold  present 
marked  signs  of  tuberculosis.  As  will  be  stated  in  the  next  section,  local 
disease  is  found  in  a  considerable  number  of  all  cadavers.  Infection  does 
not  necessarily  mean  tiie  establishment  of  a  progressive  and  fatal  disease. 
In  my  autopsies,  excluding  cases  dead  of  pulmonary  phthisis,  7*5  per  cent 
j)resented  tul)erculous  lesions  of  the  lungs — a  low  percentage  in  compari- 
son with  other  records,  as  I  carefully  excluded  the  simple  fibroid  pucker- 
ing at  the  apex  and  the  solitary  cheesy  nodule,  unless  surrounded  by  colo- 
nies of  tubercles. 

In  many  cases  a  natural  or  spontaneous  cure  is  effected,  for  the  condi- 
tions favorable  i..  *'o  development  of  the  disease  are  not  present— in 
other  words,  the  tissue-soil  is  unsuitable.  Apart  from  this  group,  a  ma- 
jority of  which  probably  do  not  show  any  sign  of  disease,  there  may  be 
spontaneous  arrest  after  the  symptoms  have  become  decided.  Many  years 
ago  Flint  called  attention  to  the  self-limitation  and  intrinsic  tendency  to 
recovery  in  well-marked  pulmonary  tuberculosis.  Of  his  670  cases,  44  re- 
covered, and  in  31  the  disease  was  arrested,  spontaneously  in  23  of  the 
first  group  and  in  15  of  the  second.  This  natural  tendency  to  cure  is 
still  more  strikingly  shown  in  lymphatic  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  jtrog- 
nosis  of  pulmonary  tuberculosis :  A  good  family  history,  previous  good 
health,  a  strong  digestion,  a  suitable  environment,  and  an  insidious  onset, 


TUIJKIICULOSIS. 


24^ 


wiilimit  high  fever,  iviul  without  oxtcTisivo  piicuinoiiic  cousolichition.  ('uses 
1).  j,'iimiiig  witli  pU'iirisy  seem  to  run  u  more  jtrotracted  iiud  more  favorable 
course.  Kepeuted  uttaeks  of  hu'iuoptysis  are  unfavorable.  When  well 
estal)lished  tlie  course  of  tuberculosis  in  any  organ  is  nuirked  by  intervals 
of  weeks  or  nu)ntlis  in  wliich  the  fever  lessens,  the  symptoms  subsidi',  and 
tlii'i'(  is  improvement  in  the  general  health. 

In  pulmonary  cases  the  duration  is  extremely  variable.  Laennec  ])la('ed 
[\\r  iiseiiige  duration  at  two  years,  an<l  for  the  nuijority  of  cases  this  is 
perliaps  a  correct  est  i mate.  Pollock's  largo  statistics  of  over  ;3,oOO  cases 
shows  a  iiicaii  duration  of  tlie  disease  of  over  two  years  and  a  half.  \\  ill- 
iums's  analysis  of  1,000  cases  in  i)rivatc  practice  .shows  a  much  more  pro- 
tractiMl  course,  as  the  average  duration  was  over  seven  years. 

Under  the  subject  of  prognosis  comes  the  question  of  the  marriage  of 
persons  wli<<  have  had  tuberculosis,  or  in  whose  family  the  disea.se  prevails. 
Tlie  following  brief  statements  may  be  made  with  reference  to  it : 

(d)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with 
personal  impunity  anil  nuiy  beget  healthy  children.  It  is  undeniable,  how- 
ever, that  in  such  families,  scrofula,  caries  of  the  bone,  arthriti.s,  cerebral 
iiiul  pidinonary  tuberculosis  are  more  comnmn.  Which  is  it,  "  heredita 
di'  graine  on  hercdite  de  terrain,"  as  the  French  hav(^  it,  the  seed  or  the 
soil,  or  both?  We  cannot  yet  say.  The  risks,  however,  are  such  us  may 
properly  be  taken. 

(/*)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured 
lung  tuberculosis  is  nu)re  dirtic^ult  to  decide.  If  a  nude,  the  persoiud  risk 
is  iu)t  so  great;  and  when  the  health  and  strength  are  good,  the  external 
enviroiiiuent  favorable,  and  the  family  history  not  extremely  bad,  the 
ex(HTinient — for  it  is  such — is  often  successful,  and  nnuiy  healthy  and 
iiappy  families  are  begotten  under  those  circumstances.  In  women  the 
i|iiestion  is  complicated  with  that  of  child-bearing,  which  increjises  the 
risks  enornujusly.  With  a  localized  lesion,  absence  of  hereditary  taint, 
;;ooJ  j)liysi(|ue,  and  favorable  environment,  marriage  might  be  permitted. 
When  iiilterculosis  has  existed,  however,  in  a  girl  whose  family  history  is 
liiul,  whose  chest  expansion  is  slight,  and  whose  physique  is  below  the 
standard,  the  physician  should,  if  possible,  place  his  veto  u})on  marriag*'. 

('•)  With  existing  disease,  fever,  bacilli,  etc.,  nuirriage  should  be  abso- 
lutely prohibited.  Pregnancy  and  parturition  hasten  the  jjroccss  in  almost 
every  ease.  There  is  nnu'h  truth,  indeed,  in  the  remark  of  Dubois:  "  If 
ii  woman  threatened  with  phthisis  niarries,  she  may  bear  the  tirat  ac- 
couehenient  well ;  a  second,  with  ditHiculty ;  a  third,  never." 

XII.    PUOIMIYLAXIS    IN   TrUKlK.'lLOSrs. 

{a)  Clvnrrdl. — The  sputa  of  phthisical  patients  should  be  carefully  col- 
lected aiul  tlestroycd.     Patie'its  should  be  urged  not  to  spit  about  care- 
lessly, but  alwavs  to  use  a  spit-cup.    Several  forms  of  portable  flasks  have 
17 


• 


248 


SPECIFIC   INFKCTIOUS  DISKASKS. 


been  (loviscd  and  nre  now  on  salo.  Tlie  deatnirtion  of  the  sputiv  of  cdti. 
BUinptivoH  hIiouM  bo  u  routine  ineusiire  in  both  liospitul  unci  iiriviite  jiiac- 
tico.  'l'lioroii<,'h  boilin;,'  or  puttinj,'  it  into  tlio  fire  is  sutVicicnt.  It  KhmiM 
be  exphiinod  to  i\w  piiticnt  timt  the  oidy  risk,  priU'ticiilly,  is  from  this 
source.  'I'iic  cimnci's  of  infection  arc  ^jjreater  in  youuf,'  cliildreti.  The 
nursing  and  care  of  consuui])tives  involve  very  sligiit  rislis  inciccil  if 
proper  precautions  are  taken.     The  ])atient  should  occui)y  a  single  bed. 

A  second  inijjortant  general  prophylactic  measure  relates  to  the  in- 
spection of  dairies  and  slaughter-houses.  The  possibility  of  the  transmis- 
sion of  tuberculosis  by  infected  milk  has  been  fully  demonstrated,  and  in 
the  interest  of  public  health  the  state  should  take  measures  to  stamp  out 
tuberculosis  in  cattle.  Systenuitic  veterinary  inspection  of  dairies,  par- 
ticularly in  the  largo  cities,  should  be  made,  and  full  power  grantcti  to 
coniiscate  and  kill  suspected  animals.  The  abattoirs  should  be  umier 
skilled  veterinary  control,  and  the  carcasses  of  aninuils  with  adviuictd 
tuberculosis  confiscated.  There  is,  however,  much  less  danger  of  infection 
through  meat  than  through  milk. 

{li)  Individual. — A  mother  with  pulmonary  tuberculosis  should  not 
suckle  her  child.  An  infant  born  of  tuberculous  parents,  or  of  a  family 
in  which  consumption  ])revails,  should  be  brought  up  with  the  greatest 
care  and  guarded  most  particularly  against  catarrhal  affections  of  all 
kinds.  Special  attention  should  be  given  to  the  throat  and  nose,  and  on 
the  first  indication  of  mouth-breathing,  or  any  obstruction  of  the  naso- 
pharynx, a  careful  examination  should  be  nmde  for  adenoid  vegetations. 
The  child  should  be  clad  in  flannel  and  live  in  the  open  air  as  much  as 
possible,  avoiding  close  rooms.  It  is  a  good  practice  to  sponge  the  tlinmt 
and  chest  night  and  morning  with  cold  water.  Special  attention  should 
be  paid  to  diet  and  to  the  mode  of  feeding.  The  meals  should  be  at  regu- 
lar hours  and  the  food  plain  and  substantial.  From  the  outset  the  cliild 
should  be  encouraged  to  drink  freely  of  milk.  Unfortunately,  in  these 
cases  there  seems  to  be  an  uncontrollable  aversion  to  fats  of  all  kinds. 
As  the  child  grows  ohler,  systematically  regulated  exercise  or  a  eoiiiso 
of  pulmonary  gymnastics  may  be  taken.  In  the  choice  of  an  occupa- 
tion preference  should  be  given  to  an  ont-of-door  life.  Families  with  a 
marked  predisposition  to  tuberculosis  should,  if  possible,  reside  in  an 
equable  clinuite.  It  would  be  best  for  a  young  man  belonging  to  such 
a  family  to  remove  to  Colorado  or  southern  California,  or  to  some  oflier 
suitable  climate,  before  trouble  begins. 

The  trifling  ailments  of  children  should  be  carefully  watched.  In  the 
convalescence  from  the  fevers,  which  so  frequently  prove  dangerous,  the 
greatest  caution  should  be  exercised  to  prevent  catching  cold.  Cod-liver 
oil,  the  syrup  of  iodide  of  iron,  and  arsenic  may  be  given.  As  mentioned. 
care  of  the  throat  in  these  children  is  very  important.  When  the  tonsils 
are  chronically  enlarged  they  should  be  removed.  •  "•  ^"^ 


TUUEltCULOSlS. 


XIII.    TUKATMKXT  OF   TrUKUdLOSIS. 


'249 


w 

1 

^ 

;  i    ■ 

■    - 

f 

( 

1 

!5i. 


I.  The  Natural  or  Spontaneous  Cure.— The  spontaiioouH  hniliiiR  of 
local  tubciH'ulosirt  is  an  i'Vi'ry-<liiy  utiair.  Many  cases  of  adenitis  and  dis- 
ease* of  the  bone  or  of  the  joints  terminate  favorably  without  the  aid  of 
iiiciiicines.  The  healin;,'  of  pulmonary  tuberculosis  is  shown  clinically  hy 
the  recovery  of  i)atient.H  in  whose  sputa  elastic  tissue  and  bacilli  have  been 
found  ;  atiiitomically,  by  the  i)resence  of  lesions  in  all  sta<,a's  of  repair.  In 
the  jfrunulation  products  and  associated  pneumonia  a  scar-tissue  is  formed, 
wliile  the  smaller  caseous  areas  i)ecome  im])ref?nated  with  lime  salts.  To 
Kiich  conditions  alone  should  the  term  healing  he  applied.  When  the 
fibroid  change  encapsulates  but  does  not  involve  the  entire  tuberculous 
ti.ssue,  the  tubercle  may  be  termed  involuted  or  quiescent,  but  is  not  de- 
stroyed. When  cavities  of  any  size  have  formed,  liealing,  in  the  proper 
sense  of  the  term,  does  not  occur.  I  have  yet  to  see  a  sjH'cimen  which 
would  indicate  that  a  vomica  had  cicatrized.  Cavities  nuiy  be  greatly 
reduced  in  size — indeed,  an  entire  series  of  cavities  may  be  m  contracted 
by  sclerosis  of  the  tissue  about  them  that  an  upper  lobe,  in  which  this 
process  most  frequently  occurs,  nuiy  be  reduced  to  a  third  of  its  ordinary 
(iiiiu'tisions.  Laennee  understood  thoroughly  this  luitufal  process  of  cure 
in  tuberculosis,  and  recognized  the  frequency  with  which  old  tuberculous 
lesions  occurred  in  the  lungs.  He  described  cica trices  compJHes  and  cica- 
trices  fisfulevsefi,  the  latter  being  the  shrunken  cavities  communicating 
Avitli  tlie  bronchi ;  and  suggested  that,  as  tubercles  growing  in  the  glands, 
wliicli  are  called  scrofula,  often  heal,  why  should  not  the  same  take  place 
iu  the  lungs? 

Tliere  is  an  old  German  axiom,  "Jedermmm  hat  am  Ende  ci'n  bischen 
Tuhcrndose,''^  a  statement  partly  borne  out  by  the  statistics  showing  the 
projKirtion  of  cases  in  persons  dying  of  all  diseases  in  whom  quiescent  or 
tulterculous  lesions  are  found  in  the  lungs.  We  find  at  the  apices  the 
following  conditions,  which  have  been  held  to  signify  healed  tuberculous 
processes :  (1)  Thickening  of  the  pleura,  usually  at  the  posterior  surface 
of  the  apex,  with  subadjacent  induration  for  a  distance  of  a  few  milli- 
metres. This  has,  perhaps,  no  greater  significance  than  the  milky  j)atch 
on  the  pericardium.  (2)  Puckered  cicatrices  at  the  apex,  depressing  the 
plenni,  and  on  section  showing  a  large  pigmented,  fibrous  scar.  The 
l)roiiehi()le3  in  the  neighborhood  may  be  dilated,  but  there  are  neither 
tutiircles  nor  cheesy  masses.  This  may  sometimes,  but  not  always,  indi- 
ciite  a  healed  tuberculous  lesion.  (3)  Puckered  cicatrices  with  cheesy  or 
cretiUM'ous  nodules,  and  with  scattered  tubercles  in  the  vicinity.  (4)  The 
cinttrirrH  fistnlettses  of  Laennee,  in  which  the  fibroid  puckering  has  re- 
'liii'od  the  size  of  one  or  more  cavities  which  communicate  directly  with 
tlie  bronchi. 

Ill  1,0110  autopsies,  excluding  the  216  cases  dead  of  phthisis,  there  were 
59  cases  (7-5  per  cent)  which  presented  undoubted  tuberculous  lesijus  in 


250 


SPECIFIC   INKKCTIOUS  DISEASES. 


tht'  lungs.  I  t'Xf'huU'd  the  siiiipU'  fibroid  pucki'rin;:^  and  the  .solitary  clitcsv 
nodiilos,  unless,  in  tin-  liitU'r  cuso,  tlu're  wcr*'  colonics  of  tiihoroli's  in  Uio 
vicinity.  Tlieso  5!)  cu-sos  died  of  viirious  dis«'a.so8  ar.d  at  various  ages.  A 
majority  of  tlu-ni  with  between  forty  and  sixty.  My  experience  tallies 
closely  with  tlie  lar;^'er  anal\sis  made  by  lleitlerof  tho  N'ienna  iiost-niortcin 
records,  in  which,  of  lii,r»(!"^  ca.se.s  in  wliicli  the  death  was  not  rlirectly  caused 
by  phthiriis,  there  wore  T80  instances  of  obsolete  tubercle — a  percentajro  oi 
4'7.  He  excluded,  as  1  have  done,  the  tiimpie  librohl  induration,  \ari- 
ous  ob.servation.s  iiavc  been  made  of  late  in  whic'.i  (lie  percentage  ranges 
from  t\venty-.si'ven  (Kullingjr)  to  thirty-nine  (.Miussini).  In  200  autoiL-ics, 
in  whicli  tiiifi  pojjit  was  specially  examined,  Harris  found  .'JHH  per  cent  in 
which  there  weni  relics  of  former  active  tuberculosis.  The  statement  is 
made  by  Moucliard  that,  of  the  post-mortems  at  the  Paris  morgue — gen. 
ciidly  upon  persons  ilyiug  suddenly — ilie  ])ercentage  found  with  s<ini(' 
evidence  of  tuln-n.-ulous  lesion,  active  or  oltsolete,  is  as  high  as  seventy-live. 
'I'lu'se  tigureti  show  the  extraordimiry  frequency  of  pulnuiiuiry  infection 
and  thfl  encouraging  fact  that  in  so  large  a  percentage  the  disease  remains 
local  an<l  undergoes  a  ))rocess  o.  arrest  or  healing. 

II.  General  Measvires. — Tiiere  are  thr«'e  indications — tirst,  to  plan-  the 
patient  in  surroundings  most  favorable  for  the  niaint(>nance  of  a  maxinuini 
degree  of  nutrition  ;  second,  to  take  such  measures  as,  in  a  local  or  general 
way,  inlluenco  the  tuberculous  processes;  third,  to  alleviate  symptom.s. 

Tlie  (piesfion  of  envirounuuit  is  of  lirst  importance  in  the  treat nimt 
of  tuberculosis,  ll  is  illtistruted  in  an  interesting  ami  practical  way  by  im 
experiment  of  TrudeiiU,  showiiif^  tliat  inoculuied  rabbits,  confined  in  a 
dark,  damp  place,  rapidly  succumb,  wliih;  otliers,  allowed  to  run  wi'd, 
either  r<-<-over  or  show  slight  lvsiitn.s.  It  is  the  sanu>  in  human  tubercu- 
losis. A  patient  conlincd  to  lUe  h(*use— particidarly  in  the  dose,  over- 
heated, HlulTy  dwellings  <»f  the  pytir,  or  treated  in  a  hmpital  ward— is 
in  a  position  analogous  to  the  rabbit  coulined  to  a  hutch  in  the  celliir; 
whereas  a  patient  living  in  the  fresh  aix  ami  sunshine  for  the  greater 
])art  of  tho  day  has  citanoos  oomparablo  to  those  of  the  rabbit  ruiuiiii).' 
wild. 

In  tho  majority  of  casoB  the  treatment  has  to  be  carried  out  at  liuine 
and  often  under  adverse  conditions.  Still,  much  can  be  done  if  the  putiint 
is  kept  out  of  doors  in  the  fresh  air  for  the  grenter  l>art  of  each  dav.  In 
pulmoiuiry  tidterculosis  iivithrr  tho  raii;//!,  the  ffi'vi't  tlw  tiit//it-Hii'r<i/s.  imr 
f/ir  /iiniiopfifsis  roiifrif-imlim/i's  this  riilr.  Only  when  the  wealli'r  in 
blustering  or  rainy  should  the  j)atient  renuiin  in  tho  house.  It  is  n  iiiMik- 
nble  how  (piickly  itnpn>vement  in  nuiny  instances  follows  this  frc>li-air 
treatHient.  In  cities  the  patient  can  be  wrapped  up  and  [daced  on  a  ci'fit 
or  in  a  reclining-cduiir  oii  tlie  balcctny  or  even  ii   the  yard. 

The  clinuitic!  treatnunt  of  tuberculosis  is  simply  a  modification  of  tlii« 
plan.  The  reqtiiroments  of  a  suitable  climate  are  n  pure  atniofiiilifrt, 
iii)  equable  temperature  not  subject  '     rapid  variations,  and  a  ma.rimu"' 


TUBERCULOSIS. 


251 


amoHut  of  sunshine.  Ciivon  these  three  factors,  and  it  makes  little  diff'^r- 
onci'  iv/icre  a  i)atient  goes  so  long  as  ho  lives  an  outiloor  life. 

TUti  purity  of  tiie  atmosphore  is  the  first  consideration,  and  it  is  this 
reqiiin'UH'iit  that  is  nii-t  so  well  in  the  mountains  and  forests.  Altitude  is 
.1  sicuiuiary  consideration.  'I'iie  rarefaction  of  the  air  in  higii  altitudes  is 
of  licuelit  in  increasing  the  respiratory  movements  in  pulmonary  disease, 
hill  lirings  about  in  time  a  comlition  of  dilatation  of  the  air-vesicles  and  a 
pcrmaiiiMit  increiuse  in  the  size  of  tiuj  chest  whicli  is  a  nuirked  disadvan- 
tiC'r  wlicn  such  persons  attempt  aiibseijiu-ntiy  to  reside  at  tlie  sea-h-vi'l. 

'{"lie  temperature  of  tlie  air  is  also  a  minor  consideration,  so  long  as  it 
is  ImI(  rahly  e(puil)le  and  not  sui)ject  to  rapid  variations.  Tht^  winter  cli- 
iiialcs  of  the  Adirondacks,  of  (,'olorado,  or  of  Davos  have  the  advantage  of 
a  slfinlv  cold  comhiiu'd  wiili  siinshiue,  just  as  the  resorts  of  the  Southern 
Stiiits  ami  California, and  of  tlu?  soiilli  of  l''raiu;e  and  l'.,ii^ ,  have  a  tolerably 
iinit'oriii  iiigii  temi)erature  with  the  maximum  amount  of  sunshine.  Tiie 
iliviicss  of  the  air  is  certainly  an  important  though  not  an  essential  factor. 
That  it  is  not  essential  is  .seen  in  the  good  results  obtaiiieil  in  the  re.sorts 
at  ilie  sea-level,  si.'ch  as  Florida,  or  even  'I'onpiay  or  Falmouth,  on  the 
.•<i)iith  coast  of  Mngl.ird — one  of  tluj  most  humid  atmospheres  in  the  world. 

Other  considera  ions  which  should  inlluenco  the  choice  of  a  locality 
aiv  good  accommodations  and  gooil  food.  Very  much  is  said  concerning 
the  clioi(!o  of  locality  in  the  ditTercnt  stages  of  pulmonary  tuberculosis, 
hilt,  when  tlic  disi>a.so  is  limited  to  an  apex,  in  a  man  of  fairly  good  p-rsotial 
;i:;.i  family  history,  the  idiances  are  that  he  iuay  light  a  winning  battle  if 
111'  lives  out  of  doors  in  any  climate,  whether  high,  dry,  and  ••old  or  low, 
iiiiii.st,and  warm.  With  bilateral  di.seaseand  «^avity  formation  there  is  but 
liltli  hope  of  permanent  cure,  auo  the  mild  or  warm  climates  are  preferable. 

WiiillitT  a  patient  should  go  from  home  or  not  is  a  grave  cpiestion 
whirli  till!  ])hysician  is  called  upon  to  d(>cide.  It  is  untloubtedly,  in 
iiiaiiv  instances,  a  positive  hardship  to  send  away  a  patient  with  tolerably 
ailvauccd  tuberculosis.  With  well-marked  cavities,  liecli(\  fiver,  iiight- 
swfiiis,  iiiid  emaciation  he  is  better  at  home,  and  the  physician  should  not 
he  too  iinieh  inlliieiiced  by  the  importunities  of  the  patient  or  his  friends. 
A'lv.iiiceil  ca-ses  and  persons  with  feeble  hearts  should  never  be  sent  to  high 
iiltiiinles.  (Jf  .\nierican  reso'-ts  I  prefer  thi?  .\dirondacks  for  early  cases. 
The  patient  should  go  in  October,  so  as  to  become  gradually  ai'customed 
'"  ihe  cold.  It  is  accessible,  the  winter  climate  is  admirable,  and  the 
iMiiip-life  ilelightfiil.  As  the  reports  of  Saranac  .Sanitarium  show,  recent 
ttilii  iviilosis  docs  remavkalily  wt^ll.  Personally  I  have  seen  better  results 
fri.m  tile  .\.lironilacks  than  from  any  other  place.  Colorado  and  southern 
'Mlifiii'iiiii  have  this  a<l vantage  for  early  cases — they  are  progressive,  pros- 
pi'rnii<  countries  in  which  .  '.lan  may  iind  means  of  livelihood  und  live 
III  '■(■nfort.* 


*  On  th'  ([lu'stion  of  eliniate,  Yi'o's  work  aiay  bo  conKUItod  with  advantage. 


252 


SPFXIFIC  INFECTIOUS  DISEASES. 


Under  this  section  reference  may  bo  maile  to  the  question  of  the  treat- 
ment of  tuberculosis  in  siiniluria.  The  larfjfor  cities  should  build  sperial 
institutions  within  easy  access  by  railway,  with  pleasant  surroundiuirh.  in 
which  early  cases  of  pulmonary  tuberculosis  among  the  poor  couhl  be 
syatematically  treated.  Advanced  ca^os  should  not  be  admitted,  but  sluaild 
be  cared  for  in  separate  wanls  of  the  city  hosjjitals.  Sanitaria  for  the  tare 
of  recent  pulmonary  tuberculosis  among  the  well-to-do  classes  are  also 
urgently  jieeded.  The  results  obtained  at  Falkenstcin  near  Frankfurt 
a.  M.  (which  certainly  has  iu)thing  special,  as  far  as  climate  is  copceriieii) 
and  at  the  Sarauac  Sanitarium  illustrate  how  much  can  be  done  by  method 
and  care. 

III.  Measures  which,  by  their  Local  or  General  Action,  influence  the 
Tuberculous  Process. —  Under  this  heading  we  may  consider  the  S2)eeiiic, 
the  dietetic,  and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  The  Spirific  Treatment. — A  glycerin  extract  of  the  cultures  df 
tubercle  bacilli  was  found  by  Koch  to  have  a  specilic  action  upon  tubercu- 
lous tissue.  The  iullueiice  of  this  tuberculin,  as  it  is  called,  is  best  seen 
in  lupus,  uj)on  wliicli  it  exercises  an  extraordinary  elTcct,  unique  in  the 
liistory  of  the  action  of  remedies.  An  injection  of  one  milligramme  i.s 
followed,  in  a  few  hours,  by  intense  constitutional  and  local  reaction. 
The  atfected  tissues  swell  enormously,  ami  the  adjacent  parts  are  deeply 
(congested.  Crusts  form  upon  the  surface,  the  swelling  and  inflammation 
gradually  8u])side,  and  a.'U'r  several  injections  the  lu])us  masses  gradually 
disappear  ami  arc  replaced  by  a  white  cicatricial  ti.ssue.  Even  in  advaiufil 
cases  of  long  duration  the  action  is,  in  a  majority  of  cases,  ])rompt  anil 
beneficial.  Therc^  is  a  great  difVicidty,  however,  in  getting  rid  of  the  tiiial 
remmmts  of  the  lupus  tissue,  and  a  combination  of  scraping  with  the 
tuberctdin  will  probably  always  be  needed. 

In  internal  tuberculosis  the  remedy,  in  very  early  oaf?c8,  may,  as  shnwn 
by  Koch's  reports,  prove  actually  curative;  unfortmuitely,  it  was  empldvcij 
in  all  elassis  of  cases.  In  pidtnonary  tubercidosis  it  is  a  remedy  to  be  used 
with  the  greatest  c;aution.  Of  twenty-three  cases  in  which  we  have  nsuil 
it  at  the  Johns  Hopkins  IIosj)ital,  only  three  were  benefited ;  in  the  others 
(he  action  was  either  negative  or  actually  dotrimetital.  It  should  net  .n' 
eniployed  in  cases  with  fever  or  with  much  consolidation.  In  many  casis 
it  seems  to  aggravate  the  general  and  local  sytnptoms. 

We  are  at  present  in  the  reaction  wave,  after  being  buoyed  up  by 
hopes  that  at  last  a  remedy  had  been  obtained  which  was  positively  cura- 
tive in  all  forms  of  tuberculous  lesions.  It  will  probably  be  several  uars 
before  we  can  sjieak  with  deei.sion  upon  the  true*  position  of  this  reiiutly. 
Mcanwliilc  our  knowledge  warrants  us  in  urging  extreme  caution  in  its 
use.  The  recent  reports  of  Schede  indicate  that  the  remedy  has  a  very 
positive  value  in  tuberculous  arthritis  when  combined  with  other  im  as- 
nres. 

(/>)  Dietetic  Treatment. — The  outlook  in  tuberculosis  depemls  imicb 


TUBERCULOSIS. 


253 


upon  tlic  digestion.  It  is  rare  to  see  recovery  in  a  case  in  whieli  there  is 
(KTsi-stont  gastric  trouble,  and  tiie  pliysician  sliould  ever  bear  in  mind  the 
fact  tiiat  in  tliis  disease  the /;r//Hfl5  vim  control  the  position.  The  early 
nausea  and  loss  of  appetite  in  many  cases  of  phtliisis  are  serious  obstacles. 
Many  patients  loathe  food  of  all  kinds.  A  change  of  air,  or  a  sea  voyage 
will  promptly  restore  the  appetite.  When  this  is  impossil)U>,  and  if,  as  is 
almost  always  the  case,  fever  is  present,  the  patient  should  be  placed  at 
iTst,  kept  in  the  open  air  nearly  all  day,  and  fed  at  stated  intervals  with 
small  (piantities  either  ,f  milk,  buttermilk,  or  koumyss,  alternating  '.f 
necessary  with  meat  juice  and  egg  albumen.  Some  cases  whi(;h  are 
disturbed  by  eggs  and  milk  do  well  on  koumyss.  It  may  be  necessary 
to  ri'sort  to  Deimve's  method  of  over-alimentation  or  forced  feeding.  The 
stomacli  is  first  washed  out  with  cold  water,  and  then,  through  the  tube, 
a  mixture  is  given  containing  a  litre  of  milk,  an  e^^g,  and  one  hundred 
jrranuues  of  very  linely  powdered  meat.  This  is  given  three  tinu's  a  day. 
S()nietinu\s  the  patients  will  take  this  mixture  without  the  unpleasant  ne- 
cessity of  the  stouuich-tube,  \u  which  case  a  smaller  amount  may  be  given. 
I  can  speak  of  the  advantage  of  tin.-;  pbui  in  cases  in  whiidi  the  gastric 
symptoms  have  been  obstimite  and  tiistressing,  and  the  general  cxiiressiou 
ot  opinion  is,  in  such  instances,  very  favorable  to  this  plan  of  treatment. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  rei'iarkable  i.ow  rapidly  the  appetite  and 
(ligestioii  improve  on  the  fresh-air  treatment,  even  in  cases  which  havu 
to  lenuiin  in  the  city.  Care  should  be  taken  that  the  ineilicines  do  not 
disturb  the  stomach.  Not  infrequently  the  sweet  syrups  used  in  the 
couirli  mixtures,  cod-liver  oil,  creasote,  and  the  hyp<)])hosphites  produce 
irritation,  and  by  interfering  with  digestion  do  more  harm  than  good. 
On  the  oliu'r  hand,  the  bitter  tonics,  with  acids,  and  tlie  various  malt 
picparations  are  often  in  these  cases  most  satisfactory.  The  indications 
lor  alcohol  in  tuberculosis  are  enfeebled  digestion  with  fever,  a  weak 
heart,  and  rapiil  pulse.  A  routine  administration  is  not  advisable,  and 
there  is  no  eviilence  that  its  })ersistent  use  promotes  libioid  pnux'sses  in 
the  tid)erculous  areas.  In  the  advaiu-ed  stages,  particularly  when  the 
letiiperature  is  low  between  «'ight  and  ten  in  the  mornins',  whiskv  and 
milk,  or  whisky,  egg,  and  milk  uiay  be  given  with  great  advantage.  Tlie 
reil  uiiu's  are  also  benelici.d  in  moderate  (jnantilies. 

(')  ilnii'nd  Mciliriil  7'/7'(f///(r///. —No  medicinal  agents  have  any  special 
'M'  peculiar  action  upon  tubercidous  processes.  The  inlluence  which  they 
exert  is  upon  the  gei.eral  nutrition,  increasing  the  physioloifical  resist- 
Miii  (■  and  rt'iiderijig  the  tissues  less  »useeptible  to  invasion.  The  f(d- 
lowijig  are  the  most  iinftortant  ren*«riies  which  schmu  to  act  in  this 
luaiiiier  : 

'rw^o/c,  which  may  I)*  administered  in  capsule.!,  in  iie'ieasing  doses, 
l>ei:iiining  with  one  minim  three  times  a  day  and,  if  well  Imrni*,  increas- 
iiii:  the  dose  to  eight  or  ten  minims.     It  nuiy  also  be  g:\cn  in  solution 


I      t     :-   ti 


it!  " 


I  ft 


,3 
■J'l 


254 


SPECIFIC   INPFX'TIOUS  DISEASES. 


with  tincture  of  oardiunom  and  alcohol.  It  is  an  old  remedy,  strongly 
recomnieiuk'd  by  Addison,  and  the  reports  of  Jaecoiid,  Fraentzel,  and 
many  otlicrs  show  that  it  has  a  positive  value  in  the  disease.  Ciiiaiarril 
may  be  given  as  a  suli.stitute,  either  internally  or  hypodennieaily.  In  Idl 
ca.se8  in  whicii  it  was  used  at  my  clinic,  by  Meredith  Reese,  the  eliiif 
action  was  on  the  cough  and  expectoration,  which  were  much  lessened,  but 
the  remedy  had  no  essential  influence  on  the  ])rogress  of  the  disease. 

Cod-lirer  Oil. — In  filanduiar  and  bone  tuberculosis,  this  remedy  is 
undoubtedly  beneficial  in  improving  the  nutrition.  In  pulmomiry  tuber- 
culosis its  action  is  less  certain,  and  it  is  scarcely  worthy  of  the  unljouiided 
confidence  which  it  enjoyed  for  so  many  years.  It  should  be  given  in 
sinall  doses,  not  more  than  a  teaspoonful  three  times  a  day  after  meals. 
It  seems  to  act  better  in  chiMrea  than  in  adults.  When  it  is  not  well 
borne,  a  dessertspoonful  of  rich  cream  three  times  a  day  is  an  excellent 
substitute.     The  clotted  or  Devonshire  cream  is  preferable. 

77/^!  Hiiju^phosphites. — These  ii:  various  forms  are  useful  tonics,  but 
it  is  diiubtful  if  they  have  any  other  action.  They  certaii\ly  exercise  no 
specific  influence  upon  tubercle.  They  may  be  given  in  the  form  of  the 
syrup  of  the  hvpctphosphites  of  calcium,  sodium,  and  potassium  of  tlie 
U.  S.  W 

Arsntir. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  than  Fowler's  solution.  It  may  be  given  in  five-minim 
do.ses  three  times  a  day  and  gradually  increased ;  stopping  its  use  when- 
ever unpleasant  6ymj)tom8  arise,  and  in  any  case  intermitting  it  evi'iv 
third  or  fourth  week. 

()iu>  or  two  special  methods  of  dealing  with  pulmonary  tuberculosis; 
nuiy  fiero  be  mentioned.  Tiie  local  treatment,  by  direct  injection  into  liii' 
lungs,  has  been  practi-sed  since  its  strong  advocacy  by  Pepper.  It  has, 
however,  not  gained  the  general  support  of  the  profession,  and  is  oeea- 
sionally  followed  by  serious  results.  As  a  rule,  it  may  be  practised  with 
impunity,  and  the  injections  may  be  made  with  a  long  hypoileriiiic 
needle  into  any  j)ortion  of  the  lung  which  is  diseased.  Iodine,  carbulic 
acid,  creasoto  (three  per  cent  solution  in  almond  oil),  and  iodoform  liave 
been  used  for  the  purpose.  'IMie  remarkable  results  which  surgeons  have 
recently  obtained  in  the  treatment  of  joint  tubereidosis  by  injections  of 
iodoform  point  to  this  as  a  remedy  which  will  probably  j>rove  of  service 
when  injected  directly  into  the  lungs. 

Treatment  by  coujpressed  aii  is  in  many  cases  beneficial,  and  iimltr 
its  use  the  appetite  inqjioves,  there  is  gain  in  weight,  and  reduction  of  ilic 
fever.     The  air  may  be  saturated  with  creasote. 

I  v.  Treatment  of  Special  Symptoms  in  Pulmonary  Tiibercuiosis.  (") 
The  Fever. — There  is  no  more  difheult  problem  in  practical  therapeutics 
than  the  treatment  of  the  pyrexia  of  tuberculosis,  The  patient  shonM  1h' 
at  rest,  aiul  when  practicable  wheeled  into  the  fresh  air  for  as  long  a  time 
!is  po.ssible  during  the  day.     Fever  does  not  contra-indieate  an  out-of-<loor 


TUBERCULOSIS. 


256 


life,  but  it  is  well  for  patients  with  a  temj>oratiire  above  101**  or  102°  to 
hv  ;it  rest.  For  the  continuous  ])yrexia  or  the  remittent  type  of  the  early 
staiii'S,  quinine,  small  doses  of  cli<^italis,  and  the  salii-ylates  may  be  tried; 
but  they  are  uncertain  and  rarely  reliable.  Under  no  circumstances  is 
tliiit  priceless  remedy,  quinine,  so  much  abused  as  in  the  fever  of  tubercu- 
losis. In  largo  doses  it  has  a  moderate  antipyretic  action,  but  it  is  just 
in  these  eflicient  doses  that  it  is  so  apt  to  disturb  tlie  stomach. 

Autipyrin  and  antifebrin  iiuiy  be  used  cautiously;  but  it  is  better, 
wlicii  tlie  fever  rises  above  1(I3 ',  to  rely  uj)on  cold  sponging  or  the  tepid 
IkiiIi,  gradually  cooled.  When  softening  has  taken  })lace  and  the  fever 
as^iiiiics  the  characteristic  septic  ty)>e,  the  problem  becomes  still  nujre 
(litliiiilt.  As  shown  by  Chart  XIII  (which  is  not  by  any  means  an  ex- 
ceptional one),  the  pyrexia,  at  this  stage,  lasts  only  for  twelve  or  fifteen 
liDiirs.  As  a  rule  it  is  not  more  than  from  eight  to  ten  hours  in  which 
the  fever  is  high  enough  to  demand  antipyretic  treatment.  Sometimes 
aiitift'brin,  given  in  two-grain  doses  every  hour  for  three  or  four  hours 
before  the  rise  in  temperature  takes  place,  either  prevents  entirely  or 
limits  the  paroxysm.  If  the  temperature  begins  to  rise  between  two  and 
throe  in  the  afternoon,  the  antifebrin  may  be  given  at  eleven,  twelve,  one, 
and,  if  necessary,  at  two.  It  answers  better  in  this  way  than  given  in  the 
single  doses.  Careful  sponging  of  the  extremities  for  from  half  an  hour 
to  an  hour  during  the  height  of  the  fever. is  useful.  Quinine  is  of  little 
benefit  in  this  type  of  fever;  the  salicylates  still  less. 

{/))  Swv<ttin;i. — Tho  atropine,  in  doses  of  gr.  jfs-^,  and  the  aromatic 
sulphuric  acid  in  large  doses  are  the  best  remedies.  When  there  are 
cough  and  nocturnal  restlessness,  an  eighth  of  a  grain  of  nutrjihia  may 
he  given  Avith  the  atropine.  Muscarin  (n),  v  of  a  one  per  cent  sohitidu), 
tiiK'tuiT  of  mix  vomica  (Tli  xxx),  picrotoxin  (gr.  ^)  may  he  tri(!d.  The 
patient  should  use  light  llannel  night-dresses,  as  the  cotton  night-shirts, 
when  soaked  with  perspiration,  have  a  very  unpleasiiut  cold,  clammy 
fri'liii','. 

(' )  'I'lio  atufjh  is  a  troublesome,  tliough  noce.>'sarv,  feature  in  pulmo- 
nary tuberculosis.  Uidess  very  worrying  and  disturbing  sleep  at  night, 
or  so  severe  as  to  produce  vomiting,  it  is  not  well  to  attemj)t  to  restrict 
it.  When  irritative  and  bronchial  in  character,  inhalations  are  useful, 
|mrti(ul;irly  the  tincture  of  benzoin  or  jireparations  of  tar,  creiuoote,  or 
turiKiitine.  \\  ■  throat  should  be  carefully  examined,  as  some  of  the 
most  i-riLvblc  and  distressing  forms  of  cough  in  phthisis  result  from 
liiryiii  -al  erosions.  The  distressing  nocturnal  cough,  which  lu'gins  just  as 
the  jMti'  ,'  /.'ts  '  )  bed  and  is  preparing  to  fall  asleep,  requires,  as  a  rule, 
Itrcpa-  .,?  of  Oj.ium.  C'odeia,  in  quarter  or  half  grain  dos(>s,  or  the 
ii\TU[i  ,  oodehc  (3j)  may  be  given.  An  excellent  combination  for  the 
iii'iiiu'n.il  oougb  of  {)hthisis  is  morphia  (gr.  |-J),  dilute  hydrocyanic  acil 
("l  ij  iij),  and  iyrup  of  wild  cherry  (3j)-  The  spirits  of  chloroform, 
1^.  1'..  or  the  :ni8turn  chloroformi,  U.  S.  P.,  or  IIolTmau's  anodyne,  given 


p 
I 


vl'      '. 


%t  I 


' !  ! "  > 


A.'. 


256 


SPECIFIC  INFECTIOUS  DISEASES. 


nt 


in  wliisky  before  goiiig  to  sleep,  arc  efficacious.  Mild  counter-irritation, 
or  the  application  of  a  hot  j)oultice,  will  sometimes  promptly  relieve  the 
cough.  In  the  later  stages  of  the  disease,  when  cavities  have  formed,  tlie 
accumulated  secretion  must  be  expectorated  and  the  paroxysms  of  cougliing 
are  now  most  exhausting.  The  sedatives,  such  as  morphia  and  hydrot  yaiiic 
acid,  should  be  given  cautiously.  The  aromatic  spirits  of  ammonia  in  full 
doses  help  to  allay  the  paroxysm.  When  the  expectoration  is  profuse, 
creasoto  internally,  or  inhalations  of  turpentine  and  iodine,  are  useful. 

{(I)  For  the  diarrhma  large  doses  of  bismuth,  combined  with  Dover 
powder,  and  snuiU  standi  eneinata,  with  or  without  opium,  may  be  given. 
The  acetate  of  lead  ami  opium  pill  often  acts  promptly,  and  the  acid  diar- 
rlui'a  mixture,  dilute  acetic  acid  (iti,  x-xv),  mor^thia  (gr.  |),  and  acetulf  of 
lead  (gr.  j-ij),  may  be  tried. 

{v)  The  treatment  of  the  haemoptysis  will  be  considered  in  the  section 
on  hmmorrliage  from  the  lungs.  Dyspnu'a  is  rarely  a  prominent  symiitoi'i 
except  in  the  advanced  stages,  when  it  may  be  very  troublesome  and  dis- 
tressing.    Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  may  be  strapped  or  painted 
with  tincture  of  iodine.  The  dyspeptic  symptoms  require  careful  treat- 
ment, as  the  outlook  in  individual  cases  depends  much  upon  the  condition 
of  the  stomach.  Small  doses  of  calomel  and  soda  often  allay  the  liis- 
tressing  nausea  of  the  early  stage. 


XXVII.    LEPROSY. 

Definition. — A  chronic  infectious  disease  caused  by  the  bacillus 
lepfu'y  cli.iracterized  by  the  presence  of  tubercular  nodules  in  the  skin 
and  mucous  membranes  (tubercular  leprosy)  or  by  changes  in  the  iiii\i» 
(ana'sthetic  leprosy).  At  lir.st  these  forms  may  be  separate,  but  iilti- 
mattdy  botii  are  conil)ine(l,  and  in  the  characteristic  tubercular  form  then' 
are  disturbances  of  .sensation. 

£tiology. — The  disease  is  very  widely  si)read,  and  within  the  jtast 
few  years  renewed  atti'iition  has  been  directed  to  it,  owing  to  a  belief  lliat 
it  is  greatly  on  the  increase.  It  is  oiu>  of  the  oldest  of  known  disi  asts. 
At  present  it  ])revails  widely,  ]mrti('ularly  in  hot  countries.  In  India  it  is 
estinuited  that  there  are  over  X'.'it •,()()()  lepers.  In  Kuroj)e,  where  it  pre- 
vailed in  the  middle  ages,  it  has  become  almost  unknown  ex('<'pt  i" 
Norway  and  in  the  Orient.  On  this  continent  leprosy  exists  in  tiic 
(Jidf  States  and  extensively  in  Mexico.  At  Key  West  Herger  .states 
that  there  are  one  hundred  cases,  and  Uluiu'  found  forty  lepers  in  New 
Orlean.s.  A  few  isolated  cases  arrive  from  timo  to  time  in  tho  cities  of 
tlie  Atlantic  coast.  In  the  Northwestern  StateH  a  few  cases  exist  anmii!: 
the  "Norwegian  and  Icelandic  settl«T«.  On  the  Tacitic  coast  cases  are  si'tu 
not  infre<pu'nlly  among  the  Chine.st'.     .\u  endemic  focus  is  at  Tracadie, 


LKPROSY. 


257 


Nrw  Hnins'vvick.  A  few  oases  are  also  met  with  in  Capo  Breton,  N,  S. 
At  Tracadie,  wliicli  is  on  a  bay  of  the  (Julf  of  St.  Lawrence,  the  disease  is 
iiiiiitt'd  to  two  or  three  countie--  whii-h  are  settled  by  French  Canadians. 
'i'lii-  ilisease  was  imported  from  X(»rmandy  about  the  end  of  the  hist 
ceiiliiry.  The  cases  are  confined  in  a  lazaretto,  to  which  they  are  sent  so 
soon  as  the  disease  is  maTiil'est.  I  made  a  visit  to  the  settlement  two  years 
usjo  with  the  medical  oflicer,  A.  A.  Smith,  of  Chatham,  at  which  time 
tlicrc  were  only  eighteen  ))atients  in  the  hosj)ital.  It  is  interesting  to 
note  that  the  disease  has  gradually  diminished  by  segregation ;  formerly 
tlicrc  were  over  forty  under  surveillance. 

In  the  Sandwich  Islands  leprosy  has  developed  to  an  enormous  extent. 
Morrow  states  that  in  1880  there  were  1,100  lepers  iu  the  settlement  at 
.Molukai, 

In  the  West  Indies  the  disease  has  l)een  long  endemic,  and  Beavan 
Kakf,  of  Triniilad,  has  contributed  some  of  the  most  interesting  of  recent 
clinical  and  pathological  studies. 

The  disease  attacks  all  classes  and  ju'rsons  of  all  ages.  It  is  probably 
couniumicated  by  contagion.  Inoculation  was  successfully  jjerformed  by 
Ariiiug  in  a  Hawaiian  convict,  (iraham,  vvlio  some  years  ago  carefully 
investigated  the  Tracadie  settlement,  came  to  the  conclusion  that  the 
disease  was  there  probably  transmitted  by  contagion  ;  and  A.  A.  Smith, 
the  prtwcnt  medical  oflicer,  tells  mo  that  he  knows  of  no  facts  which  are 
opposfd  to  that  view.  It  is,  however,  oidy  contagious  in  the  same  sense 
as  svphilis,  and  just  as  accidental  contamination  with  this  virus  is  ex- 
trciiit'Iv  rare  so  il  is  with  leprosy.  The  closest  possible  contact  nuiy  take 
lilaci!  for  years,  as  between  parent  aiul  child,  without  transmi.-'.sion,  and 
nut,  one  of  the  Sisters  of  CHiarity  who  hr.ve  for  more  than  forty  years  so 
faiilifiiliy  nursed  the  lepers  at  Tracadie  has  contracted  tlse  disciiso.  It 
is  ilillicult  to  explain  ti»e  rapid  spread  of  the  disease  in  the  Saridwich 
Islands  on  any  other  view  tlnm  contagion,  and  yet  it  is  stiange  that  there 
is  no  evidence  of  a  primary  lesion  or  extermd  sore  comparable  to  that  of 
syphilis.  Morrow  states  that  "  in  the  imuicnse  majority  of  ca.ses  the 
(lisi'asf  is  propagated  by  sexual  congr.ss.'" 

The  disapjH'arance  of  the  disease  in  the  middle  ages  no  doidit  resulted 
ilir('<tly  from  the  isolation  enforced  at  that  time,  'i'he  disease  has  possi- 
Itly  in  some  instances  be(>n  transmitted  by  vai'cinalion.  Hereditary  trans- 
mission cannot  be  excluded,  and  there  is  no  good  ri'ason  why  the  disease 
siuiuld  not  be  connnunicateil,  as  is  sypiiilis,  from  ))arent  to  child. 

.lonalhan  Hutchinson  believes  thatthedisea.se  is  always  associated  with 
siinii'  special  kind  of  food,  particularly  lish.  Though  he  does  not  deny  the 
spiMMlic  nature  of  the  dis"ase  or  the  jiossibility  of  contairinii,  lie  wouid 
liialvc  apparently  tht^  lish  diet  the  tiiiiiiin  i/idd  whicii  rcndtTs  the  patient 
s'.iseeptible,  or,  if  I  gather  aright  from  his  recent  communication,  with 
"liieli  the  poison  may  be  taken.  The  facts  which  are  numifost  at  the 
Traeadic  settlement  are  very  much  opposed  to  this  view.     If  a  fish  diet 


253 


SPECIFIC  INFECTIOUS   DISEASES. 


could  alono  in  any  way  iniluoo  tlie  discaso,  by  tliis  time  loprosy  would  be 
wide-spread  in  the  counties  along  the  Uulf  of  St.  liawrencc,  as  tlsh  is  the 
main  article  of  diet  winter  and  summer.  There  is  not  the  slightest  dillVr- 
ence  in  race,  the  mode  of  life,  or  in  the  surroundings  of  the  inhal)itaiils- 
in  the  regions  adjacent  to  Caraciuet  and  Tracadie,  and  yet  leprosy  lias 
been  for  nearly  a  century  limited  to  two  or  three  counties. 

The  Bacillus  Leprae. —  Hansen,  of  Bergen,  first  discovered  this  oriran- 
ism,  which  has  many  points  of  resemblance  to  the  bitrilliis  fii/ii'iriildsin, 
but  can  be  dilTerentiated  from  it.  It  occurs  in  extraordinary  numbers  in 
the  tubeniulous  tissue.  It  has  been  cultivated  successfully  (Babes),  but 
inocidation  experiments  on  animals  have  been  lu'gative. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  gninulimm- 
tous  tissue  made  up  of  cells  of  various  sizes  in  a  connective-lissue  matrix. 
The  bacilli  in  extraordinary  nundjcrs  lie  partly  between  aiul  ]>artly  in  the 
cells.  The  growth  gradually  involves  the  skin,  producing  tuberous  out- 
growths with  intervening  areas  of  ulcenition  or  cicatrization,  which  in  \\\v 
face  may  gradually  produce  the  so-called  /(tries  leonfiiia.  The  mmons 
membranes,  particularly  the  conjunctiva,  the  cornea,  the  larynx,  may  bo 
gradually  involved.  In  many  cases  deep  ulcers  form  Avhich  result  in 
extensive  loss  of  substance  or  loss  of  fingers  or  toes,  the  so-called  hpni 
mutilans.  In  ana'sthctic!  leprosy  there  is  a  ])eripheral  neuritis  due  to  llie 
development  of  the  bacilli  in  the  nerve-fibres.  Indeed,  this  involvetmiit 
of  the  nerves  i>lays  a  primary  i>art  in  the  etiology  of  many  of  the  im- 
portant features,  particidarly  the  tro])hic  changes  in  the  skin  and  the 
disturbances  of  sensation. 

Clinical  Forms.— («)  Tubercular  Leprosy.— Prior  to  the  nppiai- 
ance  of  the  iu)dules  there  are  areas  of  cutaneous  erythenui  which  may  be 
sharply  deliiu'd  and  often  hypera'Sthetic.  This  is  sometimes  known  as 
macular  leprosy.  The  alfected  spots  in  time  become  pigmented.  In  some 
instances  this  su|)erficial  change  continues  without  the  development  of 
nodules,  tiie  areas  become  aiu-vsthctic,  the  pigment  gradually  disa])[Hais, 
and  the  skin  gets  perfectly  white — the  lepra  alba.  Among  the  iiatimis 
at  Tracadi  J  it  was  particidarly  interesting  to  see  three  or  four  in  this  early 
stage  presenting  on  the  face  aiul  forearms  a  ])atchy  erythema  Avith  s!ii:ht 
swelling  of  the  skin.  'IMie  diagnosis  of  the  condition  is  jjcrfectly  i  tear, 
though  it  may  be  a  long  time  before  any  other  than  sensory  cliaii,i;es 
develop.  The  eyelashes  and  eyebrows  and  the  hairs  on  the  face  fidl  out. 
The  mucous  membranes  finally  become  involved,  particularly  the  uioiilh, 
throat,  and  larynx  ;  the  voice  becomes  harsh  and  finally  aphonic.  l)('alh 
results  not  infre(picntly  from  the  laryngeal  complications  and  aspiration 
pneumonia.  The  conjunctivae  are  frequently  attacked,  and  the  sight  is 
lost  by  a  leprous  keratitis. 

{//)  AnsBsthetic  Leprosy. — This  remarkable  foi-m  has,  in  chara:-teiistic 
cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually 
begins  with  pains  in  the  limbs  ami  areas  of  hyperaesthesia  or  of  numbness. 


OLANDEIIS. 


259 


\'iry  early  there  may  bo  tropliic  clmiiges,  Been  in  the  formation  of  small 
bulla'  (Ilillis).  Maculiu  appear  upon  the  trunk  and  extreniitics,  ami  after 
pcisisling  for  a  variable  time  gradually  disappear,  leaving  areas  of  ana'S- 
thc'sia,  but  the  loss  of  sensation  nuiy  come  on  independently  of  the  out- 
l)rtak  of  maoulie.  The  nerve-trunks,  where  superlicial,  may  be  felt  to  be 
laifre  and  nodular.  The  trophic  disturbances  are  iisually  nuirked.  Pem- 
pliiiriis-like  bullaj  develop  in  the  affected  areas,  which  break  and  leave 
iilcciH  which  may  be  very  destructive.  The  fingers  aiul  toes  are  liable  to 
('(•iitrui'turcs  and  to  necrosis,  so  that  in  chronic  cases  the  phalanges  are 
lost.  The  course  of  aniesthetic  leprosy  is  extraordinarily  chronic  and  may 
persist  for  years  without  leading  to  much  deformity.  Oiu!  of  the  most 
prominent  clergymen  on  this  continent  has  had  ana'sthetic  leprosy  for 
more  than  thirty  years,  which  until  recently  has  not  seriously  interfered 
witli  liis  usefulness,  and  not  in  the  slightest  with  his  career. 

Diagnosis. — Even  in  the  early  stage  the  dusky  erythematous  maculiB 
with  liyper:esthesia  or  areas  of  ami'sthesia  are  very  characteristic.  In  an 
advanced  grade  neither  the  tubercular  nor  ana'sthetic  forms  could  possi- 
bly be  mistaken  for  any  other  affection. 

Treatment. — There  are  no  s{iecitic  remedies  in  the  disease,  and  gen- 
eral tonics  combined  with  local  treatment  meet  the  only  available  indica- 
tions. The  gurjun  and  chaulmoogra  oils  have  been  recommended,  the 
former  in  doses  of  from  five  to  ten  minims,  the  latter  in  two-drachm  doses. 
The  eases  should  be  isolated,  although  the  risk  of  catching  the  disease  by 
direct  contagion  is  extremely  slight. 


XXVIII.  GLANDERS  {Farcy). 


Definition. — An  infectious  disease  of  the  horse,  communicated  ooca- 
siimiiiiy  to  man.  In  the  horse  it  is  characterized  by  the  formation  of 
uudiiies,  chiefly  in  the  nares  (glanders)  and  beneath  the  skin  (farcy). 

Etiology. — The  disease  belongs  to  the  infective  granulomata.  The 
liira!  manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to 
one  and  the  same  cause.  The  specific  germ  was  discovered  by  Loeffler 
and  Sclii'itz.  It  is  a  short,  non-motile  bacillus,  not  unlike  that  of  tubercle. 
It  LMows  readily  on  the  ordinary  culture  media.  For  the  fidl  recognition 
of  glanders  in  man  we  are  iiulel)tcd  to  the  labors  of  Kayer,  whoso  mono- 
gra[iii  remains  one  of  the  best  descriptions  ever  given  of  the  disease. 
Man  becomes  infected  by  contact  with  diseased  animals,  aiul  usually  by 
iniHulation  on  an  abraded  surface  of  the  skin.  The  contagion  may  also 
be  neeived  on  the  mucous  membrane.  Iti  one  of  tlie  Montreal  cases  a 
genilonian  was  probably  infected  by  the  material  expelled  from  the  nos- 
tiiis  of  his  horse,  which  was  not  suspected  to  have  the  disease. 

Morbid  Anatomy. — As  in  the  horse,  the  disease  may  be  localized 
in  I  In  nose  (glanders),  or  beneath  the  skin  (farcy).     The  essential  lesion 


200 


SPECIFIC  INFECTIOUS  DISEASES. 


IJS'   i' 

i.F<|- •  ;• 

m ,: 

1 

If  f 

•f " ; '  J  ^  :' 

^I'l- 

1  t 

f':  I    ;, 

is  the  pranulonmtoiiH  tumor,  clmrartorizod  by  the  prescnco  of  niitnt'ioiis 
lymphoid  and  opithflioid  cells,  iimoii;r  and  in  which  arc  Hocn  thu  ^luinicrg 
bacilli,  'riicsft  nodular  ma.'i.Hc.s  tend  to  l)rcak  down  riipidly,  and  on  the 
mucou8  nicrnbrano  form  ulcers,  while  beneath  the  skin  they  form  ah- 
hccsscf).     The  j^l  inderH  nodulcrf  may  also  occur  in  the  internal  or^ms. 

S3n3iptom8. — An  acute  and  a  chronic  form  of  glanders  miiy  be  recog- 
nized in  man,  and  an  acute  and  a  (dironic  form  of  farcy. 

Aoute  Glanders. — The  period  of  incubation  is  rarely  more  than  tlircc 
or  four  days.  There  are  sif,'nH  of  g(?neral  febrile  (listurl)anc('.  At  the 
place  of  infection  there  are  swellinjj,  red nesH,  and  lymplian^iti.s.  Within 
two  or  three  days  there  ia  involvement  of  the  mueou.s  membrane  of  the 
nose,  the  nodules  break  down  rapidly  to  ulcers,  and  there  is  a  muco- 
purulent discharije.  An  eruption  of  j)apules,  which  rapidly  become  jmst- 
ules,  breaks  out  over  tlie  face  and  about  the  joints.  It  has  been  mistukcn 
for  variola.  This  was  carefully  studied  by  Kayer  and  is  li^^ured  in  his 
moiioju^raph.  In  a  Montreal  case  this  copious  eruption  led  the  attending 
physician  to  suspctit  small-pox,  and  the  patient  was  isolated.  There  is 
j^reat  swelliuf^  of  the  iu»se.  The  ulceration  may  go  on  to  necrosis,  in 
which  case  the  discharge  is  very  otfensive.  The  lymph-glands  of  the  neck 
are  usually  much  enlarged.  Subacute  pneumonia  is  very  apt  to  develop. 
Th's  form  runs  its  course  in  about  eight  or  ten  days,  and  is  invarial)ly 
fatal. 

Chronic  glanders  is  rare  and  difficult  to  diagnose,  as  it  is  usually 
mistaken  for  a  chronic  coryza.  There  are  ulcers  in  the  nose,  and  often 
laryngeal  symptoms.  It  may  last  for  months,  or  even  longer,  and  recovery 
sometimes  takes  jdace.  The  diagnosis  may  be  extremely  dillicult.  In 
such  cases  cultures  should  be  made  and  portions  of  the  pure  culture  inocu- 
lated in  the  guinea-j)ig.  The  animal  dies  within  thirty  hours,  and  the 
testicles  are  found  to  be  enormously  swollen  and  already  in  the  condition 
of  abscess. 

Acute  farcy  in  man  results  usually  from  the  inoculation  of  the  virus 
into  the  skin.  There  is  an  intense  local  reaction  with  a  phlegmonous  in- 
llammation.  The  lymphatics  are  early  affected,  and  along  their  course 
there  are  nodular  subcutaneous  enlargements,  the  so-called  farcy  buds, 
Avhich  may  rapidly  go  on  to  suppuration.  There  are  juiins  and  swt'Iling 
in  the  joints  and  abscesses  may  form  in  the  muscles.  The  symptoms  are 
those  of  an  acute  infection,  almost  like  an  acute  septicaemia.  The  nose  is 
not  involved  ajid  the  superficial  skin  eruption  is  not  common. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  fifteen  days. 

Chronic  farcy  is  characterized  by  the  presence  of  localized  tumors,  usu- 
ally in  the  extremities.  These  tumors  break  down  into  abscesses,  Jind 
sometimes  form  deep  ulcers,  without  much  inflammatory  reaction  aiul 
without  specirl  involvement  of  the  lymphatics.  The  disease  may  last  for 
months  or  oven   years.     Death  may  result  from  pyaemia,  or  occasionally 


ACTINOMYCOSIS. 


20.1 


[li'iito  plainlcra  di'volops.  The  oclcbriitcd  Kroticli  vctfriusirian,  Houloy, 
liaii  it  iiiitl  rccoviTt'd. 

Tlu)  (lisciiHt*  is  triinsiniHsihIo  also  from  man  t(»  man.  Waslicr-womcii 
liiivc  litfii  infi'cted  from  tho  clothes  of  a  patit'iit.  In  tlu?  diajL^nosis  of  this 
atl'iction  the  ocfiiiiatinii  is  very  important.  Nowadays,  in  casi-s  of  doidtt, 
the  inoculation  shoidd  be  madu  in  animals,  as  in  this  way  the  disease  can 
be  readily  tlelermined. 

Treatment. — If  Htrn  early  the  wound  shoidd  be  either  cut  out  or 
tlioniii;;hly  destroyed  by  caustics,  and  an  antiseptic  dressing;  applied.  The 
fiircy  buds  should  be  early  opened.  In  the  acute  cases  there  is  very  littlo 
hope.     In  the  chronic  cases  recovery  is  possible,  thouyh  often  tedious. 


XXIX.  ACTINOMYCOSIS. 

Definition. — A  chronic  inflammatory  affection  produced  by  the  acti- 
noinyces  or  ray-fungus. 

Etiology. — The  disca.so  is  wide-spread  amoiifi;  outtle,  and  occurs  also 
in  the  pi,i(.  It  was  first  described  by  Hollinger  in  the  ox,  in  which  it  forms 
the  alTection  known  in  this  country  as  "  big- jaw."  Kxaniples  of  the  dis- 
ciiso  were  common  in  the  cattlo  killed  at  the  abattoir  in  Montreal,  In  man 
tlif  disease  was  first  described  by  James  Israel,  and  subse(piently  Ponllck 
insisted  upon  the  identity  of  the  disease  in  man  and  cattle. 

In  this  country  and  in  England  the  disease  is  rare,  and  only  u  few 
eases  have  been  described.  Although  familiar  with  the  affection  in  cuttle 
since  1878,  and  constantly  on  the  lookout  for  the  disease,  no  instance  hjis 
fallen  under  my  personal  observation. 

The  pdi'd.site  is  a  fungus  belonging  to  the  species  ('htdnlhri.r.  In  l)oth 
man  and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region  as  small 
yellowish  granules  from  one  half  to  two  millimetres  in  diameter.  MicTo- 
scopically  these  bodies  are  seen  to  bo  made  up  of  thnads  which  railuite 
from  a  centre  and  present  bulbous,  clnb-iike  terminations.  Hostrom  has 
rcociitly  p\iblished  an  elaborate  research  on  their  structure  and  develoj)- 

IlU'Ilt. 

The  parasite  has  been  successfully  cidtivated  and  the  disease  has  been 
inoiulated,  both  with  the  natural  and  artificially  grown  fungus. 

The  Mode  of  Infection. — The  fungus  has  not  been  detected  outside  the 
'.iinly.  It  seems  highly  probable  that  it  is  taken  in  with  the  food.  The 
site  of  infection  in  a  majority  of  cases  in  man  and  animals  is  in  the  mouth 
nr  luiiihboring  passages.  In  the  cow,  possibly  also  in  nuin,  ears  of  barley 
<ir  iir  have  been  carriers  of  'he  fu.-.gus. 

Morbid  Anatomy.— In  tin  earliest  stages  of  its  growth  the  para- 
site LMves  rise  to  a  snudl  grans  iaiioM  tumor,  not  unlike  that  jjroduced  by 
the  IniriUuH  tubemilosis,  which  contains,  in  addition  to  small  rouiul  cells, 
oiiithelioid  elements  and  giant  cells.     After  it  reaches  a  certain  size  there 


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262 


SPECIFIC  INFECTIOUS  DISEASES. 


is  great  proliferation  of  the  surrounding  connective  tisei.e,  and  the  growlh 
may,  particularly  in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo- 
sarcoma. Finally  suppuration  occurs,  which,  according  to  Israel,  may  be 
produced  directly  by  the  fungus  itself. 

Clinical  Forms.— («)  Alimentary  Canal.— Israel  is  said  to  have 
found  the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  has  been  in- 
volvcd  in  a  number  of  cases  in  man.  The  patient  comes  under  observa- 
tion with  swelling  of  one  side  of  the  face,  or  with  a  chronic  enlargement 
of  the  jaw  which  may  simulate  sarcoma.  In  the  case  described  by  JJoda- 
mer  at  the  German  Hospital,  Philadelphia,  the  swelling  involved  the 
right  side  of  the  face,  the  temporal  region,  and  the  neck ;  there  were  nu- 
merous sinuses,  and  the  case  had  the  appearance  of  chronic  necrosis  of  the 
bones. 

The  tongue  has  been  involved  in  several  cases,  forming  small  growths, 
which  in  one  instance  were  primary,  in  the  others  secondary  to  disease  of 
the  jaw.  In  the  intestines  the  disease  may  occur  either  as  a  pi-imary  or 
secondary  affection.  At  the  Charite  in  Berlin  in  1884  I  saw  with  Oscar 
Israel  a  remarkable  instance  in  which  there  were  actinomycotic  ulcers  in 
the  small  intestines.  Cases  have  been  reported  of  pericaecal  abscess  due 
to  the  fungus.  An  instance  of  primary  actinomycosis  of  the  large  intes- 
tine with  metastases  has  also  been  described.  The  liver  may  be  affected 
primarily,  as  in  the  case  reported  by  Sharkey  and  Acland, 

(b)  Pulmonary  Actinomycosis.- In  September,  1878,  James  Israel  de- 
scribed a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent 
observation  showed  to  be  the  affection  described  the  year  before  by  Bol- 
linger in  cattle.  Since  that  date  thirty-four  instances  have  been  reported 
in  which  the  lungs  were  affected,  Hodenpyl  has  analyzed  these  and 
reports  two  cases  from  the  Roosevelt  Hospital, 

It  is  a  chronic  infectious  disorder  of  the  lungs,  characterized  by  cough, 
fever,  wasting,  and  a  muco-purulent,  sometimes  foetid,  expectoration.  The 
lesions  are  unilateral  in  a  majority  of  the  cases,  Hodenpyl  classifies  them 
in  three  groups :  (1)  Lesions  of  chronic  bronchitis ;  in  one  case  the  diag- 
nosis was  made  by  the  presence  of  the  actinomyces  in  the  sputum,  (2) 
Miliary  actinomycosis,  closely  resembling  miliary  tubercle,  but  the  nodules 
are  seen  to  be  made  up  of  groups  of  fungi,  surrounded  by  granulation 
tissue.  This  form  of  pulmonary  actinomycosis  is  not  infrequent  in  oxen 
with  advanced  disease  of  the  jaw  or  adjacent  structures,  (3)  The  eases 
in  which  there  is  more  extensive  destructive  disease  of  the  lungs,  broncho- 
pneumonia, interstitial  changes,  and  abscesses,  the  latter  forming  cavities 
large  enough  to  be  diagnosed  during  life.  Actinomycotic  lesions  of  other 
organs  are  often  present  in  connection  with  the  pulmonary  disease :  ero- 
sion of  the  vertebrae,  necros's  of  the  ribs  and  sternum,  subcutaneous  ab- 
scesses, and  occasionally  metastases  in  all  parts  of  the  body. 

Symptoms. — The  fever  is  of  an  irregular  type  and  depends  largely  on 
the  existence  of  suppuration.     The  cough  is  an  important  symptom,  and 


ACTINOMYCOSIS. 


263 


the  diagnosis  in  eighteen  of  the  cases  was  made  during  life  by  the  discov- 
ery of  the  actinomyces.  Death  results  usually  with  septic  symptoms. 
Occasionally  there  is  a  condition  simulating  typhoid  fever.  The  average 
duration  of  tlie  disease  was  ten  months.  Of  the  thirty-four  cases  all  died 
except  two.  Clinically  the  disease  closely  resembles  certain  forms  of  pul- 
monary tuberculosis  and  of  fcctid  bronchitis.  It  is  not  to  be  forgotten  in 
the  examination  of  the  sputum  that,  as  Bizzozcro  mentions,  certain  degen- 
erated epithelial  cells  may  resemble  the  fungus.  The  radiating  leptothrix 
threads  about  the  epithelium  of  the  mouth  sometimes  present  a  striking 
resemblance. 

{c)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  disease  of  the  skin  the  ray-fungus  has  been  found.  It 
is  a  very  chronic  affection  associated  with  the  development  of  tumors 
which  suppurate  and  leave  open  sores  which  m"y  remain  for  years.  It 
resembles  tuberculosis  of  the  skin. 

(d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain.  The  symptoms  were  those  of  tumor.  A 
second  remarkable  case  has  been  reported  by  Gamgee  and  Delepine. 
Tlio  patient  was  admitted  to  St.  George's  Hospital  with  left-sided  pleural 
effusion.  At  the  post-mortem  three  pints  of  purulent  fluid  were  found  in 
the  left  pleura;  there  was  an  actinomycotic  abscess  of  the  liver,  and  in  the 
brain  there  were  abscesses  in  tlie  frontal,  parietal,  and  temporo-sphenoidal 
lobes  which  contained,  the  mycelium,  but  no  clubs.  A  third  case,  re- 
ported by  0.  B.  Keller,  had  emjryema  necessitatis,  which  was  opened 
and  actinomyces  were  found  in  the  pus.  Subsequently  she  had  Jack- 
Bonian  epilepsy,  for  which  she  was  trephined  twice  and  abscesses  opened, 
whicli  contained  actinomyces  grains.  Death  occurred  after  the  second 
operation. 

Diagnopls. — The  disease  is  often  mistaken  for  and  is  in  reality  a 
chronic  pytemia.  The  only  test  is  the  presence  of  the  actinomyces  in  the 
pus.  Metastases  may  occur  as  in  pycemia  and  in  tumors.  The  tendency, 
however,  is  rather  to  produce  a  local  purulent  affection  which  erodes  the 
bones  and  is  very  destructive.  In  cattle  the  disease  may  cause  metastases 
without  any  suppuration ;  thus  in  a  Montreal  case  the  jaw  and  tongue 
were  the  seat  of  the  most  extensive  disease  with  very  slight  suppuration, 
while  the  lungs  presented  numbers  of  secondary  growths  containing  the 
fungus, 

Treatmen*,— This  is  largely  surgical  and  is  practically  that  of  py- 
aemia. Incision  of  the  abscess,  removal  of  the  dead  bone,  and  thorougb 
irrigation  are  appropriate  measures. 


|ii  t¥' 


18 


\-^\ 


264 


SPECIFIC  INFECTIOUS  DISEASES. 


XXX.  INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE. 


J;  r 

In:; 


H:^  m 


(1)  FEBRICULA— EPHEMERAL  FEVER. 

Deflnition. — Fever  of  slight  duration,  probably  depending  upon  a 
variety  of  causes. 

A  febrile  paroxysm  lasting  for  twenty-four  hours  and  disappearing  com- 
pletely is  spoken  of  as  ephemeral  fever.  If  it  persists  for  three,  four,  or 
more  days  without  local  affection  it  is  referred  to  as  febricula. 

The  Ciises  may  be  divided  into  several  groups : 

(a)  Those  which  represent  mild  or  abortive  types  of  the  infectious 
diseases.  It  is  not  very  infrequent,  during  an  epidemic  of  typhoid,  scarlet 
fever,  or  measles,  to  sc^.  cases  with  some  of  the  prodromal  symptoms  and 
slight  fever  which  persist  for  two  or  three  days  without  any  distinctive 
features.  I  have  already  spoken  of  these  in  connection  with  the  abortive 
type  of  typhoid  fever.  Possibly,  as  Kahler  suggests,  some  of  the  cases  of 
transient  fever  are  due  to  the  rheumatic  poison. 

(b)  In  a  larger  and  perhaps  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intes- 
tinal  catarrh  are  often  accompanied  by  fever.  Possibly  some  instances 
of  longer  duration  may  be  due  to  the  absorption  of  certain  toxic  sub- 
stances. Slight  fever  has  been  known  to  follow  the  eating  of  decompos- 
ing substances  or  the  drinking  of  stale  beer;  but  the  gastric  juice  has 
remarkable  antiseptic  properties,  and  the  frequency  with  which  persons 
take  from  choice  articles  which  are  "  high,"  shows  that  poisoning  is  not 
likely  to  occur  unless  there  is  existing  gastro-intestinal  disturbance. 

(f)  Cases  which  follow  exposure  to  foul  odors  or-  sewer-gas.  That  a 
febrile  paroxysm  may  follow  a  prolonged  exposure  to  noxious  odors  has 
long  been  recognized.  The  cases  which  have  been  described  under  this 
heading  are  of  two  kinds ;  an  acute  severe  form  with  nausea,  vomiting, 
colic,  and  fever,  followed  perhaps  by  a  condition  of  collcnse  or  coma; 
secondly,  a  form  of  low  fever  with  or  without  chills.  A  good  deal  of 
doubt  still  exists  in  the  minds  of  the  profession  about  these  cases  of  so- 
called  sewer-gas  poisoning.  It  is  a  notorious  fact  that  workers  in  sewers 
are  remarkably  free  from  disease,  and  in  many  of  the  cases  which  have 
been  reported  the  illness  may  have  been  only  a  coincidence.  There  are 
instances  in  which  persons  have  been  taken  ill  with  vomiting  and  slight 
fever  after  exposure  to  the  odor  of  a  very  offensive  post-mortem.  Whether 
true  or  not,  the  idea  is  firmly  implanted  in  the  minds  of  the  laity  that  very 
powerful  odors  from  decomposing  matters  may  produce  sickness. 

{(l)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions, 
such  as  tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Chil- 
dren are  much  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptly,  though  in  some  instances 
there  may  have  been  preliminary  malaise  and  indisposition.    Headache, 


INFECTIOUS  DISEASES  OF  DOUBTFUL  CUARACTER. 


265 


loss  of  appetite,  and  furred  tongiio  are  present.  Tlie  urine  is  scanty  and 
high-colored,  the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it 
rises  higher.  The  cheeks  may  be  flushed  and  the  patient  has  the  outward 
iniinifestations  of  fever.  In  children  there  may  be  bronchial  catarrh  with 
slight  cough.  Herpes  on  the  lips  is  a  common  symptom.  Occasionally 
in  children  the  cerebral  symptoms  are  marked  at  the  outset,  and  there 
may  be  irritation,  restlessness,  and  nocturnal  delirium.  The  fever  termi- 
nates abruptly  by  crisis  from  the  second  to  the  fourth  day ;  in  some  in- 
stances it  may  continue  for  a  week. 

The  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and  most 
important  of  all  the  rapid  disappearance  of  the  pyrexia.  The  cases  most 
read,     recognized  are  those  with  acute  gastro-intestinal  disturbance. 

The  treatment  is  that  of  mild  pyrexia — rest  in  bed,  a  laxative,  and  a 
fever  mixture  containing  nitrate  of  potash  and  sweet  spirits  of  nitre. 


(2)  WEIL'S  DISEASE. 

Acute  Febrile  Icterus. — In  188G  Weil  described  an  acute  infectious 
(list'ase,  characterized  by  fever  and  jaundice.  Much  discussion  has  taken 
jilaco  concerning  the  true  nature  ol  this  affection,  but  it  has  not  been 
definitely  determined  whether  it  is  a  specific  disease  or  only  a  jaundice 
which  may  be  due  to  various  causes.  The  majority  of  the  cases  have  oc- 
curred during  the  summer  months.  The  cases  have  occurred  in  groups  in 
different  cities.  A  few  cases  have  been  reported  in  this  country  (Lan- 
pliear).  Males  are  most  frequently  affected.  Many  of  the  cases  have  been 
in  butchers.     The  age  of  the  patients  has  been  from  twenty-five  to  forty. 

The  disease  sets  in  abruptly,  usually  without  prodromata  and  often 
with  a  chill.  There  are  headache,  pains  in  the  back,  and  sometimes  in- 
tense pains  in  the  legs  and  muscles.  The  fever  is  characterized  by  marked 
remissions.  Jaundice  appears  early.  The  liver  and  spleen  are  usually 
swollen ;  the  former  may  be  tender.  The  jaundice  may  be  light,  but  in 
many  of  the  cases  described  it  has  been  of  the  obstructive  form,  and  the 
stools  have  been  clay-colored.  Gastro-intestinal  symptoms  are  rarely  pres- 
ent. The  fever  lasts  from  ten  to  fourteen  days ;  sometimes  there  are  slight 
recurrences,  but  a  definite  relapse  is  rare. 

Albumen  is  usually  present  in  the  urine ;  ha?maturia  has  occurred  in 
some  cases. 

Ccebral  symptoms,  delirium  and  coma,  have  been  met. 

In  the  few  post-mortems  which  have  been  made  nothing-  distinctive 
has  been  found.  Its  occurrence  as  an  independent  malady,  apart  from 
other  infectious  processes,  has  scarcely  yet  been  definitely  established. 


266 


SPECIFIC   INFECTIOUS  DISEASES. 


(3)  MILK-SICKNESS. 

This  remarkable  disease  prevails  in  certain  districts  of  the  United 
States,  west  of  the  Alleghany  Mountains,  and  is  connected  with  the  affec- 
tion in  cattle  known  as  the  trembles.  It  prevailed  extensively  in  the  early 
settlements  in  certain  of  the  Western  States  and  proved  very  fatal,  'i'lio 
general  opinion  is  that  it  is  communicated  to  man  only  by  eating  the  flesh 
or  drinking  the  milk  of  rliseased  animals.  The  butter  and  cheese  are  also 
poisonous.  In  animals,  cattle  and  the  young  of  liorses  and  sheep  are  most 
susceptible.  It  is  stated  that  cows  giving  milk  do  not  themselves  show 
marked  symptoms  unless  driven  rapidly,  and,  according  to  Graff,  the  secre- 
tion may  be  infective  when  the  disease  is  latent.  When  a  cow  is  very  ill, 
food  is  refused,  the  eyes  are  injected,  the  animal  staggers,  the  entire  mus- 
cular system  trembles,  and  death  occurs  in  convulsions,  sometimes  with 
great  suddenness.  Nothing  definite  is  known  as  to  the  cause  of  the  dis- 
ease.    It  is  most  frequent  in  new  settlements. 

In  man  the  symptoms  are  those  of  a  more  or  less  acute  intoxication. 
After  a  few  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains 
in  the  stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is 
usually  obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the 
breath  is  extremely  foul  and,  according  to  Graff,  is  as  characteristic  of  the 
disease  as  the  odor  is  of  small-pox.  Cerebral  symptoms — restlessness, 
irritability,  coma,  and  convulsions — are  sometimes  marked,  and  there  may 
gradually  be  produced  a  typhoid  state  in  which  the  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  forms  death 
occurs  within  two  or  three  days.  It  may  last  for  ten  days,  or  even  for 
three  or  four  weeks.  Graff  states  that  insanity  occurred  in  one  case.  The 
poisonous  nature  of  the  flesh  and  of  the  milk  has  been  demonstrated  ex- 
perimentally. An  ounce  of  butter  or  cheese,  :r  four  ounces  of  the  beef, 
raw  or  boiled,  three  times  a  day  will  kill  a  dog  within  six  days.  No  defi- 
nite pathological  lesions  are  known.  Fortunately,  the  disease  has  become 
rare,  and  the  observation  of  Drake,  Yandell,  and  others,  that  the  disease 
gradually  disappears  with  the  clearing  of  the  forests  and  improved  tillage, 
has  been  amply  substantiated.     It  still  prevails  in  parts  of  North  Carolina. 

(4)  MALTA  FEVER. 

This  disease,  also  known  as  Mediterranean  fever,  Neapolitan  fever,  and 
rock  fever,  has  been  studied  particularly  by  the  naval  and  military  medi- 
cal officers  who  have  been  stationed  on  the  island  of  Malta.  It  prevails 
also  in  Naples  and  other  districts  of  the  Mediterranean.  While  endemic 
in  the  island  of  Malta,  the  disease  in  some  years  reaches  epidemic  propor- 
lions.  Young  persons  are,  as  a  rule,  affected.  The  incubation  may  be 
from  six  to  ten  days. 

The  symptoms  are  thus  briefly  and  clearly  described  in  an  editorial  in 


jffli  'Vf  *»^« 


INFECTIOUS  DISEASES  OP  DOUBTFUL  CHARACTER. 


267 


the  IJi'itiiih  Medical  Journal :  "  The  disease  declares  itself  gradually,  with 
lieiuiaclie,  sleeplessness,  loss  of  appetite,  and  thirst,  often  without  shiver- 
ing or  diarrha'u,  and  without  spots.  Symptoms  of  this  kind,  with  more 
or  less  severity,  lust  for  three  or  four  weeks ;  apparent  but  deceptive  con- 
valescence then  usually  sets  in,  to  be  followed  in  a  few  days  by  a  relapse, 
with  rigors,  intense  headache  and  fever,  with,  frequently,  diarrha-a.  In 
tliis  state  the  patient  may  continue  for  five  or  six  weeks,  with  more  or  less 
delirium.  Improvement  again  sets  in,  to  be  followed,  it  may  be,  by  an- 
otlicr  relapse  in  about  ten  days  or  a  fortnight,  with  shivering,  headache, 
sleeplessness,  great  debility,  with  night-sweats,  pains  in  the  hips,  knees, 
ankles,  and  elbows,  and  often  in  one  or  both  testicles.  Again,  the  patient 
enters  on  a  state  of  convalescence,  which  may  last  for  a  month  or  six 
weeks.  The  old  symptoms  may  again  appear,  with  extreme  debility,  a 
thickly  coated  tongue,  with  thirst,  a  temperature  ranging  from  105°  Fahr. 
in  the  evening  to  nearly  normal  in  the  morning,  with  night-sweats  bring- 
ing no  relief  to  the  general  distress.  The  rheumatic  symptoms  are  the 
most  constant  and  the  most  distressing;  all  the  joints,  large  and  small, 
may  suffer.  Dr.  Veale  described  cases  in  which  the  intervertebral  joints, 
especially  those  of  the  lumbar  region  and  the  sacro-iliac  synchondroses, 
were  so  severely  affected  that  the  patient  "  dreads  every  movement " ;  he 
will  lie  for  days  in  one  position,  risking  the  formation  of  bed-sores,  and 
resisting  the  desire  to  evacuate  his  bowels  rather  than  encounter  the  suf- 
fering that  a  movement  will  entail.  Oftentimes  the  tendo  Achillis  and 
the  fibrous  structures  around  the  ankle-joint  are  involved ;  but  perhaps 
the  lumbar  aponeuroses  and  the  sheaths  of  the  nerves  issuing  from  the 
sacral  plexus  are  still  more  commonly  affected."* 

The  nature  of  the  disease  is  still  under  discussion.  McLean,  of  the 
Army  Med'cal  School,  in  1879,  suggested  that  it  was  a  typho- malarial 
fever,  and  Veale  called  it  febris  compUcata.  Others  have  supposed  that 
it  is  an  anomalous  form  of  malaria,  but  it  does  not  behave  like  any  ordi- 
nary form  of  paludal  fever  and  resists  quinine.  This  is  a  question  which 
could  be  determined  positively  by  the  blood  examination.  According  to 
Bruce,  no  characteristic  typhoid  lesions  are  found  in  fatal  cases.  This 
autlior  has  described  the  presence  of  a  micrococcus  in  the  spleen.  The 
Italian  observers  have  noted  enlargement  of  the  mesenteric  glands,  and 
Cantani  regards  it  as  an  adeno-typhoid.  The  identity  of  Malta  and  the 
so-called  rock  fever  of  Gibraltar  is,  however,  by  no  means  certain.  In  the 
mimbor  of  the  Journal  referred  to,  Surgeon  Perry  states  that  of  about  a 
hundred  autopsies  during  four  years  in  Gibraltar,  in  cases  of  the  so-called 
rock  fever,  in  not  one  were  the  typical  lesions  of  typhoid  absent.  On  the 
other  hand,  it  is  held  to  be  a  fever  due  to  chronic  poisoning  with  faecal 
emanations. 

Fortunately,  the  mortality  is  not  great.    With  reference  to  the  treat- 


•  British  Medical  Journal,  vol.  i,  1889. 


268 


SPECIFIC  INFECTIOUS  DISEASES. 


ment  Bruco  concludes  that  it  should  be  directed  principally  to  keeping 
the  patient's  strength  up  by  fluid,  easily  digested  food,  by  stimulants  whon 
required  and  by  attention  to  ordinary  hygienic  principles.  The  removal 
of  the  patient  from  the  infected  area  does  not  cut  short  the  fever. 


M-fi,.i--' 


I  '■  »  --i  ;?, 


(5)  MOUNTAIN   FEVER. 

Residence  for  a  time  at  a  high  altitude  is  in  some  instances  followed  bv 
a  group  of  symptoms  to  which  the  term  mountain  sickness  or  mountain 
fever  has  been  given.  Several  distinct  diseases  have  undoubtedly  been 
described.  It  is  by  no  means  certain  that  there  is  a  special  affection  to 
which  the  term  may  be  applied.  An  important  group,  the  mountain 
avcBmin,  is  associated  with  the  anchylostoma,  which  has  not  yet  been  met 
with  in  this  country.  A  second  group  of  cases  belongs  unquestionably  to 
typhoid  fever,  and  undoubted  instances  of  this  disease  occurring  in  mount- 
ainous regions  in  the  West  are  referred  to  as  mountain  fever. 

In  the  very  full  and  clear  report  which  Iloff  *  gives  of  five  cases,  the 
clinical  picture  is  that  of  typhoid  fever,  and  one  of  the  patients  died  of 
perforation  of  the  ileum  with  well-defined  typhoid  lesion.  Even  from  the 
clinical  reports,  unless  biased  by  notions  of  a  rigidly  characteristic  picture 
of  the  disease,  one  might  have  said  that  all  of  Surgeon  Iloff's  cases  were 
typhoid  fever,  and  the  post-mortem  record  leaves  no  question  as  to  the 
nature  of  the  malady.  Woodward,  commenting  upon  this  communication, 
states  that  there  is  in  the  United  States  Army  Medical  Museum  a  second 
specimen  from  the  case  of  so-called  mountain  fever  contributed  by  Sur- 
geon Girard. 

Smart,  who  reviewed  the  entire  question  a  few  ydars  ago,  regarded  the 
disease  as  a  typho-malarial  fever;  but  there  is  nothing  in  his  account 
opposed  to  the  opinion  that  it  is  a  typhoid  fever. 

There  is  a  third  group  to  which,  perhaps,  alone  the  term  mountain 
sickness  should  be  applied — cases  which  present  respiratory  and  cardiac 
symptoms,  due  to  a  high  altitude.  The  pulse  is  rapid,  there  are  giddiness, 
headache,  sometimes  nausea  and  vomiting,  sensations  of  great  prostration, 
and  considerable  respiratory  dist-'ess.  The  original  cases  described  by" 
General  Fremont  were  of  this  nature.  ' 


(C)  MILIARY  FEVER-SWEATING  SICKNESS. 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption 
of  miliary  vesicles.  The  disease  prevailed  and  was  very  fatal  in  England 
in  the  fifteenth  and  sixteenth  centuries,  but  of  late  years  it  has  been  con- 
fined entirely  to  certain  districts  in  France  (Picardy)  and  Italy.  An 
epidemic  of  some  extent  occurred  iu  France  in  1887.     Hirsch  gives  a 

*  American  Journal  of  the  Medical  Sciences,  January,  1880. 


INFECTIOUS  DISEASES  OF   DOUBTFUL  CIIAUACTEll. 


269 


chronological  account  of  194  epidemics  between  1718  and  1879,  many 
of  wliich  were  limited  to  a  single  village  or  to  a  few  localities.  Oocasion- 
iilly  the  disease  has  become  widely  B])rcad.  Slight  epidemics  have  oc- 
curred in  Germany  and  Switzerland.  They  are  usually  of  short  duration, 
lasting  only  for  three  or  four  weeks — sometimes  not  more  than  seven  or 
ciglit  days.  As  in  influenza,  a  very  large  number  of  persons  are  attacked  in 
rapid  succession.  II.  the  mild  cases  there  is  only  slight  fever,  with  loss  of 
appetite,  an  erythematous  eruption,  profuse  perspiration,  and  an  outbreak 
of  miliary  vesicles.  The  severe  cases  present  the  symptoms  of  intense 
infection — delirium,  high  fever,  profound  prostration,  and  haemorrhage. 
The  death-rate  at  the  outset  of  the  disease  is  usually  high,  and,  as  is  so 
graphically  described  in  the  account  of  some  of  the  epidemics  of  the  mid- 
dle ages,  death  may  follow  in  a  few  liours. 


J!  !||ii 


SECTION  II. 


CONSTITUTIOIS^AL  DISEASES. 


I.  RHEUMATIC  FEVER. 


Deflnition. — An  acute,  non-contagious,  febrile  affection,  depending 
probably  upon  an  unknown  infective  agent,  and  characterized  by  multiple 
arthritis  and  a  special  tendency  to  involve  the  heart. 

Etiology. — Acute  rheumatism  prevails  in  temperate  and  in  humid 
climates.  It  is  rare  in  the  tropics.  Statistics  on  the  point  are  not  availa- 
ble, but,  judging  from  my  own  observations,  I  think  that,  in  hospital 
practice  at  least,  cases  arc  much  more  frequent  in  England  than  in  Amer- 
ica. It  prevails  most  extensively  during  the  spring  months.  In  Bell's 
statistics,  of  456  cases  treated  at  the  Montreal  General  Hospital  during 
ten  years,  the  largest  number  of  cases  were  admitted  in  February,  March, 
and  April.  The  same  proportion  seems  true  in  Europe  and  in  the  cities 
of  the  Atlantic  coast. 

Age. — Young  adults  are  most  frequently  affected,  but  the  disease  is  by 
no  means  uncommon  in  children  between  the  ages  of  ten  and  fifteen  years. 
Sucklings  are  rarely  affected,  and  probably  many  of  the  cases  which  have 
been  described  belong  to  a  totally  different  affection,  the  arthritis  of  in- 
fants. In  exceptional  cases,  however,  true  rheumatism  does  occur.  Tht 
following  age  table  is  based  upon  45G  cases  admitted  to  the  Montreal  Gen- 
eral Hospital :  Under  15  years,  4*38  per  cent ;  from  15  to  25  years,  48C8 
per  cent;  from  25  to  35  years,  25-87  per  cent;  from  35  to  45  years,  13-6 
per  cent;  above  45  years,  7'4  per  cent.  Of  the  G55  cases  analyzed  by 
Whipham  for  the  Collective  Investigation  Committee  of  the  British  Medi- 
cal Association,  only  32  cases  occurred  under  the  tenth  year  and  80  per 
cent  between  the  twentieth  and  fortieth  year.  These  figures  scarcely  give 
the  ratio  of  cases  in  children. 

Sex. — If  all  ages  are  taken,  males  are  affected  oftener  than  females. 
In  the  Collective  Investigation  Report  there  were  375  males  and  279 
females.  Up  to  the  age  of  twenty,  however,  females  predominate.  Be- 
tween the  ages  of  ten  and  fifteen  girls  are  more  prone  to  the  disease. 

Occupations  which  necessitate  exposure  to  cold  and  to  great  changes 


m^i 


RHEUMATIC   FKVKR, 


271 


in  temperature  predispose  strongly  to  rheumatism.  We  meet  the  disease 
oftonest  in  drivers,  servants,  bakers,  sailors,  and  laborers.  Heredity  seems 
in  «omo  cases  to  have  a  special  influence,  and  the  disease  is  more  common 
in  certain  families.  Of  all  etiological  factors,  cold  is  believed  to  be  the 
most  potent.     Many  cases  follow  a  sudden  wetting  or  cbilliiig  of  the  skin. 

Tlic  essential  cause  of  rheumatism  is  still  unknown.  There  are  three 
chief  theories : 

[(i)  Metabolic :  that  it  depends  upon  a  morbid  material  produced 
witliin  the  system  in  defective  processes  of  assimilation.  It  has  been  sug- 
gested that  this  mateiial  is  lactic  acid  (I'rout)  or  certain  combinations 
witli  lactic  acid  (Latham).  Our  knowledge  of  the  chemical  relations  of 
tlie  various  products  produced  in  the  regressive  nutritive  changes  is  too 
limited  to  base  much  reliance  iipon  these  views,  llichardson  claims  to 
have  produced  rheumatism  by  injecting  lactic  acid  and  by  its  internal  ad- 
ministration. 

(b)  The  nervous  theory  advanced  by  J.  K.  ilitchell  has  many  advo- 
cates. According  to  this  view,  either  the  nerve-centres  are  primarily 
iilTected  by  cold  and  the  local  lesions  are  really  trophic  in  character,  oe 
tlio  primary  nervous  disturbance  leads  to  errors  in  metabolism  and  the 
accumulation  of  lactic  acid  in  the  system.  The  advocates  of  this  view 
regard  as  analogous  the  arthropathies  of  myelitis,  locomotor  ataxia,  and 
(;horea. 

(r)  Ocrm  theory :  that  the  arthritis  is  due  to  a  specific  microbe.  In 
favor  of  this  view  may  bo  mentioned  the  close  analogy  whicii  exists  be- 
tween rheumatism  and  certain  of  the  infectious  diseases.  The  analogy  is 
marked  with  gonorrhoea,  scarlet  fever,  and  septic  processes,  which  are  fre- 
quently associated  with  arthritis  and  endocarditis.  The  investigations 
hitherto  made  have  not,  however,  shown  the  constancy  of  any  micro- 
organism in  the  disease.  Mantle  and  others  have  described  micrococci  in 
the  l)lood,  and  several  organisms  have  been  found  in  the  secondary  inflam- 
mations of  the  disease,  but  none  of  them  can  be  said  to  be  specific  or 
peculiar. 

Morbid  Anatomy. — There  are  no  changes  characteristic  of  the 
disease.  The  affected  joints  show  hyperjemia  and  swelling  of  the  synovial 
membranes  and  of  the  ligamentous  tissues.  There  may  be  slight  erosion 
of  the  cartilage.  The  fluid  in  the  joint  is  turbid,  albuminous  in  charac- 
ter, and  contains  leucocytes  and  a  few  fibrin  flakes.  Pus  is  very  rare  in 
inicomplicated  cases.  Rheumatism  rarely  proves  fatal,  except  when  there 
are  serious  complications,  such  as  pericarditis,  endocarditis,  myocarditis, 
pleurisy,  or  pneumonia.  The  conditions  found  have  nothing  peculiar, 
notliing  to  distinguish  them  from  other  forms  of  inflammation.  In  death 
from  hyperpyrexia  no  special  changes  occur.  The  blood  usually  contains 
an  excessive  amount  of  fibrin.  In  the  secondary  rheumatic  inflammations, 
as  pleurisy  and  pericarditis,  various  pus  organisms  have  been  found,  possi- 
bly the  result  of  a  mixed  infection.  '       . 


1 

j 


f 


272 


CONSTITUTIONAL  DISEASES. 


If 


K^-,  i 


Symptoms. — As  a  rule,  tlio  discnso  sots  in  abruptly,  but  it  may  bo 
prooeik'd  by  irri'fjuhir  puins  in  tho  joints,  slight  malniac,  soro  throat,  and 
particularly  by  tonsillitis.  A  (Iffmito  rigor  is  uncommon;  more  often 
tlicro  is  slight  chilliness,  'i'ho  fovor  rises  quickly,  and  with  it  one  or  nioro 
of  the  joints  become  painful.  Within  twenty-four  hours  from  the  onset, 
the  disease  is  fully  developed.  Tho  temperature  range  is  from  10'^"  to 
104°.  The  pidso  is  frequent,  soft,  and  usually  above  lUO.  Tho  tongue  is 
moist,  and  rupidly  becomes  covered  with  a  white  fur.  There  are  the  ordi- 
nary symptoms  associated  with  an  acute  fever,  such  as  loss  of  appetite, 
thirst,  constipation,  and  a  scanty,  highly  acid,  highly  colored  urine.  In  a 
majority  of  the  cases  there  are  profuse,  very  acid  sweats,  of  a  peculiar  sour 
odor.  Sudaiiiinal  and  miliary  vesicles  are  abundant.  Tho  mind  is  clear, 
except  in  the  cases  with  hyperpyrexia.  Tho  alfected  joints  are  painful  to 
move,  and  soon  become  swollen  and  liot,  and  present  a  reddish  Hush. 
Tho  knees,  ankles,  elbows,  and  Avrists  are  the  joints  usually  attacked,  not 
together,  but  successively.  For  example,'  if  the  knee  is  first  atlected,  the 
redness  may  disappear  from  it  as  the  wrists  become  painful  and  hot. 
The  disease  is  seldom  limited  to  a  single  articulation.  The  amount  of 
swelling  is  liable.  Extensive  effusion  into  a  joint  is  rare,  and  much  of 
tho  enlargement  is  duo  to  the  infiltration  of  the  periarticular  tissues  with 
serum.  The  swelling  may  be  limited  to  the  joint  proper,  but  in  the  wrists 
and  ankles  it  sometimes  involves  tho  sheaths  of  the  tendons  and  p;-  .duces 
great  enlargement  of  the  hands  and  feet.  Corresponding  joints  are  often 
all'ected.  In  attacks  of  great  severity  every  one  of  the  larger  joints  may 
be  involved.  The  vertebral,  sterno- clavicular,  and  phalangeal  articula- 
tions are  less  often  inflamed  in  acute  than  in  gonorrhoeal  rheumatism. 
Perhaps  no  disease  is  more  painful  than  acute  pohj'arthritis.  The  in- 
ability to  change  the  posture  without  agonizing  pain,  the  drenching 
sweat?,  the  prostration  and  utter  helplessness,  combine  to  make  it  one  of 
tho  most  distressing  of  febrile  affections.  A  special  feature  of  the  disease 
is  the  tendency  of  the  inflammation  to  subside  in  one  joint  while  develop- 
ing with  great  intensity  in  another. 

The  temperature  range  in  an  ordinary  attack  is  between  102°  and 
104°.  It  is  peculiarly  irregular,  Avith  marked  remissions  and  exacerba- 
tions, depending  very  much  upon  the  intensity  and  extent  of  the  articular 
inflammation.  Defervescence  is  usually  gradual.  The  profuse  sweats 
materially  influence  the  temperature  curve.  If  a  two-hourly  chart  is  made 
and  observations  upon  the  sweats  are  noted,  the  remissions  will  usually  be 
found  coincident  with  the  sweats.  The  perspiration  is  sour-smelling  and 
acid  at  first ;  but,  when  persistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  and  rapidly  altered  in  acute  rheumatism. 
There  is,  indeed,  no  acute  febrile  disease  in  which  the  anaemia  develops 
with  greater  rapidity. 

With  the  high  fever  a  murmuF  may  often  be  heard  at  the  apex  re- 
gion.   Endocarditis  is  also  a  common  cause  of  an  apex  bruit.    The  heart 


sliould 
•lay. 

Tlu 

»»r.     It 

greatly 

Tho 

excess  o 


This 
tonis  are 
are  invol 
wii. ks  or 
not  be  fo 
ciated  wi 

Com] 

(OH: 

tlio  onset, 
teniporatu 
oercbi'al  -'j 
liyperpyre: 
qiient,  the 

(2)  Cat 

oils  compl 

statistics  u 

leased,  as  a 

base.     Tlii 

other  than 

volved  and 

ative  endoc; 

cases  of  thif 

severe  endoi 

tism.    This 

symptoms  a 

tinie  may  nc 

lead  to  scler 

disease. 

{b)  Peru 
carditis.  It 
lent.  Clinic 
f'sm  than  a 
characteristic 
section.  A  j 
''heumatic  pe 


RUEUMATIC  FEVEH. 


978 


should  be  carefully  examined  at  the  first  visit  and  subsequently  each 

•by. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high  col- 
or. It  is  very  ucid,  and,  on  cooling,  dejwsits  urates.  The  chlorides  may  bo 
greatly  diminished  or  even  absent.     Febrile  albuminuria  is  not  uncommon. 

The  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an 
excess  of  sulphocyanidcs. 

Subacute  Rheumatism. 

This  represents  a  milder  form  of  the  disease,  in  which  all  the  symp- 
toms are  loss  pronounced.  The  fever  rarely  rises  above  101° ;  fewer  joints 
are  involved ;  and  the  arthritis  is  less  intense.  The  cases  may  drag  on  for 
wt  cks  or  months,  and  the  disease  may  finally  become  chronic.  It  should 
not  be  forgotten  that  in  children  this  mild  or  subacute  form  may  be  asso- 
ciated with  endocarditis  or  perioarJitia. 

Complications. — These  ai"  important  and  serious. 

(1)  Hyperpyrexia. — The  tempern'Mre  may  rise  rapidly  a  few  days  after 
tlic  onset,  and  be  assoeiateii  with  delirium;  but  not  necessarily,  for  the 
temperature  may  rise  to  108°  or,  aa  in  one  of  Da  Costa's  cases,  110°,  without 
eer((bral  symptoms.  The  delirium  may  precede  or  follow  the  onset  of  the 
hyperpyrexia.  As  a  rule,  with  the  high  fever,  the  pulse  is  feeble  and  fre- 
quent, the  prostration  is  extreme,  and  finally  stupor  supervenes. 

(2)  Cardiac  Affeotions. — {n)  Endocarditis,  the  most  frequent  and  seri- 
ous complication,  occurs  in  a  considerable  percentage  of  all  cases.  The 
statistics  upon  this  point  are  not  of  much  value,  as  the  diagnosis  has  been 
based,  as  a  rule,  upon  the  development  of  a  systolic  murmur  at  apex  or 
base.  This  is  quite  untrustworthy;  since  it  may  depend  upon  causes 
otlio''  than  endocarditis.  The  mitral  segments  are  most  frequently  in- 
volved and  the  affection  is  usually  of  the  simple,  verrucose  variety.  Ulcer- 
ative endocarditis  in  the  course  of  acute  rheumatism  is  very  rare.  Of  209 
cases  of  this  disease  which  I  analyzed,  in  only  24  did  the  symptoms  of  a 
severe  endocarditis  arise  during  the  progress  of  acute  or  subacute  rheuma- 
tism. This  complication,  in  itself,  is  rarely  dangerous.  It  produces  few 
symptoms  and  is  usually  overlooked.  Unhappily,  though  the  valve  at  the 
time  may  not  be  seriously  damaged,  the  inflammation  starts  changes  which 
lead  to  sclerosis  and  retraction  of  the  segments,  and  so  to  chroLic  valvular 
disease. 

(i)  Pericnrdiiis  may  occur  independently  of  or  together  with  endo- 
carditis. It  may  be  simple  fibrinous,  sero-fibrinous,  or  in  children  puru- 
lent. Clinically  we  meet  it  more  frequently  in  connection  with  rheuma- 
tism than  all  other  affections  combined.  The  physical  signs  are  very 
characteristic.  The  condition  will  be  fully  described  under  its  appropriate 
section.  A  peculiar  form  of  delirium  may  develop  during  the  progress  of 
rheumatic  pericarditis. 


1 


274 


CONSTITUTIONAL  DISEASES. 


■Mm, 


(c)  Myocarditis  is  most  frequent  in  connect-on  witli  ondo-pericardial 
changes.  The  anatomical  condition  is  a  granular  or  fatty  degenei'atiou  of 
the  heart-muscle,  which  leads  to  weakening  of  the  walls  and  to  dilata- 
tion.  It  is  not,  I  think,  nearly  so  common  as  the  ouier  cardiac  affections. 
S.  West  has  reported  instances  of  acute  dilatation  of  the  heart  in  rheu- 
matic fever,  in  one  of  which  marked  fatty  changCb  were  found  in  the 
heart-fibres. 

(3)  Pulmonary  Affections. — Pneumonia  and  pleurisy  are  not  uncom- 
mon, and  frequently  accompany  the  ciises  of  endo-pericarditis.  According 
to  Howard's  analysis  of  a  large  liumber  of  cases,  there  were  pulmonary 
complications  in  only  10-5  per  cent  of  cases  of  rheumatic  endocarditis ;  in 
58  per  cent  of  cases  of  pericarditis;  and  in  71  per  cent  of  cases  of  endo- 
pericarditis.  Congestion  of  the  lung  is  occasionally  found,  and  in  several 
cases  has  proved  rapidly  fatal. 

(4)  Cerebral  Complications. — These  are  due,  in  part,  to  the  hyper- 
pyrexia and  in  part  to  the  special  action  upon  the  brain  of  the  toxic  agent 
of  the  disease.  They  may  be  grouped  as  follows :  (a)  Delirium,  This  is 
usually  associated  with  the  hyperpyrexia,  but  may  be  independent  of  it. 
It  may  be  active  and  noisy  in  character;  more  rarely  a  low  muttering 
delirium,  passing  into  stupor  and  coma.  Special  mention  must  be  made 
of  the  delirium  which  occurs  in  connection  with  rheumatic  pericarditis. 
Delirium,  too,  may  be  excited  by  the  salicylate  of  soda,  either  shortly  after 
its  administration,  or  more  commonly  a  week  or  ten  days  later,  {b)  Coma,, 
which  is  more;  serious,  may  develop  without  preliminary  delirium  or  con- 
vulsions, and  may  prove  rapidly  fata'.  Certain  of  these  cases  are  asso- 
ciated with  hyperpyrexia ;  but  Southey  has  reported  the  case  of  a  girl  who, 
without  previous  delirium  or  high  fever,  became  comatose,  and  died  in  less 
than  an  hour.  A  certain  number  of  such  cases,  as  those  reported  by  Da 
Costa,  have  been  associated  with  marked  renal  changes  and  were  evidently 
uraemic.  The  coma  may  develop  during  the  attack,  or  after  convalescence 
hsis  set  in.  (c)  Commlsions  are  less  common,  though  they  may  precede 
the  coma.  Of  127  observations  cited  by  Besnier,  there  were  37  of  delirium, 
only  7  of  convulsions,  17  of  coma  and  convulsions,  54  of  delirium,  coma, 
and  convulsions,  and  3  of  other  varieties  (Howard),  {d)  Chorea.  Tlie 
relations  of  this  disease  and  rheumatism  will  be  subsequently  discussed. 
It  is  sufficient  here  to  say  that  in  only  88  out  of  554  cases  which  I  liave 
analyzed  from  the  Infirmary  for  Diseases  of  the  Nervous  System,  Pliila- 
delphia,  were  chorea  and  rheumatism  associated.  It  is  most  apt  to  develop 
in  the  slighter  attacks  in  childhood,  {r)  Meningitis  is  extremely  rare, 
though  undoubtedly  it  does  occur.  It  must  not  be  forgotten  that  in 
ulcerative  endocarditis,  which  is  occasionally  associated  with  acute  rheu- 
matism, meningitis  is  frequent. 

(5)  Cutaneous  Aflfections.— Sweat- vesicles  have  already  been  mentioned 
as  extremely  common.  A  red  miliary  rash  may  also  develop.  Scarlatini- 
form  eruptions  are  occasionally  seen.     Purpura,  with  or  without  u^'ticaria, 


RHEUMATIC  FEVER. 


275 


may  occur,  and  various  forma  of  erythema.  It  is  doubtful  whether  the 
cases  of  extensive  purpura  with  urticaria  and  arthritis — peliosis  rheumatica 
— helong  truly  to  acute  rheumatism. 

(G)  Rheumatic  Nodules. — These  curious  structures,  in  the  form  of  small 
subcutaneous  nodules  attached  to  the  tendons  and  fasciss,  have  been  known 
for  some  years ;  but  special  attention  has  been  paid  to  them  of  late,  since 
their  careful  study  by  Barlow  and  Warner.  They  vary  iii  size  from  a 
small  shot  to  a  large  pea,  and  are  most  numerous  on  the  fingers,  hands, 
and  wrists.  They  also  occur  about  the  elbows,  knees,  the  spines  of  the 
vertebrae,  and  the  scapulae.  They  are  not  often  tender.  They  do  not 
necessarily  come  on  during  the  ftver,  but  may  be  found  on  its  decline,  or 
even  independently  altogether  of  an  acute  attack.  They  may  develop 
with  great  rapidity  and  usually  last  for  weeks  or  months.  They  are  more 
common  in  children  than  in  adults,  and  their  presence  may  be  regarded 
as  a  positive  indication  of  rheumatism.  They  have  been  noted  particularly 
in  association  with  severe  and  chronic  rheumatic  endocarditis.  They  may 
occur  in  large  numbers  in  adults,  as  in  a  case  reported  from  my  clinic  in 
Pliiladelphia,  by  J.  K.  Mitchell.  Histologically  they  are  made  up  of  round 
and  spindle-shaped  cells. 

Tlie  course  of  acute  rheumatism  is  ext -emely  variable.  It  is,  as  Austin 
Flint  first  sho.ved,  a  self-limited  disease,  and  it  is  not  probable  that  medi- 
cines have  any  special  influence  upon  its  duration  or  course.  Gull  and 
Sutton  who  likewise  studied  a  series  of  sixty-two  cases  without  special 
treatment  arrived  at  the  same  conclusion. 

Diagnosis. — Practically,  the  recognition  of  acute  rheumatism  is  very 
easy ;  but  there  are  several  affections  which,  in  some  particulars,  closely 
resemble  it. 

(1)  Multiple  Secondary  Arthritis. — Under  this  term  may  be  embraced 
the  various  forms  of  arthritis  which  come  on  or  follow  in  the  course 
of  the  infective  diseases,  such  as  gonorrhcea,  scarlet  fever,  dysentery,  and 
cerebro-spinal  meningitis.  Of  these  the  gonorrhceal  form  will  receive 
special  consideration  and  is  the  type  of  the  entire  gupup. 

(i)  Septic  Arthritis,  which  develops  in  the  course  of  pyaemia  from 
any  cause,  and  particularl}  u.  puerperal  fever.  No  hard  and  fast  line 
can  be  drawn  between  these  and  the  cases  in  the  first  group ;  but  the 
inflammation  rapidly  passes  on  to  suppuration  and  there  is  more  or  less 
destruction  of  the  joints.  The  conditions  under  wiiich  the  arthritis  de- 
velops give  a  clew  at  once  to  the  nature  of  the  case.  Under  this  section 
may  also  be  mentioned  : 

(a)  Acute  necrosis  or  acute  osteo-myelitis,  occurring  in  the  lower  end 
of  tlie  femur,  or  in  the  tibia,  and  which  may  be  mistaken  for  acute  rheu- 
matism. Sometimes,  too,  it  is  multiple.  The  greater  intensity  of  the  local 
cymptoms,  the  involvement  of  the  epiphyses  rather  than  the  joints,  and 
the  more  serious  constitutional  disturbances  are  points  to  be  considered. 
The  condition  is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as 


I 


' 


276 


CONSTITUTIONAL  DISEASES. 


:■  '-''.hi  ?  Tff 


the  treatment  is  essentially  surgical,  the  error  is  one  which  may  cost  the 
life  of  the  patient. 

{b)  The  acute  arthritis  of  infants  must  be  distinguished  from  rheu- 
matism. It  is  a  disease  which  is  usually  confined  to  one  joint  (the  hip  or 
knee),  the  effusion  in  which  rapidly  becomes  purulent.  The  affection  is 
most  common  in  sucklings  and  is  undoubtedly  pyaemic  in  character.*  It 
may  also  develop  in  the  gonorrhopal  ophthalmia  or  vaginitis  of  the  new- 
born, as  pointed  out  by  Clement  Lucas. 

(3)  It  is  only  in  rare  instances  that  gout  and  acute  rheumatism  are 
confounded.  The  localization  in  a  single,  usually  a  small,  joint,  the  age, 
the  history,  the  mode  of  onset — are  features  which  enable  us  to  recognize 
the  cases  readily. 

Treatment. — The  bed  should  have  a  smooth,  soft,  yet  elafitic  mattress. 
The  patient  should  wear  a  flannel  night-gown,  which  may  be  opened  all  the 
way  down  the  front  and  slit  along  the  outer  margin  of  the  sleeves.  Three 
or  four  of  these  should  be  made,  so  as  to  facilitate  the  frequent  changes 
required  after  the  sweats.  Ke  may  wear  also  a  light  flannel  cape  about  the 
shoulders.  He  should  sleep  in  blankets,  not  in  sheets,  so  as  to  reduce  the 
liability  to  catch  cold  and  obviate  the  unpleasant  clamminess  consequent 
upon  heavy  sweating.  Chambers  insisted  that  the  liability  to  endocar- 
ditis and  pericarditis  was  much  reduced  when  the  patients  were  in  blankets. 

Milk  is  the  most  suitable  diet.  It  may  be  diluted  with  alkaline  min- 
eral waters.  Lemonade  and  oatmeal  or  barley  water  should  be  freely 
given.  The  thirst  is  usually  great  and  may  be  fully  satisfied.  There  is 
no  objection  to  broths  and  soups  if  the  milk  is  not  well  borne.  The  food 
should  be  given  at  short  and  stated  intervals.  As  convalescence  is  estab- 
lished a  fuller  diet  may  bo  allowed,  but  meat  should  'be  used  sparingly. 

The  local  treatment  is  of  the  greatest  importance.  It  often  suffices  to 
wrap  the  affected  joints  in  cotton.  If  the  pain  is  severe,  hot  cloths  may 
be  applied,  saturated  with  Fuller's  lotion  (carbonate  of  soda,  6  drachms ; 
laudanum,  1  oz. ;  glycerine,  2  oz. ;  and  water,  9  oz.).  Tincture  of  aconite 
or  chloral  may  be  en^ployed  in  an  alkaline  solution.  Chloroform  liniment 
is  also  a  good  application.  Fixation  of  the  joints  is  of  great  service  in 
allaying  the  pain.  I  have  seen,  in  a  German  hospital,  the  joints  enclosed 
in  plaster  of  Paris,  apparently  with  great  relief.  Splints,  padded  and 
bandaged  with  moderate  firmness,  will  often  be  found  to  relieve  pain. 
Friction  is  rarely  well  borne  in  an  acutely  inflamed  joint.  Cold  com- 
presses are  much  used  in  Germany.  The  application  of  blisters  above 
and  below  the  joint,  often  relieves  the  pain.  This  method,  which  was 
used  so  much  a  few  years  ago,  is  not  to  be  compared  with  the  light  appli- 
cation of  the  Paquelin  thermo-cautery. 

Medicines  have  little  or  no  control  over  the  duration  or  course  of  tlie 


*  Townsend,  Acute  Arthritis  of  Infants,  American  Journal  of  the  Medical  Sciences, 
January,  1890.  ..  - 


llll'i  i' 


v< 


RHEUMATIC  FEVER. 


277 


disease,  which,  like  other  solf-liraited  affections,  practically  takes  its  own 
time  to  disappear.  Salicyl  compounds,  which  were  regarded  so  long  as 
specific  in  the  disease,  are  now  known  to  act  chiefly  by  relievii.g  pain, 
li  P.  Howard's  elaborate  analysis  shows  tliat  they  do  not  influence  the 
duration  of  the  disease.  Nor  do  they  prevent  the  occurrence  of  cardiac 
complications,  while  under  their  use  relapses  are  considerably  more  fre- 
quent than  in  any  other  method  of  treatment.  In  acute  cases  with  severe 
ptiin  the  salicyl  compounds  give  prompt  relief  and  rarely  disappoint  us  in 
their  action.  Sodium  salicylate,  in  fifteen-grain  doses  for  eight  or  ten 
doses,  may  be  given.  The  bicarbonate  of  potassium  in  twenty-grain  doses 
may  be  used  with  it.  Many  prefer  salicin  (gr.  30)  in  wafers ;  others  the 
salicylic  acid  (gr.  20)  or  salol.  I  have  for  the  past  five  or  six  years  used 
the  oil  of  wintergreen,  recommended  by  Kinnicutt,  and  have  found  it  quite 
as  efficacious.  Twenty  minims  may  be  given  every  two  hours  in  milk. 
The  salicyl  compounds  are  best  given  in  full  doses  at  the  outset  of  the 
disease,  to  relieve  the  pain.  Then  the  dose  should  be  reduced  in  fre- 
quency, or,  if  the  symptoms  have  abated,  stopped  altogether,  as  relapses 
are  certainly  more  frequent  under  their  use. 

Alkalies  may  be  combined  with  the  salicylates,  or  may  be  used  alone. 
The  potassium  bicarbonate  in  half-drachm  doses  may  be  given  every  three 
or  four  hours  until  the  urine  is  rendered  alkaline.  T'uUer,  who  so  warmly 
supported  this  method  of  treatment,  was  in  the  habiu  of  ordering  a  drachm 
and  a  half  of  the  sodium  bicarbonate  with  half  a  drachm  of  potassium 
acetate  in  three  ounces  of  water,  rendered  effervescent  at  the  time  of  pd- 
ministration  by  half  a  drachm  of  citric  acid  or  an  ounce  of  lemon-juice. 
This  is  given  every  three  or  four  hours,  and  usually  by  the  end  of  twenty- 
four  hours  the  urine  is  alkaline  in  reaction.  The  alkali  is  then  reduced, 
and  the  amount  subsequently  regulated  by  the  degree  of  acidity  of  the 
urine,  only  enough  being  given  to  keep  the  secretion  alkaline.  Opinion 
is  almost  unanimous  that,  under  the  alkaline  treatment,  cardiac  complica- 
tions are  less  common.  The  combination  of  the  salicylates  with  the  alkali 
is  probably  the  most  satis'.actory.  Care  must  be  taken  to  watch  the  heart 
during  the  administration  of  these  remedies.  In  the  only  fatal  case  of 
rheumatism  which  has  come  in  my  experience  the  patient  had,  owing  to 
au  error,  taken  the  full  first  day's  dose  of  Fuller's  alkaline  treatment  for 
five  successive  days,  insteed  of  having  the  salt  gradually  reduced.  She 
died  suddenly  on  the  fifth  day  after  sitting  up  in  bed.  Salicylates  also,  if 
given  largely,  are  very  depressing  to  the  circulation. 

To  allay  the  pain  opium  may  be  given  in  the  form  of  Dover's  powder, 
or  morphia  hypodermically.  Antipyrin,  antifebrin,  and  phenacetin  are 
useful  sometimes  for  the  purpose.  During  convalescence  iron  is  indicated 
in  full  doses,  and  quinine  is  a  useful  tonic.  Of  the  complications,  hyper- 
pyrexia  should  be  treated  by  the  cold  bath  or  the  cold-pack.  The  treat- 
ment of  endocarditis  and  pericarditis  and  the  pulmonary  complications 
will  be  considered  under  their  respective  sections. 


!  ^  1 


;<i,'.: 


f 


If: 


278 


CONSTITUTIONAL  DISEASES. 


II.    CHRONIC    RHEUMATISM. 


Etiology. — This  affection  may  follow  an  acute  or  subacute  attack,  but 
more  commonly  comes  on  insidiously  in  persons  who  have  passed  tbo 
middle  period  of  life.  In  my  experience  it  is  extremely  rare  as  a  sequence 
of  acute  rheumsitism.  It  is  most  common  among  the  poor,  particularly 
washer-women,  day  laborers,  and  those  whose  occupation  exposes  them  to 
cold  and  damp. 

Morbid  Anatomy. — The  synovia^  membranes  are  injected,  but  there 
is  usually  not  much  effusion.  The  capsule  and  ligaments  of  the  joints  are 
thickened,  and  the  sheaths  of  the  tendons  in  the  neighborhood  undergo 
similar  alterations,  so  that  the  free  play  of  the  jcint  is  greatly  impaired. 
In  long-standing  cases  the  cartilages  also  undergo  changes,  and  may  show 
erosions.  Even  in  cases  with  the  severest  symptoms,  the  joint  may  be 
very  slightly  altered  in  appearance.  Important  changes  take  place  in  the 
muscles  and  nerves  adjacent  to  chronically  inflamed  joints,  particularly 
in  the  mono-articular  lesions  of  the  shoulder  or  hip.  Muscular  atrophy 
supervenes  partly  from  disuse,  partly  through  nervous  influences,  eillier 
centric  or  reflex  (Vulpian),  or  as  a  result  of  peripheral  neuritis.  In  some 
cases  when  the  joint  is  much  distended  the  wasting  may  be  due  to  press- 
ure, either  on  the  muscles  themselves  or  on  the  vessels  supplying  them. 

Symptoms. — Stiffness  and  pain  arc  the  chief  features  of  chronic 
rlieumatism.  The  latter  is  very  liable  to  exacerbations,  especially  dur- 
ing changes  in  the  weather.  The  joints  may  be  tender  to  the  touch  and  a 
little  swollen,  but  seldom  reddened.  As  a  rule,  many  joints  are  affected ; 
but  there  are  instances  in  which  the  disease  is  confined  to  one  shoulder, 
knee,  or  hip.  The  stiffness  and  pain  are  more  marked  after  rest,  and  as  tlie 
day  advances  the  joints  may,  with  exertion,  become  much  more  supple. 
The  general  healtii  may  not  be  seriously  impaired.  The  disease  is  not 
immediately  dangerous.  Anchylosis  may  occur,  and  ultimately  the  joints 
may  become  very  distorted.  In  many  instances,  particularly  those  in 
which  the  pain  is  severe,  the  general  health  may  be  seriously  involved 
and  the  subjects  become  anaemic  and  very  apt  to  suffer  with  neuralgia  and 
dyspepsia.  Valvular  lesions,  due  to  slow  sclerotic  changes,  are  not  un- 
common. They  are  associated  with,  not  dependent  upon,  tbf'  articular 
disease. 

The  prognosis  is  not  favorable,  as  a  majority  of  the  cases  resist  all 
methods  of  treatment.  It  is,  however,  a  disease  which  persists  indefin- 
itely, and  does  not  necessarily  shorten  life. 

Treatment. — Internal  remedies  are  of  little  service.  It  is  important 
to  maintain  the  digestive  functions  and  to  keep  the  general  health  at  a 
high  standard.  Iodide  of  potassium,  sarsaparilla,  and  guaiacum  are  sonic- 
times  beneficial.    The  salicylates  are  useless. 

Local  treatment  is  very  beneficial.  "  JMring "  with  the  Paquelin 
cautery  relieves  the  pain,  and  it  is  perhaps  the  best  form  of  counter- 


V  i 


PSEUDO-RHEUMATIC  AFFECTIONS. 


279 


irritation.  Massage,  with  passive  motion,  helps  to  reduce  swelling,  and 
prevents  anchylosis.  It  is  particularly  useful  in  cases  which  are  asso- 
ciated with  atrophy  of  the  muscles.  Electricity  is  not  of  much  benefit. 
Climatic  treatment  is  veiy  advantageous.  Many  cases  are  greatly  helped 
l)v  prolonged  residence  in  southern  Europe  or  southern  California.  Kich 
[Kilients  should  always  winter  in  the  South,  and  in  this  way  avoid  the 
cukl,  damp  weather. 

Ilydrotherapeutic  measures  are  specially  beneficial  in  chronic  rheu- 
miuism.  Great  relief  is  afforded  by  wrapping  the  affected  joints  in  cold 
cloths,  covered  with  a  thin  layer  of  blanket,  and  protected  with  oiled  silk. 
The  Turkish  bath  is  useful,  but  the  full  benefit  of  this  treatment  is  rarely 
seen  except  at  bathing  establishments.  The  hot  alkaline  waters  are  par- 
ticularly useful,  and  a  residence  at  the  Hot  Springs  of  Virginia  or  Ar- 
kansas, or  at  Banff,  in  the  Rocky  Mountains,  on  the  Canadian  Pacific  Rail- 
way, will  sometimes  cure  even  obstinate  cases. 


III.    PSEUDO-RHEUMATIC   AFFECTIONS. 


These  are  numerous,  and  occur  as  complications  or  sequelae  of  many 
infectious  diseases  with  which  they  have  been  considered.  The  one  which 
is  of  most  importance,  and  which,  though  a  surgical  affection,  is  usually 
treated  of  in  works  on  medicine,  is — 

GonorrhoBal  Rheumatism. — T'hough  custom  has  sanctioned  this  term, 
the  affection  here  considered  has  probably  nothing  whatever  to  do  with 
rheumatism,  but  is  an  arthritis  or  synovitis  of  a  septic  nature,  due  to  in- 
fection from  the  urethral  discharge.  It  occurs  either  during  an  acute 
attack  of  gonorrhoea,  or,  more  commonly,  as  the  attack  subsides,  or  when 
it  has  become  chronic.  It  is  far  more  frequent  in  men  than  in  women. 
It  is  liable  to  recur,  and  is  an  affection  of  extraordinary  obstinacy.  It 
may  involve  many  joints,  but  the  knees  and  ankles  are  most  commonly 
attectcd.  It  is  peculiar  in  attacking  certain  joints  which  are  rarely  in- 
volved in  acute  rheumatism — as  the  sterno-clavicular,  the  intervertebral, 
the  temporo-maxillary,  and  the  sacro-iliac. 

Tlie  anatomical  chanrjes  are  variable.  The  inflammation  is  often  peri- 
articular, and  extends  along  the  sheaths  of  the  tendons.  When  effu&ion 
occurs  in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly 
the  cluiracters  of  a  synovitis.  About  the  wrist  and  hand  suppuration 
>otiietimcs  occurs  in  the  sheaths.  In  the  bacteriological  examination  the 
i(onococci  have  been  found  in  the  exudate,  but  not  invariably.  They 
may  be  present  in  the  tissues,  however,  and  cause  an  effusion  which 
may  be  sterile.  It  has  been  suggested  that  the  simple  arthritis  or  syn- 
ovitis follows  absorption  of  ptomaines  from  the  urethral  discharge,  while 
the  more  severe  suppurating  forms  are  due  to  infection  with  pus  organ- 
isms. 

19 


I 


280 


CONSTITUTIONAL  DISEASES. 


Oi': 


-i'^l^V' 


...  •  :    Sr 


The  symptoms  of  this  disease  are  very  variable.  R.  P.  Howard  recog- 
nized five  clinical  forms : 

(a)  Arthr'dyic,  in  which  there  are  wandering  pains  about  the  joints, 
without  redness  or  swelling.     These  persist  for  a  long  time. 

{b)  Rheumatic,  in  which  several  joints  become  affected,  just  as  in  sub- 
acute articular  rheumatism.  The  fever  is  slight ;  the  local  inflammation 
may  fix  itself  in  one  joint,  but  more  commonly  several  become  swollen 
and  tender.     In  this  form  cerebral  and  cardiac  complications  may  occur. 

(6')  Acute  (joiiorrhceal  arthritis,  in  which  a  single  articulation  becomes 
suddenly  involved.  The  pain  is  severe,  the  swelling  extensive,  and  due 
chiefly  to  peri-articular  oedema.  The  genera!  fever  is  not  at  all  propor- 
tionate to  the  intensity  of  the  local  signs.  The  affection  usually  resolves, 
though  suppuration  occasionally  supervenes. 

{(l)  Chronic  Hydrarthrosis. — This  is  usually  mono-articular,  and  is 
particularly  apt  to  involve  the  knee.  It  comes  on  often  without  pain, 
redness,  or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in 
ninety-six  cases  tabulated  by  Nolen. 

(e)  Bursal  and  Synovial  Form. — This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursfe  and  the  periosteum.  The  articulations  may 
not  be  affected.  The  bursoe  of  the  patella,  the  olecranon,  and  the  tendo 
Achillis  are  most  apt  to  be  involved. 

The  disease  is  much  more  intractable  than  ordinary  rheumatism,  and 
relapses  are  extremely  common.  It  may  become  chronic  and  last  for 
years.  A  patient  under  my  care,  at  the  University  Hospital,  Philadel- 
phia, was  practically  bedridden  for  nearly  ten  years  with  his  first  attack, 
and  was  carried  from  one  health  resort  to  another  without  getting  much 
benefit.  He  finally  recovered  sufl[iciently  to  resume  work,  and  enjoyed 
fair  health  for  more  than  a  year.  Then  he  unfortunately  had  anotlier 
attack  of  gonorrhoea.  The  multiple  arthritis  recurred,  and  when  he  came 
under  my  observation  he  had  been  ill  nearly  two  years. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  suc- 
cessive attacks.  The  visceral  complication?  are  rare.  Endocarditis,  peri- 
carditis, and  pleurisy  may  occur.  R.  L.  MacDonnell  recently  analyzed 
twenty-seven  cases  of  gonorrhoea!  rheumatism  at  the  Montreal  General  Hos- 
pital, of  which  four  presented  signs  of  recent  cardiac  disease.  Gluzinski 
has  collected  thirty-one  cases  from  the  literature.  The  endocarditis  is 
usually  simple,  but  occasionally  there  is  an  intense  infection  and  ulcera- 
tive endocarditis  with  symptoms  resembling  typhoid  fever. 

Treatment. — The  salicylates  are  of  very  little  service,  nor  do  they 
often  relieve  the  pains  in  this  affection.  Iodide  of  potassium  has  also 
proved  useless  in  my  hands,  even  given  in  large  doses.  A  general  tonic 
treatment  seems  much  more  suitable — quinine,  iron,  and,  in  the  chronic 
cases,  arsenic. 

Th  3  local  treatment  of  the  joints  is  very  important.  The  thermo- 
cautery may  be  used  to  allay  the  pain  and  reduce  the  swelling.    In  acute 


MUSCULAR  RHEUMATISM. 


281 


cases,  fixation  of  the  joiuts  is  very  beneficial,  and  in  the  chronic  forms, 
massage  and  passive  motion.  The  surgical  treatment  of  this  affection,  as 
cairied  out  nowadays, is  more  satisfactory, and  I  have  seen  strilcingly  good 
results  follow  incision  and  irrigation. 


IV.  MUSCULAR  RHEUMATISM  {Myalgia). 

Definition. — A  painful  affercion  of  the  voluntary  muscles  and  of  he 
fasciiL'  and  periosteum  to  whicK  they  are  attached.  The  affection  has  re- 
ceived various  names,  accordi.ig  to  its  seat,  as  torticollis,  lumbago,  pleuro- 
dynia, etc. 

Etiology. — The  attacks  follow  cold  and  exposure,  the  usual  condi- 
tions favorable  to  the  d'.velopment  of  rheumatism.  It  is  by  no  means  cer- 
tain that  the  muscul'ir  tissues  are  the  seat  of  the  disease.  Many  writers 
claim,  perhaps  corroctly,  that  it  is  a  neuralgia  of  the  sensory  nerves  of  the 
muscles.  Until  r  ar  knowledge  is  more  accurate,  however,  it  may  be  con- 
sidered under  t'le  rheumatic  affections. 

It  is  most  commonly  met  with  in  men,  particularly  those  exposed  to 
cold  and  whose  occupations  are  laborious.  It  is  apt  to  folic..'  exposure  to 
a  draught  of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sud- 
den chilling  after  heavy  exertion  may  also  bring  on  an  attack  of  lumbago. 
Persons  of  a  rheumatic  or  gouty  habit  are  certainly  more  prone  to  this 
ulTection.  One  attack  renders  an  individual  more  liable  to  another.  It  is 
usually  acute,  but  may  become  subacute  or  even  chronic. 

Symptoms. — The  affection  is  entirely  local.  The  constitutional  dis- 
turbance is  slight,  and,  even  in  severe  cases,  there  may  be  no  fever.  Pain 
is  a  prominent  symptom.  It  may  be  constant,  or  may  occur  only  when 
the  muscles  are  drawn  into  certain  positions.  It  may  be  a  dull  ache  or  a 
bruised  pain,  or  sharp,  severe,  and  cramp-like.  It  is  often  sufficiently  in- 
tense to  cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usu- 
ally gives  relief.  As  a  rule,  myalgia  is  a  transient  alTection,  lasting  from 
a  few  hours  to  a  few  days.  Occasionally  it  is  prolonged  for  several  weeks. 
It  is  very  apt  to  recur. 

The  following  are  the  principal  varieties : 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefly  in 
workingmen.  It  comes  on  suddenly,  and  in  very  severe  cases  completely 
incapacitates  the  patient,  who  may  be  unable  to  turn  in  bed  or  to  rise  from 
the  sitting  posture. 

(2)  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral 
rei^ion  of  the  neck.  It  is  very  common,  and  occurs  most  frequently  in 
the  young.  The  person  holds  the  head  in  a  peculiar  manner,  and  rotates 
the  whole  body  in  attempting  to  turn  it.  Usually  it  is  confined  to  one 
side.    The  muscles  at  the  back  of  the  neck  may  also  be  affected. 


11? 


283 


CONSTITUTIONAL  DISEASES. 


(3)  Pleurodynia  involves  the  intercostal  muscles  on  one  side,  and  in 
some  instances  tlie  pectorals  and  serratus  magnus.  Tliis  is,  perhaps,  tlic 
most  painful  form  of  tlie  disease,  as  the  chest  cannot  be  at  rest.  It  is  more 
common  on  the  left  tlian  on  the  right  side.  A  deep  breath,  or  coughini:, 
causes  very  intense  pain,  and  the  respiratory  movements  are  restricted  on 
the  ailected  side.  There  may  be  pain  on  pressure,  sometimes  over  a  very 
limited  area.  It  may  be  difficult  to  distinguish  from  intercostal  neuralgiii, 
in  wliich  alTection,  however,  the  pain  is  usually  more  circumscribed  and 
paroxysmal,  and  there  are  tender  points  along  the  course  of  the  nerves. 
It  is  sometimes  mistaken  for  pleurisy,  but  careful  physical  examination 
readily  distinguishes  between  the  two  affections. 

(4)  Among  other  forms  which  may  be  mentioned  are  cephalodynia, 
affecting  the  muscles  of  the  head  ;  scapulodynia,  omodynia,  and  dorsodynia, 
affecting  the  muscles  about  the  shoulder  and  upper  part  of  the  back.  !My- 
algia  may  also  occur  in  the  abdominal  muscles  and  iu  the  muscles  of  tlio 
extremities. 

Treatment. — Rest  of  the  affected  muscles  is  of  the  first  importance. 
Strapping  the  side  will  sometimes  completely  relieve  pleurodynia.  No 
belief  is  more  wide-spread  among  the  public  than  the  efficacy  of  porous 
plasters  for  muscular  pains  of  all  sorts,  particularly  those  about  the  trunk. 
If  the  pain  is  severe  and  agonizing,  a  hypodermic  of  morphia  gives  im- 
mediate relief.  For  lumbago  acupuncture  is,  in  acute  cases,  the  most  efli- 
cient  treatment.  Needles  of  from  three  to  four  iiiches  in  length  (ordinary 
bonnet-needles,  sterilized,  will  do)  are  thrust  into  the  lumbar  muscles  at 
the  seat  of  the  pain,  and  withdrawn  after  five  or  ten  minutes.  In  many 
instances  the  relief  is  immediate,  and  I  can  corroborate  fully  the  state- 
ments of  Ringer,  who  taught  me  this  practice,  as  to  i'ts  extraordinary  and 
prompt  efficacy  in  many  instances.  The  constant  current  is  sometimes 
very  beneficial.  In  many  forms  of  myalgia  the  thermo-cautery  gives  groat 
relief.  In  obstinate  cases  blisters  may  be  tried.  Hot  fomentations  are 
soothing,  and  at  the  outset  a  Turkish  bath  may  cut  short  the  attack.  In 
chronic  cases  iodide  of  potassium  may  be  used,  and  both  guaiacum  and 
sulphur  have  been  strongly  recommended.  Persons  subject  to  this  affec- 
tion should  be  warmly  clothed,  and  avoid,  if  possible,  exposure  to  C(»ld 
and  damp.  In  gouty  persons  the  diet  should  be  restricted  and  the  alka- 
line mineral  waters  taken  freely.  Large  doses  of  nux  vomica  are  some- 
times beneficial. 


V.   ARTHRITIS   DEFORMANS  {Rheumatoid  arthritis). 


Deflnition. — A  chronic  disease  of  the  joints,  characterized  by  changes 
in  the  cartilages  and  synovial  membranes,  with  periarticular  formation  of 
bone  and  great  deformity. 

Etiology. — Long  believed  to  be  intimately  associated  both  with  gout 


ARTHRITIS   DEFORMANS. 


283 


and  rheumatism  (whence  the  names  rheumatic  gout  and  rheumatoid  ar- 
tliritis),  this  close  relationship  seems  now  very  doubtful,  since  in  a  ma- 
jority of  the  cases  no  history  of  either  affection  can  be  determined.  It  is 
ditlicult  to  separate  some  cases  from  ordinary  chronic  rheumatism,  but  the 
iiiultiple  form  has,  in  all  probability,  a  nervous  origin,  as  suggested  by  J. 
Iv.  Mitchell.  This  view  is  based  upon  such  facts  as  the  association  of  the 
disease  with  shock,  worry,  and  grief;  the  similarity  of  the  arthritis  to  the 
arthropathies  due  to  disease  of  the  cord,  as  in  locomotor  ataxia;  the  sym- 
Miulrical  distribution  of  the  losious;  the  remarkable  trophic  changes  which 
lead  to  alterations  in  the  skin  and  nails,  and  occasionally  to  muscular 
wasting  out  of  proportion  to  the  joint  mischief.  Ord  regards  the  disease 
as  analogous  to  progressive  muscular  atrophy  and  due  either  to  a  primary 
lesion  in  the  cord  or  to  changes  the  result  of  peripheral  irritation,  trau- 
matic, uterine,  urethral,  etc.  The  true  nature  of  the  disease  is  still  ob- 
scure, but  the  neuro-trophic  theory  meets  very  many  of  the  fiicts.  Females 
arc  more  liable  to  the  disease  than  males.  In  Archibald  E.  Garrod's  table 
of  tiOO  cases  there  were  411  females  and  89  males.  It  most  commonly  sets 
in  between  the  ages  of  twenty  and  thirty,  but  it  may  begin  as  late  as  fifty. 
It  occurs  also  in  children ;  within  the  past  five  years  there  have  been  at 
my  clinics  four  cases  in  children  under  twelve.  I'he  degree  of  deformity 
may  be  extreme  even  at  this  early  age.  Hereditary  influences  are  not 
inieommon.  In  Garrod's  cases  there  were  in  210  instances  a  family  history 
of  joint  disease.  Seguin  has  reported  the  occurrence  of  three  cases  in 
children  of  the  same  family.  It  is  si.ited  that  the  disease  is  more  common 
in  families  with  jjlithisical  history.  It  seems  to  be  more  frequent  in  women 
who  have  had  ovarian  and  uterine  trouble,  or  who  are  sterile.  In  this 
country  acute  rheumatism  or  gout  in  the  forebears  is  rare.  Mental  worry, 
grief,  and  anxiety  seem  frequent  antecedents.  It  is  an  affection  quite  as 
common  in  the  rich  as  in  the  poorer  classes,  though  in  England  aiul  the 
continent  the  latter  seem  more  prone  to  the  disease.  Though  often  attrib- 
uted to  cold  or  damp,  and  occasionally  to  injury,  there  is  no  evidence  that 
tiiesc  are  efficient  causes. 

Morbid  Anatomy. — The  changes  in  the  joints  differ  essentially 
from  those  of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from 
chronic  rheumatism  by  the  existence  of  extensive  structural  alterations, 
particularly  in  the  cartilages.  We  are  largely  indebted  to  the  magnificent 
Work  of  Adams  for  our  knowledge  of  the  anatomy  of  this  disease.  The 
cli;u>ges  begin  in  the  cartilages  and  synovial  membranes,  the  cells  of 
whicli  proliferate.  The  cartilage  covering  the  joint  undergoes  a  peculiar 
iibrillation,  becomes  soft,  and  is  either  absorbed  or  gradually  thinned  by 
attrition,  thus  laying  bare  the  ends  of  the  bone,  which  become  smooth, 
jjolislied,  and  eburnated.  At  the  margins,  where  the  pressure  is  less,  the 
proliferating  elements  may  develop  into  irregular  nodules,  which  ossifiy 
and  enlarge  the  heads  of  the  bones,  forming  osteophytes  which  completely 
look  the  joint.     The  periosteum  may  also  form  new  bone.    There  is  usu- 


■n-':  ' 


r/ 


ifc''' 


■\;f 


'■'  In' 


284 


CONSTITUTIONAL   DISEASES. 


ally  ffreat  tluckoiiing  of  tho  ligaments,  and  finally  complete  anchylosis 
results.  Tliis  is  rarely,  however,  a  true  anchylosis,  but  is  caused  by  the 
08teo])hyte3  and  thickened  ligaments.  There  are  often  hyperostosis  aiul 
increase  in  the  articular  ends  of  the  bone  in  length  and  thickness.  In 
long-standing  cases  and  in  old  persons  there  may,  on  tho  other  hand,  bo 
great  atroj)hy  of  tho  heads  of  the  affected  bones.  Tho  spongy  substance 
becomes  friable,  and  in  tho  hip-joint  tho  wasting  nuiy  reach  such  an 
extreme  grade  that  the  articulating  surface  lies  between  tho  trochanters. 
This  is  sometimes  called  morbus  coxce  senili.s.  Tho  anatomical  changes 
may  lead  to  great  deformity.  The  metacarpal  joints  are  enlarged  and 
thickened,  and  tlie  fingers  are  deflected  toward  the  ulnar  side.  The  toes 
often  show  a  similar  deflection. 

The  muscles  become  atrophied,  and  in  some  cases  the  wasting  reaclios 
a  higli  grade.  Neuritis  has  been  demonstrated  in  the  nerves  about  the 
joints. 

Symptoms. — Charcot  makes  a  convenient  division  of  the  cases  into 
Ileberden's  nodosities,  the  general  progressive  form,  and  the  partial  or 
mono-articular  form. 

Heberden's  Nodosities.— In  this  form  the  fingers  are  affected,  and  little 
hard  nodules  develop  gradually  at  the  sides  of  the  distal  phalanges.  Tlicy 
are  much  more  common  in  women  than  in  men.  They  begin  usually  be- 
tween tho  thirtieth  and  fortieth  year.  Tho  subjects  may  be  in  ]ierfect 
health,  though  more  commonly  they  have  digestive  troubles,  neuralgia,  or 
rheumatic  piiins,  or  have  had  gout.  Although  these  nodules  are  usually 
regarded  as  gouty,  in  many  cases  no  manifestations  of  this  disease  occur. 
Ileberden  did  not  lay  any  stress  upon  the  association.  In  the  early  stage 
the  joints  may  be  swollen,  tender,  and  slightly  red,  particularly  when 
knocked.  The  attacks  of  pain  and  swelling  may  come  on  in  the  joints  at 
long  intervals  or  follow  indiscretion  in  diet.  The  little  tubercles  at  the 
sides  of  the  dorsal  surface  of  the  second  phalanx  increase  in  size,  and  give 
tho  characteristic  appearance  to  tho  affection.  The  cartilages  also  become 
soft,  and  the  ends  of  the  bones  eburnated.  The  condition  is  not  curable; 
but  there  is  this  hopeful  feature — the  subjects  of  these  nodosities  rarely 
have  involvement  of  the  larger  joints.  They  have  been  regarded,  too,  as 
an  indication  of  longevity.  Charcot  states  that  in  women  with  these 
nodes  cancer  seems  more  frequent. 

General  Progressive  Form. — This  occurs  in  two  varieties,  acute  and 
chronic.  The  acute  form  may  resemble,  at  its  outset,  ordinary  articular 
rheumatism.  There  is  involvement  of  many  joints ;  swelling,  particularly 
of  tho  synovial  sheaths  and  bui'sa? ;  not  often  redness ;  but  there  is  niod- 
erato  fever.  Howard  describes  this  condition  as  most  frequent  in  young 
women  from  twenty  to  thirty  years  of  age,  often  in  connection  with  reccut 
delivery,  lactation,  or  rapid  child-bearing.  Acute  cases  may  develop  at 
the  menopause.  It  may  also  come  on  in  children.  "  These  patients  sn(Tor 
in  their  general  health,  become  weak,  pale,  depressed  in  spirits,  and  lose 


AIITIIUITIS   DEFORMANS. 


285 


Iksli.  In  several  cases  of  tliis  form  marked  intervals  of  improvement  have 
occurred ;  the  local  disease  has  ceasetl  to  progress,  and  tolerable  comfort 
Ims  been  experienced  perhaps  until  pregnancy,  delivery,  or  lactation  again 
(Ictorinino  a  fresh  outbreak  of  the  disease." 

The  clirouic  form  is  by  far  the  most  common.  The  joints  are  usually 
involved  symmetrically.  The  first  symptoms  are  pain  on  movement  and 
slight  swelling,  which  may  be  in  the  joint  itself  or  in  the  peri-articular 
siieaths.  In  some  cases  the  eiTusion  is  marked,  in  others  slight.  The 
local  conditions  vary  greatly,  and  periods  of  improvement  alternate  with 
attacks  of  swelling,  redness,  and  pain.  At  first  only  one  or  two  joints  are 
ail'ected ;  usually  the  joints  of  the  hands,  then  the  knees  and  feet;  gradu- 
ally other  articulations  are  involved,  and  in  extreme  cases  every  articula- 
tion in  the  body  is  alfected.  Pain  is  an  extremely  variable  symptom. 
Some  cases  proceed  to  the  most  extreme  deformity  without  i)ain ;  in 
others  the  sulfering  is  very  great,  particularly  at  night  and  during  the 
exacerbations  of  the  disease.  There  are  cases  in  which  pain  of  an  agoniz- 
ing character  is  an  almost  constant  symptom,  requiring  for  years  the  use 
of  morphia. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  by  the  pres- 
ence of  osteophytes,  partly  by  the  great  thickening  of  the  capsular  liga- 
ments, and  still  more  by  the  retraction  of  the  muscles.     In  moving  the 
afl't'cted  joint  crepitation  can  be  felt,  due  to  theeburnation  of  the  articular 
surfaces.     Ultimately  the  joints  become  completely  locked,  not  by  a  true 
bony  anchylosis,  but  by  the  osteophytes  which  form  around  the  articular 
surfaces,  like  ring-bone  in  horses.     There  is  also  a  spurious  anchylosis, 
caused  by  the  thickening  of  the  capsular  ligaments  and  fibrous  adhesions. 
The  muscles  about  the  joints  undergo  important  changes.     Atrophy  from 
disuse  gradually  supervenes,  and  contractures  tend  to  fiex  the  thigh  ui^on 
the  abdomen  and  the  leg  upon  the  thigh.     There  are  cases  with  ,apid 
muscular  wasting,  symmetrical  involvement  of  the  joints,  aiid  trophic 
clianges,  which  strongly  suggest  a  central  origin.     Numbness,  tingling, 
pigmentation  or  glossiness  of  the  skin,  and  onychia  may  be  present.     In 
extreme  cases  the  patient  is  completely  helpless,  and  lies  on  one  side  with 
the  logs  drawn  up,  the  arms  fixed,  and  all  tlie  articulations  of  the  extremi- 
ties locked.     Fortunately,  it  often  happens  in  these  severe  general  cases 
thill  the  joints  of  the  hand  are  not  so  much  affected,  and  the  patient  may 
be  able  to  knit  or  to  Avrite,  though  unable  to  walk  or  to  use  the  arms.     It 
is  surprising  indeed  how  much  certain  patients  with  advanced  arthritis 
deformans  can  accomplish.     No  one  who  had  seen  the  beautiful  models 
ami  microscopic  preparations  of  the  late  II.  D.  Schmidt,  of  New  Orleans, 
•ould  imagine  that  he  had  been  afflicted  for  years  with  a  most  extreme 
giade  of  this  terrible  disease.      In  many  cases,  after   involving   two  or 
throe  joints,  the  disease  becomes  arrested,  and  no  further  development 
occurs.    It  may  be  limited  to  the  wrists,  or  to  the  knees  and  wrists,  or 
to  the  knees  and  ankles.    A  majority  of  the  patients  finally  reach  a 


i 


1: .  I 


28fi 


CONSTITUTION  A  li  DISEASES. 


quiescent  stupe,  iti  which  they  nro  free  from  pain  inul  enjoy  excellent 
health,  HulTerinj,'  only  from  the  inconvenienee  and  crippling  uectissurily 
associated  with  the  disease. 

(.'oiiieideiit  all'ections  are  not  iincomnion.  In  the  active  sta^o  the  pa- 
tients are  often  ainemic  and  siilTer  from  dyspejjsia,  which  may  recur  al 
intervals.     There  is  no  tendency  to  involvement  of  the  heart. 

The  partial  or  mono-articular  form  alTects  chielly  old  persons,  and  is 
seen  particularly  in  the  hip,  the  knee,  the  spinal  colinnn,  or  shoulder,  it 
is,  in  its  anatomical  features,  identii-al  with  the  general  disease.  In  the 
hip  and  shoulder  the  nnisclea  early  show  wasting,  and  in  the  liip  tlie  con- 
dition idtinuitely  becomes  tliat  already  described  as  ?norbus  coxm  senilis. 
These  cases  seem  not  infrerpiently  to  follow  an  injury.  Th(>y  differ  from 
the  polyarticular  form  in  occurring  chielly  in  men  and  at  a  later  period  of 
life.  One  of  the  nu)st  interesting  forms  alTects  the  vertebrae,  completely 
locking  the  articulations,  and  producing  the  condition  known  as  xpojuli/- 
litis  drfiirmans.  When  the  cervical  sijine  is  involved  the  head  cannot 
be  moved  up  and  down,  but  is  carried  stillly.  ITsnally  rotation  can  lie 
elfected.  Tlio  dorsal  and  lumbar  .sjjines  may  also  be  involved,  and  tin 
body  cannot  be  Hexed  in  the  slightest  degree.  No  other  joints  may  bf 
utTecited. 

Diajpiosis. — Arthritis  deformans  can  rarely  he  mistaken  for  either 
rheumatism  or  gout.  It  is  important  to  distinguish  from  the  mono-articii- 
lar  form  the  local  arthritis  of  the  shoulder-joint  which  is  characterized  hy 
pain,  thickening  of  the  capsule  and  of  the  ligaments,  Avasting  of  tlie 
shoulder-girdle  muscles,  and  sometimes  by  neuritis.  This  is  an  affection 
which  is  quite  distinct  from  arthritis  deformans,  and  is,  moreover,  in  a 
majority  of  cases  curable. 

Treatment. — Arthritis  deformans  is  an  incurable  disease.  In  many 
cases,  after  involvement  of  two  or  three  joints,  the  progress  is  arresteil. 
Too  often  it  invades  successively  all  the  articulations,  and  iji  ten,  fifteen, 
or  twenty  years  the  crippling  becomes  general  and  permanciit. 

The  best  that  can  be  hoped  for  is  a  gradual  arrest.  It  is  useless  to 
saturate  the  patients  with  iodide  of  potassium,  salicylates,  or  quiniro. 
Arsenic  seems  to  do  good  as  a  general  tonic.  The  improvement  may  be 
marked  if  large  doses  ©f  it  are  given.  Iron  sluiuld  be  used  freely,  if 
there  is  anaemia.  Cf.reful  attention  to  the  digestion,  plenty  of  good  food, 
and  fresh  air  are  important  measures.  Hydrotherapy,  with  carefully  pei- 
formed  massage,  is  best  for  the  alleviation  of  the  pain,  and  may  possibly 
restrain  the  progress  of  the  alfection.  In  early  cases  local  improvement 
and  often  great  gain  in  the  general  strength  follow  a  prolonged  treat- 
ment at  the  h  t  mineral  baths;  but  the  practitioner  should  exercise  care 
in  recommending  this  mode  of  treatment,  which  is  of  very  doubtful  vahif 
when  the  disease  is  well  established.  I  have  repeatedly  known  cases  to  bc^ 
rendered  much  worse  by  residence  at  these  institutions.  When  good 
results,  it  is  largely  from  change  of  scene  and  climate,  and  the  careful 


GOUT. 


287 


rcgiiliition  of  the  diet.  Tlie  local  trcutmont  is  of  boncflt  in  arrostin}?  tho 
proijress.  When  thero  aro  iniicli  lu'at  and  j)ain  the  liiiil)  slioiild  Im;  at  rest, 
cold  coinpiVHSt's  ai»|>li('d  ut  iii<,'lit,  tlio  joiiita  wnippod  in  odeil  tilk,  and  in 
till!  nioriuii}^  tli()roiij,dily  inassu<,'od.  It  is  surprising  liow  miudi  can  bo 
(joiio  by  carefully  applied  friction  to  redii(;o  the  thiekening,  to  promote 
absorption  of  elTiision,  and  to  restore  tnohilily.  Massaj,'e  is  also  of  special 
hciietil  in  maintaining,'  the  nutrition  of  the  nniscles,  which  early  tend  to 
alr(i[ihy.  In  the  case  of  the  knees  this  mode  of  treatment  will  sometimes 
prevent  tho  retraction  of  the  mnscles  and  tho  gradual  flexion  of  tho  legs 
(III  the  thighs.     No  benefit  can  be  expected  from  electricity. 


VI.    GOUT   (fodai/ru.) 

Deflnltion. — A  nutritional  disorder,  associated  witli  an  excessive 
formation  of  uri(!  acid,  and  eharai-terized  clinically  by  attacks  of  acute 
arthritis,  by  the  gradual  deposition  of  urate  of  sodainaiul  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 

Etiology. — It  is  now  generally  recogni/x'd  that  the  disease  depends 
upon  disturbed  metabolism;  most  probably  upon  defective  oxidation  of 
nitrogenous  food-stu:Ts. 

Among  important  etiological  factors  in  gout  are  the  following: 

{a)  Hereditary/  Iiijfueiires. — Statistics  show  that  in  from  lifty  to  sixty 
percent  of  all  cases  the  disease  existed  in  tho  j)arents  or  grandparents. 
The  transmission  is  supposed   to   be  more  marked  from  tho  male  side. 
Cases  with  a  strong  hereditary  taint  have  been  known  to  develop  before 
puhorty.     The  disease  has  boon  soon  even  in  infants  at  tho  breast.     Jlales 
are  more  subject  to  the  disease  than  females.     It  rarely  develops  before 
the  thirtieth  year ;  and  in  a  largo  majority  of  the  cases  the  first  manifes- 
tations appear  before  the  ago  of  fifty,      (b)  Alcohol  is  the  most  ])otent 
factor  in  the  etiology  of  the  disease.     Fermented  liquors  favor  its  develop- 
ment much  more  than  distilled  spirits,  and  it  prevails  most  extensively  in 
loiintrios  like  England  and  (Jermany,  which  consume  tho  most  beer  and 
ale.    Probably  the  greater  tendency  of  malt  liquors  to  induce  gout  is  asso- 
ciated with  the  production  of  an  acid  dyspepsia.     The  lighter  beers  used 
in  tills  country  are  much  less  liable  to  produce  gout  than  the  heavier  Eng- 
lish and  Scotch  ales,     (r)  Food  plays  a  role  equal  in  importance  to  that  of 
alcohol.     From  tho  tinui  of  Hippocrates  overeating  has  been  regarded  as 
a  s[)ecial  predisposing  cause.     The  excessive  use  of  food,  particularly  of 
meats,  disturbs  gastric  digestion  and  leads  to  the  formation  of  lactic  and 
volatile  fatty  acids.     It  is  held  by  Garrod  and  others  that  these  tend  to  de- 
crease the  alkalinity  of  the  blood  and  to  reduce  its  power  of  holding  urates 
in  s(»lution.     A  special  form  of  gouty  dyspepsia  has  been  described.     A 
roi)ust  and  active  digestion  is,  however,  of  ten  met  in  gouty  persons.    Gout 
is  by  no  means  confined  to  the  rich.     In  England  the  combination  of 


288 


CONSTITUTIONAL  DISEASES. 


poor  food,  defective  hygiene,  and  an  excessive  consuin^jcion  of  malt  liquors 
makes  the  "  poor  man's  gout "  a  common  affection.  (</)  Lead.  Gurrod 
has  shown  that  workers  in  load  are  specially  jirone  to  gout.  In  thirty 
per  cent  of  his  hospital  cases  the  patients  had  been  painters  or  workers  in 
lead.  The  association  is  probably  to  be  sought  in  the  production  by  this 
poison  of  arterio-sclerosis  aiid  chronic  nephritis.  Something  in  addition 
is  necessary,  or  certainly  in  this  country  we  should  more  frequently  see 
cases  of  the  kind  so  common  in  London  hospitals.  Chronic  lead-poison- 
ing is  here  frequently  associated  with  arterio-sclerosis  and  contracted  kid- 
neys, but  acute  arthritis  is  rare.  Gouty  deposits  are,  however,  to  be  found 
in  the  big-toe  joint  and  in  the  kidneys  in  these  cases. 
There  are  three  theories  with  reference  to  gout : 

(1)  The  Uric-acid  Theory. — Sir  Alfred  Garrod,  to  whom  the  profession 
is  indebted  for  so  many  careful  studies  in  this  disease,  showed  that  there 
was  an  increase  in  the  uric  acid  in  the  blood,  due  either  to  increased  2)ro- 
duction  or  to  diminished  elimination ;  and  that  the  alkalinity  of  the  blood 
was  also  lessened,  lie  attributes  the  deposition  of  the  urate  of  soda  to 
the  diminished  alkalinity  of  the  plasma,  which  is  unable  to  hold  it  in  solu- 
tion. An  increase  in  the  quantity  of  the  uric  acid  produced,  or  any  inter- 
ference with  elimination  througli  the  kidneys,  may  cause  a  sudden  out- 
break. The  acute  paroxysm  is  due  to  an  accumulation  of  the  urates  in 
the  blood,  which  he  believes  are  responsible  also  for  the  preliminary  dys- 
pepsia, the  coated  tongue,  the  irritability  of  temper,  and  the  general  feel- 
ings of  malaise.  The  sudden  deposit  of  the  crystalline  urates  about  the 
joint  leads  to  inflammation. 

(2)  The  Xervous  Theory. — The  view  of  CuUen  that  gout  was  priniaiily 
an  affection  of  the  nervous  system  has  been  modified  into  a  neuro-humorul 
view  which  has  been  advocated  particularly  by  Sir  Dyce  Duckworth.  On 
this  theory  there  is  a  basic,  arthritic  stock — a  diathetic  habit,  of  which 
gout  and  rheumatism  are  two  distinct  branches.  The  gouty  diathesis  ii 
expiGssed  iii  ya)  a  neurosis  of  the  nerve-centres,  which  may  be  inherited  or 
acquired ;  and  {b)  "  a  peculiar  incapacity  for  normal  elaboration  within 
the  whole  body,  not  merely  in  the  liver  or  in  one  or  two  organs,  of  food, 
whereby  uric  acid  is  formed  at  times  in  excess,  or  is  incapable  of  bi-nig 
duly  transformed  into  more  soluble  and  less  noxious  products  "  (Duck 
worth).  The  explosive  neuroses  and  the  influence  of  depressing  circum- 
stances, physical  or  mental,  point  strongly  to  the  part  played  by  the  nerv- 
ous system  in  the  disease. 

(3)  Eh>^fein''s  Theory. — A  nutritive  tissue  disturbance  is  the  primary 
change-  leading  to  necrosis,  and  in  the  necrotic  areas  tl^p  urates  are  de- 
posited. I'his  is  not  unlike  the  view  of  Ord,  who  hoidd  that  there  is 
a  tendency,  inherited  or  acquired,  to  a  special  form  of  tissue  degenera- 
tion. 

Morbid  Anatomy. — The  blood  shows  an  excess  of  uric  acid,  as 
proved  originally  by  Garrod.    The  uric,  acid  maybe  obtained  from  tlio 


GOUT, 


289 


blood-scrum  by  the  method  known  as  uric-acid  thread  experiment,  or  from 
the  serum  obtained  from  a  bUster.  To  3  ij  of  serum  add  tilv-vj  of  acetic 
acid  in  a  watch-ghiss.  A  thread  immersed  in  this  will  show  in  a  few 
hours  an  incrustation  of  uric  acid.  This  is  not,  however,  peculiar  to  gout, 
but  occurs  in  leukaemia  and  chlorosis.  The  important  changes  are  in  the 
articular  tissues.  The  first  joint  of  the  great  toe  is  most  frequently  in- 
volved ;  then  the  ankles,  knees,  and  the  small  joints  of  the  hands  and 
wrists.  The  deposits  may  be  in  all  the  joints  of  the  lower  limbs  and 
absent  from  those  of  the  upper  limbs  (Norman  Moore).  If  death  takes 
place  during  an  acute  paroxysm,  there  are  signs  of  inflammation,  hyperae- 
mia,  swelling  of  the  ligamentous  tissues,  and  of  effusion  into  the  joint. 
The  primary  change,  according  to  Ebstein,  is  a  local  necrosis,  due  to  tlie 
presence  of  an  excess  of  urates  in  the  blood.  This  is  seen  in  the  cartilage 
and  other  articular  tissues  m  which  the  nutritional  currents  are  slow.  lu 
these  areas  of  coagulation  necrosis  the  reaction  is  always  acid  and  the 
neutral  urates  are  deposited  in  crystalline  form,  as  insoluble  acid  urates. 
The  articular  cartilages  are  first  involved.  The  gouty  deposit  may  be  uni- 
form, or  in  small  areas.  Though  it  looks  superficial,  the  deposit  is  in- 
variably interstitial  and  covered  by  a  thin  lamina  of  cartilage.  The  de- 
posit is  thickest  at  the  part  most  distant  from  the  circulation.  The  liga- 
ments and  fibro-cartilage  ultimately  become  involved  and  are  infiltrated 
with  chalky  deposits,  the  so-called  chalk-stones,  or  tophi.  These  are  usu- 
ally covered  by  skin ;  but  in  some  cases,  particularly  in  the  metacarpo- 
phalangeal articulations,  this  ulcerates  and  the  chalk-stones  appear  ex- 
ternally. The  synovial  fluid  may  also  contain  crystals.  In  very  long- 
standing cases,  owing  to  an  excessive  deposit,  the  joint  becomes  immobile. 
The  marginal  outgrowths  in  gouty  arthritis  are  true  exostoses  (Wynne). 
riie  cartilage  of  the  ear  may  contain  tophi,  which  are  seen  as  yellowish 
nodules  at  the  margin  of  the  helix.  The  cartilages  of  the  nose,  eyelids, 
and  larynx  are  less  frequently  affected. 

Of  changes  in  the  internal  oi-gans,  those  in  the  renal  and  vascular  sys- 
tems are  the  most  important.  The  kidney  changes  believed  to  be  charac- 
teristic of  gout  are :  (a)  A  deposit  of  urates  chiefly  in  the  region  of  the 
papillie.  T'his  is  a  less  common  change,  however,  than  is  usually  sup- 
itosed.  Norman  Moore  found  it  in  only  twelve  out  of  eighty  cases.  The 
ainces  of  the  pyramids  show  lines  of  whitish  deposit.  On  microscopical 
examination  the  material  is  seen  to  be  largely  in  the  intertubular  tissue. 
In  some  instances,  however,  the  deposit  seems  to  be  both  in  the  tissue  and 
in  the  tubules.  Ebstein,  in  his  monograph,  has  described  and  figured 
areas  of  necrosis  in  both  cortex  and  medulla,  in  the  interior  of  which  were 
civsiiillinn  deposits  of  urate  of  soda.  The  presence  of  these  uratic  con- 
cretions at  the  apices  of  the  pyramids  is  not  a  positive  in  lication  of  gout. 
riiry  are  not  infrequent  in  this  country,  in  which  gout  is  rare,  {b)  An 
interstitial  nephritis,  either  the  ordinary  "  contrsicted  kidney"  or  the 
arterio-sclerotic  form,  neither  of  which  are  in  any  way  distinctive.     It  is 


■ 


:; . 


•,  I-    1 


290 


CONSTITUTIONAL  DISEASES. 


not  possible  to  say  in  a  given  case  that  the  condition  has  been  due  to  gout 
unless  marked  evidences  of  the  disease  coexist. 

The  metatarso-phalangeal  joint  of  the  big  toe  should  be  carefully  ex- 
amined, as  it  may  show  typical  lesions  of  gout  without  any  outward  token 
of  arLliritis. 

Arterio-sclerosis  is  a  very  constant  lesion.  With  it  the  heart,  particu- 
larly the  left  ventricle,  is  found  hypertrophied.  According  to  some  au- 
thors, concretions  of  urate  of  soda  may  occur  on  the  valves. 

Changes  in  the  respiratory  system  are  rare.  Dci)osit8  have  been  found 
in  the  vocal  cords,  and  uric-acid  crystals  have  been  met  in  the  sputa  of  a 
gouty  patient  (J.  W.  Moore).  Emphysema  is  a  very  constant  condition 
in  old  cases. 

Symptoms. — Gout  is  usually  divided  into  acute,  chronic,  and  irregu- 
lar forms. 

Acute  Gout. — Premonitory  symptoms  are  common — twinges  of  pain 
in  the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irrita- 
bility of  temptM',  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high- 
colored.  It  deposits  urates  on  cooling,  and  there  may  be,  according  to 
Garrod,  transient  albuminuria.  There  may  be  traces  of  sugar  (gouty  gly- 
cosuria). Before  an  attack  the  output  of  uric  acid  is  low  and  is  also  di- 
minished in  the  early  part  of  the  paroxysm.  In  some  instances  the  throat 
is  sore,  and  there  may  be  asthmatic  attacks.  The  attack  sets  in  usually 
in  the  early  morning  hours.  The  patient  is  aroused  by  a  severe  pain  in 
the  metatarso-phalangeal  articulation  of  the  big  toe,  and  more  commonly 
on  the  right  than  on  the  left  side.  The  pain  is  agonizing,  the  joint  swells 
rapidly,  and  becomes  hot,  tense,  and  shiny.  The  sensitiveness  is  extreme, 
and  the  patient  describes  the  pain  as  if  the  joint  AVtre  being  pressed  in  a 
vice.  There  is  fever,  and  the  temperature  may  rise  to  103°  or  103°. 
Toward  morning  the  severity  of  the  symptoms  subsides,  and,  although  the 
joint  remains  swollen,  the  day  may  be  passed  in  comparative  comfort. 
The  symptoms  recur  the  next  night,  and  the  fit,  as  it  is  called,  usually  lasts 
for  from  live  to  eight  days,  the  severity  of  the  symptoms  gradually  abating. 
Occasionally  other  joints  are  involved,  particularly  the  Itig  toe  of  the  oj)- 
posite  foot.  The  inflammation,  however  intense,  never  goes  on  to  suppu- 
ration. With  the  subsidence  of  the  swelling  the  skin  descpiamates.  After 
the  attack  the  general  health  may  be  much  improved.  Recurrences  are 
frequent.  Some  patients  have  three  or  four  attacks  in  a  year ;  others  at 
longer  intervals.  Lecorchc  has  shown  that  the  amount  of  uric  acid  is 
reduced  prior  to  an  attack,  diminishes  during  the  first  two  days,  then  in- 
creases very  much  and  falls  toward  the  close. 

The  term  rctroccdent  or  st(p].)ressed  gout  is  applied  to  serious  internal 
symptoms,  coincident  with  a  rapid  disappearance  or  improvement  of  the 
local  signs.  Very  remarkable  manifestations  may  occur  under  these  cir- 
cumstances. The  patient  may  have  severe  gastro-intestinal  symptoms- 
pain,  vomiting,  diarrhoea,  and  great  depression — and  death  may  occur 


GOUT. 


291 


(luring  sucli  au  attack.  Or  there  may  be  cardiac  manifestations— dyspnoea, 
iniiii,  and  irregular  action  of  the  heart.  In  some  instances  in  which  the 
gout  is  said  to  attack  the  heart,  an  acute  pericarditis  develops  and  proves 
fatal.  So,  too,  there  may  be  marked  cerebral  manifestations — delirium 
iind  coma,  and  even  apoplexy — but  in  a  majority  of  these  instances  the 
symptoms  are,  in  all  probability,  urajmic. 

Acute  gout  is  a  rare  disease  in  America,  and  in  hospital  practice  is 
almost  unknown.  Among  the  well-to-do  and  even  among  club-men — a 
class  particularly  liable — it  is  infrequent,  in  comparison  with  the  preva- 
lence in  the  corresponding  classes  in  England.  Men  in  large  family  prac- 
tice may  pass  a  year  or  more  without  seeing  a  case.  It  has  become  more 
common,  however,  during  the  past  twenty-live  years. 

Chronic  Gout. — With  increased  frequency  in  the  attacks,  the  articular 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  become 
alTected.  Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages 
and  then  in  the  ligaments  and  capsular  tissues ;  so  that  in  the  course  of 
years  the  Joints  become  swollen,  irregular,  and  deformed.  The  feet  are 
usiuilly  first  affected,  then  the  hands.  In  severe  cases  there  may  be  exten- 
sive concretions  about  the  elbows  and  knees  and  along  the  tendons  and  in 
tlic  bnrsaj.  The  tophi  appear  in  the  ears.  Finally,  a  unique  clinical  pict- 
ure is  produced  which  cannot  be  mistaken  for  any  other  affection.  The 
skin  over  the  tophi  may  rupture  or  ulcerate,  and  about  the  knuckles  the 
clialk-stones  may  be  freely  exposed.  Patients  with  chronic  gout  are  usu- 
ally dyspeptic,  often  of  a  sallow  complexion,  and  show  signs  of  arterio- 
sclerosis. The  pulse  tension  is  increased,  the  vessels  are  stiff,  and  the  left 
ventricle  is  hypertrophied.  The  urine  is  increased  in  amount,  is  of  low 
specific  gravity,  and  usually  contains  a  slight  amount  of  albumen,  with  a 
few  hyaline  casts.  Patients  with  chronic  gout  may  show  remarkable 
nieutai  and  even  bodily  vigor.  Certain  of  the  most  distinguished  mem- 
bers of  our  profession  have  been  terrible  sufferers  from  this  disease — nota- 
l)ly  the  elder  Scaliger,  Jerome  Cardan,  and  Sydenham,  whose  statement 
tliat  "  more  wise  men  than  fools  are  victims  of  the  affection  "  still  holds 
good. 

Irregular  Gout. — This  is  a  motley,  ill-defined  group  of  symptoms, 
manifestations  of  a  condition  of  disordered  nutrition,  to  which  the  terms 
'joulii  diathesis  or  Uthmmic  state  have  been  given.  Cases  are  seen  in  mem- 
bers of  gouty  families,  who  may  never  themselves  have  suffered  from  the 
acute  disease,  and  in  persons  who  have  lived  not  wisely  but  too  well,  who 
bavc  eaten  and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  for- 
tunate enough  to  escape  an  acute  attack.  It  is  interesting  to  note  the 
various  manifestations  of  the  disease  in  a  family  with  marked  hereditary 
ilispoaition.  The  daughters  often  escape,  while  one  son  may  have  gouty 
attacks  of  great  severity,  even  though  he  lives  a  temperate  life  and  tries 
in  every  way  to  avoid  the  conditions  favoring  the  disorder.  Another  son 
lia^;,  perhaps,  only  the  irregular  manifestations  and  never  the  acute  articu- 


1. 


it 


I 


'm 


292 


CONSTITUTIONAL  DISEASES. 


lar  affection.  While  the  irregular  features  are  perhaps  more  often  met 
with  in  the  hereditary  affection,  they  are  by  no  means  infrequent  in  per- 
sons who  appear  to  have  acquired  the  disease.  The  tendency  in  some 
families  is  to  call  every  affection  gouty.  Even  infantile  complaints,  such 
as  scald-head,  naso-pharyngeal  vegetations,  and  enuresis,  are  often  re- 
garded, without  sufficient  grounds,  I  believe,  as  evidences  of  the  family 
ailment.  Among  the  commonest  manifestations  of  irregular  gout  are  the 
following : 

(a)  Cuimicous  Eriqytions. — Garrod  and  others  have  called  special 
attention  to  the  frequent  association  of  eczema  with  the  gouty  hubit. 
The  French  in  particular  insist  upon  the  special  liability  of  gouty  persons 
to  skin  affections,  the  arthrUUles,  as  they  call  them. 

(b)  Gastro-intestinal  Disorders. — Attacks  of  what  is  termed  bilious- 
ness, in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  consti- 
pated, and  the  action  of  the  liver  torpid,  are  not  uncommon  in  gouty 
persons. 

(c)  Cardio-vascular  Symptoms. — With  the  lithtcmia,  artcrio-sclerosis  is 
frequently  associated.  The  blood  tension  is  persistently  high,  the  vessel 
walls  become  stiff,  and  cardiac  and  renal  changes  gradually  develop.  In 
this  condition  the  manifestations  may  be  renal,  as  when  the  albuminuria 
becomes  more  marked,  or  dropsical  symptoms  supervene.  The  manifesta- 
tions may  be  cardiac,  when  the  hypertrophy  of  the  left  ventricle  fails  and 
there  are  palpitation,  irregular  action,  and  ultimately  a  condition  of  asystole. 
Or,  finally,  the  manifestations  may  be  vascular,  and  involvement  of  the 
coronary  arteries  may  cause  sudden  death.  Aneurism  may  develop  and 
prove  fatal,  or,  as  most  frequently  happens,  a  blood-vessel  gives  way  in  the 
brain,  and  the  patient  dies  of  apoplexy.  It  makes  but  little  difference 
whether  we  regard  this  condition  as  primarily  an  arterio-sclerosis  or  as  a 
gouty  nephritis ;  the  point  to  be  remembered  is  that  the  nutritional  dis- 
order wHh  which  an  excess  of  uric  acid  is  associated  induces  in  time  in- 
creased 1  ension,  arterio-sclerosis,  chronic  interstitial  nepiiritis,  and  changes 
in  the  inyocardium.  Pericarditis  is  not  infrequent  in  connection  with 
the  granular  kidney  met  with  in  gout. 

(d)  Cerebrcd  Manifestations. — Headache  is  frequent.  Haig  has  called 
special  attention  to  the  association  of  this  symptom  with  retention  of  uric 
acid  in  the  system.  Neuralgias  are  not  uncommon ;  sciatica  and  pares- 
thesias may  develop.  A  common  gouty  manifestation,  upon  which  Duck- 
worth has  laid  stress,  is  the  occurrence  of  hot  or  itching  feet  at  night. 
Cramps  in  the  legs  may  also  be  very  troublesome.  Hutchinson  has  called 
attention  to  hot  and  itching  eyeballs  as  a  frequent  sign  of  masked  gout. 
More  serious  cerebral  manifestations  result  from  a  condition  of  arterio- 
sclerosis. Apoplexy  is  a  common  termination  of  gout.  A  low  meningitis 
may  develop,  usually  basilar. 

(e)  Urinary  Disorders. — The  urine  is  highly  acid  and  liigh-colored, 
and  may  deposit  on  standing  crystals  of  Jithic  acid.     Transient  and  tern- 


ii 


GOUT. 


293 


porary  increase  in  this  ingredient  cannot  be  regarded  as  serious.  In  many 
cases  of  chronic  gout  the  amount  may  be  diminished,  and  only  increased 
at  certain  periods,  forming  the  so-called  uric-acid  showers.  Sugar  is  found 
intermittently  in  the  urine  of  gouty  persons — gouty  glycosuria.  It  may 
pass  into  true  diabetes,  but  is  usually  very  amenable  to  treatment.  Oxaluria 
iiuiy  also  be  ])resent  Gouty  persons  are  specially  prone  to  calculi,  Jerome 
Cardan  to  the  contrary,  who  reckoned  freedom  from  stone  among  the  chief 
of  the  dona  poilagrcB.  Minute  quantities  of  albumen  are  very  common  in 
persons  of  gouty  dyscrasia,  and,  when  the  renal  changes  are  well  estab- 
lished, tube-casts.  Urethritis,  accompfinied  with  a  well-marked  purulent 
discharge,  may  develop,  so  it  is  stated,  usually  at  the  end  of  an  attack.  It 
may  occur  spontaneously,  or  follow  a  pure  connection. 

(/)  Pulmonary  Disorders. — There  are  no  characteristic  changes,  but, 
as  (ireenhow  has  pointed  out,  chronic  bronchitis  occurs  with  great  fre- 
quency in  persons  of  a  gouty  habit. 

[g)  Of  eye  affections,  iritis,  glaucoma,  haemorrhagic  retinitis,  and  sup- 
purative panopthalmitis  have  been  described. 

Treatment. — Individuals  who  have  inherited  a  tendency  to  gout,  or 
who  have  shown  any  manifestations  of  it,  should  live  temperately,  abstain 
from  alcohol,  and  eat  moderately.  An  open-air  life,  with  plenty  of  exer- 
cise and  regular  hours,  does  much  to  counteract  an  inborn  tendency  to 
the  disease. 

Diet. — Experience  has  shown  that  a  modified  nitrogenous  diet  is  the 
most  suitable.  Starchy  and  saccharine  articles  of  food  are  to  be  taken  in 
very  limited  quantities ;  as  "  the  conversion  of  azotized  food  is  more  com- 
plete with  a  minimum  of  carbohydrates  than  it  is  with  an  excess  of  them 
—in  other  words,  one  of  the  best  means  of  avoiding  the  accumulation  of 
lithic  acid  in  the  blood  is  to  diminish  the  carbohydrates  rather  than  the 
azotized  foods  "  (Draper).  Meats  of  all  kinds,  except  perhaps  the  coarser 
sorts,  such  as  pork  and  veal,  and  salted  provisions,  may  be  used.  Eggs, 
oysters,  and  fish  may  be  taken.  Lobsters  and  crabs,  particularly  when 
luiide  into  salads,  are  to  be  eschewed.  The  sugar  should  be  reduced  to  a 
minimum.  The  sweeter  fruits  should  not  be  taken.  Oranges  and  lemons 
may  be  allowed.  Strawberries,  bananas,  and  melons  should  not  be  eaten. 
It'  necessary,  saccharin  may  be  substituted  for  cane  sugar.  Potatoes 
sliould  be  sparingly  used.  The  fresh  vegetables,  such  as  lettuce,  cucum- 
bers, tomatoes,  and  cauliflower,  may  be  taken  freely.  Hot  rolls  and  cakes 
of  all  sorts,  hominy,  grits,  and  the  more  starchy  forms  of  prepared  foods 
arc  not  suitable.  The  various  articles  of  diet  prepared  from  corn  should 
bo  avoided.  Fats  are  easily  digested  and  may  be  taken  freely.  In  obsti- 
nate cases  great  benefit  is  derived  from  an  exclusively  milk  diet. 

Persons  with  a  gouty  tendency  should  be  encouraged  to  drink  freely 
of  such  mineral  waters  as  they  prefer.  They  keep  the  interstitial  circula- 
tion active  and  so  favor  elimination.  Milk  and  potash-water  form  a  pleas- 
ant and  wholesome  drink  for  a  lithaemic  patient.    Alcohol  in  all  forms 


294 


CONSTITUTIONAL   DISEASES. 


su 


"^ ,  !;•»,»  Miri>..t!.    )■   Si 


i:     ■■    ■Si  >'■:" 


''■"m-i 


should  be  avoided.  When  from  any  cause  a  stimulant  is  indicated,  claret, 
dry  sherry,  or  good  whisky  is  preferable.  Champagne  is  particularly  per- 
nicious. Persons  with  a  marked  tendency  to  litluemia  should  be  urged  to 
restrict  the  appetite  and  to  take  only  a  moderate  amount  of  food.  Over- 
eating is  not  far  behind  excessive  drinking  in  its  injurious  effects.  In- 
deed, a  majority  of  people  over  forty  years  of  age  take  more  food  than  i.s 
required  to  maintain  the  equilibrium  of  health,  (rout,  in  many  cases, 
is  evidence  of  an  overfed,  overworked,  and  consequently  clogged  niii- 
chine. 

The  skin  should  be  kept  active  :  if  the  patient  is  robust,  by  the  morn- 
ing cold  bath  with  friction  after  it ;  but  if  weak  or  debilitated,  the  even- 
ing warm  bath  should  be  substituted.  An  occasional  Turkish  bath  with 
active  shampooing  is  advantageous.  The  secretion  of  urine  should  be 
fully  maintained,  and  the  spocilic  gravity  reduced  by  diluents  to  at  least 
1-015.  The  bowels  should  be  kept  open  and  an  occasional  saline  purga- 
tive may  be  administered.  The  patient  should  dress  warmly,  avoid  raj)id 
alterations  in  temperature,  and  be  careful  not  to  have  the  skin  suddenly 
chilled.  Gouty  persons  derive  much  benefit  from  taking  certain  waters, 
such  as  Saratoga,  the  Bedford,  the  White  Sulphur  of  Virginia,  in  this 
country ;  the  Bath  and  Harrogate,  in  England ;  and  those  of  Carlsbad, 
Kissingen,  Horaburg,  Vichy,  and  Controxeville,  on  the  continent. 

In  an  acute  attack  the  limb  should  be  elevated  and  the  affected  joint 
wrapped  in  cotton-wool.  W^arm  fomentations,  or  Fuller's  lotion,  may  be 
used.  Steaming  the  joint  is  sometimes  beneficial.  A  brisk  mercurial 
purge  is  always  advantageous  at  the  outset.  The  wine  or  tincture  of  col- 
chicum,  in  doses  of  twenty  to  thirty  minims,  may  bo  given  every  four 
hours  in  combination  with  the  citrate  of  potash  or  the  citrate  of  lithium. 
T'he  colchicum  should  be  carefully  M'atched.  It  has,  in  a  majority  of  tlie 
cases,  a  powerful  influence  over  the  symptoms ;  relieving  the  pain  and 
reducing,  sometimes  with  great  rapidity,  the  swelling  and  redness.  It 
should  be  promptly  stopped  as  soon  as  it  has  relieved  the  pain.  In  cases 
in  which  the  pain  and  sleeplessness  are  more  distressing  and  do  not  yield 
to  colchicum,  morphia  may  be  necessary.  The  patient  should  be  placed 
on  a  low  diet,  chiefly  of  milk  and  barley-water,  but  if  there  is  any  de- 
bility, strong  broths  may  be  given,  or  eggs.  It  is  occasionally  necessary 
to  give  small  quantities  of  stimulants.  Potash  water,  Apollinaris,  or 
Seltzer  water  should  be  taken  freely.  Waters  with  the  sodium  salts 
should  be  avoided.  During  convalescence  meats  and  fish  and  game  may 
be  taken,  .and  gradually  the  patient  may  resume  the  diet  previously  laid 
down. 

In  the  chronic  and  irregular  forms  of  gout  the  treatment  by  hygiene 
and  diet  is  most  suitable.  Colchicum  is  not  often  required,  though  in 
small  doses  it  is  sometimes  beneficial.  Lithium  salts  do  good,  since  a 
combination  of  uric  acid  with  lithium  is  more  soluble  than  the  sodium 
salt.     There  is  no  good  native  lithia  water.     The  medicine  is  best  given 


-^i^ 


DIABETES  MELLITUS. 


295 


in  potash  water,  in  a  glassful  of  which  five  grains  of  the  citrate  of  lithium 
may  bo  taken  three  times  a  day,  or  the  liquor  lithim  effervescens  of  the 
Uritish  Pharmacopoeia  may  bo  used.  The  mineral  waters  above  men- 
tioned are  particularly  beneficial,  partly  in  themselves,  and  partly  owing 
to  the  strict  regulations  to  which  the  patient  is  subjected  when  taking  the 
"cure."  Ammoniacum,  guaiacum,  and  preparations  of  quinine  and  iron 
iiro  sometimes  serviceable  in  the  chronic  gout.  Iodide  of  potassium  and 
the  benzoates  are  also  recommended.  The  local  treatment  of  joints  affect- 
ed with  chronic  gout  is  not  satisfactory.  Ilydrotherapeutic  measures,  the 
Paquelin,  and  massage  may  be  tried. 


VII.  DIABETES   MELLITUS. 


'TT 


Definition. — A  disorder  of  nutrition,  in  which  sugar  accumulates 
in  the  blood  and  is  excreted  in  the  urine,  the  daily  amount  of  which  is 
greatly  increased. 

Etiology. — Hereditary  influences  play  an  important  rdle,  and  cases 
are  on  record  of  its  occurrence  in  many  members  of  the  same  family. 
There  are  instances  of  the  coexistence  of  the  disease  in  husband  and 
wife.  Men  are  more  frequently  affected  than  women.  It  is  a  disease  of 
adult  life ;  a  majority  of  the  cases  occur  from  the  third  to  the  sixth  decade. 
It  is  rare  in  childhood,  but  cases  are  on  record  in  children  under  one  year 
of  age.  Persons  of  a  neurotic  temperament  are  often  affected.  It  is  a 
disease  of  the  higher  classes.  Hebrews  seem  especially  prone  to  it ;  one 
fourth  of  Frerichs'  cases  were  of  the  Semitic  race.  In  a  considerable  pr'^- 
portion  of  the  cases  of  diabetes  the  subjects  have  been  excessively  fat ,  « 
the  beginning  of,  or  prior  to,  the  onset  of  the  disease.  It  must  be  remem- 
bered, however,  that  a  slight  trace  of  sugar  is  not  very  uncommon  in  obese 
persons.  This  so-called  lipogenic  glycosuria  is  not  of  grave  significance, 
and  is  only  occasionally  followed  by  true  diabetes.  There  are  instances 
on  record  in  which  obesity  with  diabetes  has  occurred  in  three  genera- 
tions. It  is  more  common  in  cities  than  in  country  districts.  Gout, 
syphilis,  and  malaria  have  been  regarded  as  predisposing  causes.  Mental 
shock,  severe  nervous  strain,  and  worry  precede  many  cases.  The  combi- 
nation of  intense  application  to  business,  over-indulgence  in  food  and 
drink,  with  a  sedentary  life,  seem  particularly  prone  to  induce  the  disease. 
It  may  set  in  during  pregnancy,  and  in  rare  instances  may  only  occur  at 
this  period.  Injury  to  or  disease  of  the  spinal  cord  or  brain  has  been 
followed  by  diabetes.  In  the  carefully  analyzed  cases  of  Frerichs  there 
were  thirty  instances  of  organic  disease  of  these  parts.  The  medulla  is 
not  always  involved.  In  only  four  of  his  cases,  which  showed  organic  dis- 
ease, was  there  sclerosis  or  other  anomaly  of  this  part.  An  irritative  lesion 
of  Bernard's  diabetic  centre  in  the  medulla  is  an  occasional  cause.  I  saw 
with  Riess,  at  the  Friedrichshain,  Berlin,  a  woman  who  had  anomalous 
20 


296 


CONSTITUTIONAL  DISEASES. 


ilir-  >   • 


■«u- 


;<<J  < 


cerebral  symptoms  and  diabetes,  and  in  whom  there  was  found  post  mor- 
tem a  cysticorcus  in  the  fourth  ventricle. 

Of  late  years  lesions  of  the  pancreas  liave  been  held  to  cause  diabetes, 
and  in  a  certain  number  of  cases  this  organ  is  atfected.  The  disease  has  oc- 
casionally followed  the  infectious  fevers.  A  few  cases  have  followed  injury 
without  involvemetit  of  the  brain  or  cord. 

In  comparison  with  European  countries  diabetes  is  a  rare  disease  in 
America.  The  last  census  gave  only  iiS  per  one  hundred  thousand  of 
population,  against  a  ratio  of  from  live  to  nine  in  the  former.  In  tliis 
region  tlie  incidence  of  tlie  disease  may  be  gathered  from  the  fact  that 
among  thirty-five  thousand  patients  under  treatment  at  the  Johns  IIo])- 
kins  Hospital  and  Dispensary  there  were  only  ten  cases. 

We  are  ignorant  of  the  nature  of  the  disease.  Normally  the  carbo- 
hydrates taken  with  the  food  are  stored  in  the  liver  as  glycogen,  and  then 
utilized  as  needed  by  the  system.  Glycogen  can  also  be  formed  from  the 
proteidsof  the  food,  and  under  certain  circumstances  sugar  may  be  direct- 
ly formed  from  the  body  proteids.  Whenever  the  sugar  in  the  systemic 
blood  exceeds  adeiinite  amount  it  is  discharged  by  the  kidneys,  producing 
glycosuria.    Theoretically  the  condition  may  be  supposed  to  be  induced  by : 

(a)  The  ingestion  of  a  larger  quantity  of  carbohydrates  and  peptones 
than  can  be  warehoused,  so  to  speak,  in  the  liver  as  glycogen,  so  that 
part  has  to  pass  over  into  the  hepatic  blood.  Some  of  the  instances  of 
lipogcnic  or  dietetic  glycosuria  are  of  this  nature. 

(b)  Disturbances  of  the  liver  function :  (1)  Changes  in  the  circula- 
tion under  nervous  influences.  Puncture  of  the  medulla,  lesions  of  the 
cord,  and  central  irritation  of  various  kinds  are  followed  by  glycosuria, 
which  is  attributed  to  a  vaso-motor  paralysis  (more  rapid  blood-flow)  in- 
duced by  these  causes.  On  this  view  the  disease  is  a  neurosis.  (2)  In- 
stability of  the  glycogen,  owing  either  to  imperfect  formation  or  to  con- 
ditions of  the  cells  which  render  it  less  stable.  Phloridzin  and  other 
substances  which  cause  diabetes  very  probably  act  in  this  way. 

(c)  Defective  assimilation  of  the  glucose  in  the  system.  How  and 
under  what  normal  circumstances  the  sugar  is  utilized  we  do  not  yet 
know.    Theoretically  faulty  metabolism  would  explain  the  condition. 

Interesting  observations  have  of  late  made  it  probable  that  the  pancreas 
may  in  some  cases  be  the  seat  of  the  trouble.  Lesions  of  this  organ  have 
frequently  been  met  with  in  diabetes.  Von  Mering  and  Minkowski  have 
shown  that  extirpation  of  the  gland  in  dogs  is  followed  by  glycosuria,  but, 
if  a  small  portion  remains,  sugar  does  not  ajipear  in  the  urine,  facts  which 
have  been  confirmed  by  Lepine  and  others.  The  pancreas,  on  this  view, 
has,  like  the  liver,  a  double  secretion — an  external,  which  is  poured  into 
the  intestines,  and  an  internal,  which  passes  into  the  blood.  This  latter 
is  supposed  to  be  of  the  nature  of  a  ferment,  in  the  presence  of  which 
alone  the  normal  assimilative  processes  can  take  place  with  the  glycogen. 
Disease  of  the  pancreas  causes  diabetes  by  preventing  the  formation  of 


DIABETES  MELLITUS. 


297 


Iho  glycolytic  ferment.  Even  when,  as  in  a  majority  of  instances  of 
(liiibotus,  the  organ  is  apparently  normal,  a  functional  trouble  may  disturb 
tlio  formation  of  this  ferment.  The  fact  that  if  a  small  portion  of  the 
j,'liuul  is  left,  in  tlie  experiments  upon  dogs,  diabetes  does  not  occur,  is 
uiKilogous  to  'lie  remarkable  circumstance  that  a  small  fragment  of  tlio 
thyroid  is  sufficient  to  prevent  the  development  of  articifial  myxcudema. 
It  has  recently  been  stated  by  Falkenberg  that  extirpation  of  the  thyroid 
gland  in  dogs  is  also  followed  by  diabetes. 

Morbid  Anatomy. — Saundby  *  has  recently  analyzed  the  changes 
which  occur  in  this  disease. 

The  nervous  system  shows  no  constant  lesions.  In  a  few  instances 
tlicrc  have  been  tumors  or  sclerosis  in  the  medulla,  or,  as  in  the  case  above 
mentioned,  a  cysticercus  has  pressed  on  the  lloor.  Cysts  have  been  met 
with  in  the  white  matter  of  the  cerebrum  and  perivascular  changes  have 
been  described.  Glycogen  has  been  found  in  the  spinal  cord.  In  the 
pi'riplieral  nervous  system  there  are  instances  in  which  tumors  have  been 
found  pressing  on  the  vagus.  A  secondary  multiple  neuritis  is  not  rare, 
and  to  it  the  so-called  diabetic  tabes  is  probably  due. 

In  the  sympathetic  system  the  ganglia  have  been  enlarged  and  in  some 
instances  sclerosed,  but  there  is  nothing  peculiar  in  these  changes.  The 
bimd  may  contain  as  high  as  0*4  per  cent  of  sugar  instead  of  0"15  per  cent. 
Tlic  plasma  is  usually  loaded  with  fat,  the  molecules  of  which  may  be  seen 
as  tine  particles.  When  drawn,  a  white  creamy  layer  coats  the  coagulum, 
and  there  may  be  lipoemic  clots  in  the  small  vessels.  There  are  no  special 
changes  in  the  red  or  white  corpuscles.  Gabritschewsky  has  shown  that 
tlie  "  polynuclear  "  leucocytes  in  diabetes  contain  glycogen.  Glycogen  can 
occur  in  normal  blood,  but  it  is  here  extra-cellular.  It  has  been  also 
found  in  the  polynuclear  leucocytes  in  leukagmia.  The  heart  shows  no 
characteristic  changes.  Endocarditis  is  very  rare.  The  lungs  show  im- 
portant changes.  Acute  broncho-pneumonia  or  croupous  pneumonia 
(eitlier  of  which  may  terminate  in  gangrene)  and  tuberculosis  are  com- 
mon. The  so-called  diabetic  phthisis  is  always  tuberculous  and  results 
from  a  caseating  broncho-pneumonia.  In  rare  cases  there  is  a  chronic 
interstitial  pneumonia,  non-tuberculous.  Fatty  embolism  of  the  pulmo- 
nary vessels  has  been  described  in  connection  with  diabetic  coma. 

The  liver  is  usually  enlarged,  fatty  degeneration  is  common,  and 
French  writers  have  described  a  form  of  cirrhosis.  Letulle,  who  has  de- 
scribed remarkable  examples  of  this  so-called  diabetic  cirrhosis — the  cir- 
rlioHc pigmentaire — thinks  the  change  is  due  to  abnormal  destruction  of 
the  blood-cells.     It  may  be  associated  with  bronzing  of  the  skin. 

Tlie  pancreas,  as  pointed  out  by  Lancereaux,  shows  important  changes. 
."^aiindby  states  that  in  seven  out  of  fifteen  cases  it  Avas  atrophied,  abnor- 


*  Brailshaw  Lecture,  Royal  College  of  Physicians  of  London,  1890 ;  and  Lectures  on 
Ui.il/L;tes,  E.  B.  Treat,  New  York,  1891. 


11 


mmmm 


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298 


CONSTITUTIONAL   DISEASES. 


rnally  firm  and  fibroid  in  four,  and  normal  in  only  four.  A  i)atient  of  W. 
T.  Bull  died  of  diabetes  after  extirpation  of  the  pancreas.  In  some  in- 
stances there  is  a  pigmentary  cirrhosis  analogous  to  that  which  occurs  in 
the  liver,  and  this  induration  seems  to  bo  an  important  change.  Cancer 
of  the  pancreas  has  been  met  with,  and  Longstreth  found,  in  one  instance, 
cystic  disease.  Fat  necrosis  of  the  pancreas  has  also  been  found.  Neither 
the  stomach  nor  the  intcHtines  show  any  characteristic  lesions. 

Tiie  hidneys  are  sometimes  fatty,  and  sliow  a  hyalino  change  in  tlio 
tubular  epithelium,  particularly  in  the  descending  limb  of  the  loop  (if 
Ilenle.  It  also  occurs  in  the  capillary  vessels.  Saundby  confirms  the 
occurrence  of  this  hyaline  change,  and  its  restriction  to  the  epithelium  of 
Ilenlo's  tubes. 

Symptoms. — Acute  and  chronic  forms  aro  recognized,  but  there  is 
no  essential  ditference  between  them,  except  that  in  the  former  the  pa- 
tionts  are  younger,  the  course  more  rapid,  and  the  emaciation  more 
marked. 

It  is  also  possible  to  divide  the  cases  into  (1)  Upogenic  or  dietetic,  which 
includes  the  transient  glycosuria  of  stout  persons ;  (3)  neurotic,  due  to 
injuries  or  functional  disorders  of  the  nervous  system ;  and  (3)  pancreatic, 
in  which  there  is  a  lesion  of  the  pancreas.  It  is,  however,  by  no  means 
easy  ^,o  discriminate  in  all  cases  between  these  forms.  Of  late  attempts 
have  been  made  to  separate  a  clinical  variety  analogous  to  experimental 
pancreatic  diabetes.  Ilirschfeld,  from  Guttmann's  clinic,  has  described 
cases  running  a  rapid  and  severe  course  usually  in  young  and  middle-aged 
persons.  The  polyuria  is  less  common  or  even  absent,  and  there  is  a  strik- 
ing defect  in  the  assimilation  of  the  albuminoids  and  fats,  as  shown  by 
the  examination  of  the  faeces  and  urine.  In  four  of  seven  cases  autopsies 
were  made  and  the  pancreas  was  found  atrophic  in  two,  cancerous  in  one, 
and  in  the  fourth  exceedingly  soft. 

The  onset  of  the  disease  is  gradual  and  either  frequent  micturition  or 
inordinate  thirst  first  attracts  attention.  Very  rarely  it  sets  in  rapidly, 
after  a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  When  fully 
established  the  disease  is  characterized  by  great  thirst,  the  passage  of  large 
quantities  of  saccharine  urine,  a  voracious  appetite,  and,  as  a  rule,  pro- 
gressive emaciation. 

The  Urine. — The  amount  varies  from  six  or  eight  pints  in  mild  cases 
to  thirty  or  forty  pints  in  very  severe  cases.  In  rare  instances  the  quan- 
tity of  urine  is  not  much  increased.  Under  strict  diet  the  amount  is 
much  lessened,  and  in  intercurrent  febrile  affections  it  may  be  reduced  to 
normal.  The  specific  gravity  is  high,  ranging  from  1'025  to  1'045.  Tlie 
urine  is  pale  in  color,  almost  like  water,  and  has  a  sweetish  odor  and  a  dis- 
tinctly sweetish  taste.  The  reaction  is  acid.  Sugar  is  present  in  varying 
amounts.  In  mild  cases  it  does  not  exceed  one  and  a  half  or  two  per  cent, 
but  it  may  reach  from  five  to  ten  per  cent.  The  total  amount  excreted 
in  the  twenty-four  hours  may  range  from  ten  to  twenty  ounces,  and  in 


Fll 


DIABETES  MELLITUS. 


iil)9 


exceptional  cases  from  one  to  two  pounds.  The  following  are  the  most 
Hutisfactory  tests : 

Fi'liUnifs  Test. — The  solution  consists  of  sulphate  of  copper  (j^rs.  90^), 
neutral  tartrate  of  potash  (grs.  304),  solution  of  caustic  soda  (11.  ozs.  4), 
and  distilled  water  to  make  up  six  ounces.  Put  a  drachm  of  this  in  a  test- 
tube  and  boil  (to  test  the  reagent) ;  add  an  equal  quantity  of  urine  and  boil 
again,  when,  if  sugar  is  present,  the  yellow  suboxide  of  copjjcr  is  thrown 
down.     The  solution  must  bo  freshly  prepared,  as  it  is  apt  to  decom])ose. 

Trommer^s  Test. — To  a  draclnn  of  urine  in  a  test-tube  add  a  few  drops 
of  a  dilute  sulphate-of-copper  solution  and  tiien  as  much  liquor  potassce 
as  urine.  On  boiling,  tho  co[)])er  is  reduced  if  sugar  be  i)resent,  forming 
the  yellow  or  orange-red  suboxide.  There  are  certain  faUacies  in  the  cop- 
per tests.  Thus,  a  substance  called  glycuronic  acid  is  met  with  in  the 
urine  after  the  use  of  certain  drugs — chloral,  phenacctin,  morphia,  chloro- 
form, etc. — which  reduces  copper.  It  has  been  found  in  the  urine  of  an 
apparently  healthy  man  (Ashdown). 

Fermentation  Test. — T'his  is  free  from  all  doubt.  Place  a  small  frag- 
ment of  yeast  in  a  test-tube  full  of  urine,  which  is  then  inverted  over  a 
glass  vessel  containing  the  same  fluid.  If  sugar  is  present,  fermentation 
goes  on  with  the  formation  of  carbon  dioxide,  which  accumulates  in  the 
upper  part  of  the  tube  and  gradually  expels  the  urine.* 

Of  other  ingredients  in  the  urine,  the  urea  is  increased,  the  uric  acid 
does  not  show  special  changes,  and  the  phosphates  may  be  greatly  in  ex- 
cess, llalfe  has  described  a  great  increase  in  the  phosi)hates,  and  in  some 
of  these  cases,  with  an  excessive  excretion,  the  symptoms  may  be  very 
siinilar  to  those  of  diabetes,  though  the  sugar  may  not  be  constantly  pres- 
ent. The  term  phosphatic  diabetes  has  sometimes  been  applied  to  them. 
Acetone  and  acetone-forming  substances  are  not  infrequently  present.  Lo 
Nobel's  test  for  acetone  is  as  follows :  "  Pour  an  ounce  of  urine  into  a 
uiiue  glass ;  add  a  drachm  or  two  of  nitro-prusside  of  sodium  (five  grains 
to  one  ounce)  and  a  few  drops  of  strong  liquid  ammonia.  After  standing 
u  few  minutes  a  rose-violet  color  is  developed,  which,  if  much  acetone  is 
present,  may  require  diluting  with  water  in  order  to  bring  out  the  brill- 
iancy of  its  color  "  (Saundby). 

Glycogen  has  also  been  described  as  present  in  the  urine. 

AJhionen  is  not  infrequent.  It  occurred  in  nearly  thirty-seven  per  cent 
of  the  examinations  made  by  Lippman  at  Carkbad. 

Among  the  general  symptoms  of  the  disease,  thirst  is  one  of  the  most 
distressing.  A  very  large  amount  of  water  is  required  to  keep  the  sugar 
in  solution  and  for  its  excretion  in  the  urine.  The  amount  of  water  con- 
sumed will  be  found  to  bear  a  definite  ratio  to  the  quantity  excreted.  In- 
s lances,  however,  are  not  uncommon  of  pronounced  diabetes  in  which  the 


*  For  quantitative  and  other  tests  the  student  is  referred  to  Tyson,  On  the  Urine,  or 
the  standard  works  on  urinalysis. 


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800 


CONSTITUTIONAL  DISEASES. 


tliirst  ia  not  excessive;  but  in  such  civsos  tlio  amount  of  urino  passed  U 
never  largo.  The  tliirst  is  most  intense  an  hour  or  two  after  meuls.  As 
u  rule,  the  <li;>estion  is  j^ood  and  the  appetite  inordiiuite.  A  story  is  '  Id 
of  a  man  with  ('iuljctes  who  was  paid  to  stay  awy  'rom  a  certain  restau- 
rant at  which  dinners  were  given  at  fixed  jjrices.  It  is  sotnctimes  impos- 
siblo  to  satiate  the  ravenous  appetite  of  a  diabetic  patient.  The  condition 
is  sometimes  termed  huliiinn  ov  jmbjphdijia. 

The  tongue  is  usually  dry,  red,  ami  glazed,  and  the  saliva  scanty.  Tlu! 
gums  luay  be(!ome  swollen,  ami  in  the  later  stages  a])hthous  stomatitis  is 
common.     Constipation  is  the  rule. 

•  In  spite  of  the  enormous  amount  of  food  consumed  a  ])atient  may  be- 
come rapidly  emaciated.  This  loss  of  tlesh  bears  some  ratio  to  tlu!  ]«^ly- 
nria,  and  when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  iiiiiy 
quickly  gain  in  llesh.  The  skin  is  dry  and  harsh,  and  perspirations  rarely 
Q.^cur,  except  when  jihthisis  coexists.  Drenching  sweats  have  been  kiu)\vii 
to  alternate  with  excessive  polyuria.  The  temperature  is  often  subnor- 
mal;  the  pulse  is  usually  frequent,  and  the  tension  increased.  Many  dia- 
betics, however,  do  not  show  marked  emaciation.  Patients  past  the  mid- 
dle period  of  life  may  have  the  disease  for  years  without  nnudi  disturlKiuco 
of  the  health,  and  may  remain  well  nourished.  These  are  the  cases  of  the 
diabi'te  ijrds  in  contradistinction  to  didbi'tfi  muiijre. 

Diabetes  in  Children. — Recently  Stem  Inis  analyzed  117  cases  in  chil- 
dren. They  usually  occur  among  the  better  classes.  Six  were  under  one 
year  of  age.  Hereditary  influences  were  marked.  The  course  of  the  dis- 
ease is,  as  a  rule,  much  more  rapid  than  in  aduHs.  The  shortest  duration 
was  two  days.  In  seven  cases  it  did  not  last  a  month.  One  case  is  men- 
tioned of  a  child  apparently  born  with  the  glycosuria,  who  recovered  in 
eight  months. 

Complications. — («)  Cutaneous. — Boils  and  carbuncles  are  extreme- 
ly common.  Eczema  is  also  met  with  and  at  times  an  intolerable  itching. 
In  wjmen  the  irritation  of  the  urine  may  cause  the  most  intense  pruiitus 
pudendi,  and  in  men  a  balanitis.  Rarer  affections  are  xanthonm  aiul  pur- 
pur.a.  Gangreiio  is  not  uncommon.  William  Hunt  has  analyzed  04  cases. 
In  50  the  loruliiijs  were  as  follows  :  Feet  and  legs,  37;  thigh  and  buttock, 
2;  nucha,  3;  fvternal  genitals,  1;  lungs,  3;  fingers,  3;  back,  1;  eyes,  1. 
Perforating  ulcer  of  the  foot  may  occur. 

{b)  Pulmonary. — The  patients  are  not  infrequently  carried  off  by  acute 
pneutnonia,  which  may  be  lobar  or  lobular.  Gangrene  is  very  apt  to 
supervene,  but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordi- 
nary gangrene. 

Tuberculous  broncho-pneumonia  is  very  common.  It  was  formerly 
thpught,  from  its  rapid  course  and  the  limitation  of  the  disease  to  the 
lung,  that  this  was  not  a  true  tuberculous  affection  ;.but  in  the  cases  whi^h 
have  come  under  my  notice  bacilli  have  been  present,  and  the  condition  is 
now  generally  regarded  as  tuberculous. 


DUnKTKS  MELMTUS. 


301 


(r)  Renal. — AJhuminnrin  is  a  tolcrahly  frequent  eomplieiition.  The 
amount  varies  greatly,  iiiul,  when  sliglit,  doeH  not  Heein  to  be  of  nitu-h  nio- 
\w'\\t  It  in  sonietinu'S  associated  with  arterio-sclerosis.  It  occasionally 
preeeiles  tho  dcvelo]»inent  of  tho  Uiabetio  coimi.  Occa.sionally  eystitia 
develops. 

{(I)  Nervous  System. — (1)  Diahi'Hc  mmn,  first  studied  by  Kiissniaul,  is 
the  most  serious  eoniplication  of  the  disease,  and  carries  otT  a  considerable 
proportion  of  all  cases,  particularly  in  tho  young.  It  nuiy  occur  when 
diabetes  is  unsuspected,  as  in  two  cases  recently  reported  by  Francis 
Miuot.  Frorichs  recognized  three  groups  of  cases:  (o)  Those  in  which 
after  exertion  the  patients  were  suddenly  attacked  with  weakness,  syncope, 
sornnoleiuie,  and  gradually  deepening  unconsciousness ;  death  occurring 
ill  a  few  hours.  (/8)  Cases  with  preliniiiuiry  gastric  disturbance,  such  as 
nausea  and  vomiting,  or  some  local  alTection,  as  pharyngitis,  phlegmon,  or 
11  pulmonary  complication.  In  such  cases  the  attack  begins  with  head- 
iii'lie,  delirium,  great  distress,  and  dyspmra,  atfecting  both  insjiiration  and 
expiration,  a  coiulition  called  by  Kiissnmul  air-hunucr.  Cyanosis  nuiy  or 
may  not  be  present.  If  it  is,  tho  i)ul30  becomes  rapid  aiul  Aveak  and  tho 
patient  gradually  sinks  into  coma;  tho  attack  lasting  from  one  to  five 
(lays.  There  may  bo  a  very  heavy,  sweetish  odor  of  the  breath,  due  ^  the 
presence  of  acetone,  (y)  Cases  in  whicli,  without  any  previous  dyspncea 
or  distress,  tho  patient  is  attacked  with  headache  and  a  feeling  of  intoxi- 
cation, and  rapidly  falls  into  a  deep  and  fatal  coma. 

There  has  boon  much  dispute  as  to  the  nature  of  these  symptoms,  but 
our  knowledge  of  the  disease  is  not  yet  sufficiently  advanced  to  give  a 
rational  explanation.  Tho  character  of  the  attack  and  the  similarity,  in 
many  instances,  to  ura3mia  would  indicate  that  it  depended  upon  some 
toxic  agent  in  the  blood.  The  theory  most  commonly  held,  that  this 
material  is  acetone,  is  supported  by  the  presence  of  the  acetone  reaction  in 
tho  urine  and  its  odor  in  tho  breath.  Stadelmann  believes  that  tho  con- 
dition is  not  acotoniBmia,  but  that  tho  poisonous  agent  is  an  intermediate 
product  between  the  sugar  and  acetone,  an  oxy-butyric  acid. 

Saunders  and  Hamilton  have  described  cases  in  which  the  lung  capil- 
laries were  blocked  with  fat.  They  attributed  tho  symptoms  to  fat  embo-- 
lism,  but  there  are  many  cases  on  record  in  which  this  condition  was  not 
found,  though  lipaemia  is  by  no  means  infrequent  in  diabetes. 

The  symptoms  have  been  attributed  to  ura>mia,  and  albuminuria  fre- 
quently precedes  or  accompanies  the  attack. 

(3)  Peripheral  Neuritis. — The  neu7'alffias,  numbness,  and  tingling, 
which  are  not  uncommon  symptoms  in  diabetes,  are  probably  minor  neu- 
ritic  manifestations. 

Diabetic  Tabes  (so  called). — This  is  a  peripheral  neuritis,  characterized 
by  lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  occur  with- 
out the  other  symptoms — and  a  loss  of  power  in  the  Oa tensors  of  the  feet. 
Tlie  gait  is  the  characteristic  steppage,  as  in  arsenical,  alcoholic,  and  other 


■-  it 


S!P 


■■■■p 


803 


CONSTITUTIONAL  DISEASES. 


forma  of  neuritic  paralysis.     Charcot  states  that  there  may  be  atrophy  of 
the  optic  nerves. 

Diabetic  Paraplcf/ia. — This  is  also  in  all  probability  due  to  neuritis. 
There  are  cases  in  wliich  power  haa  been  lost  in  both  arms  and  legs. 

(3)  Modal  Si/iiij)foms. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  become  hypocliondriacal.  General  paralysis  has  been 
known  to  develop. 

(i)  Special  Senses. — Cataract  is  liable  to  occur,  and  may  develop  with 
rapidity  in  young  persons.  Diabetic  retinitis  closely  resemblec  the  albu- 
minuric form.  Ilasmorrhages  are  common.  Sudden  amaurosis,  similar 
to  that  Avhich  occurs  in  uraemia,  may  occur.  Paralysis  of  the  muscles  of 
accommodation  may  be  present ;  and  lastly  atrophy  of  the  optic  nerves. 
Aural  sym])toms  may  come  on  with  great  rapidity,  either  an  otitis  media, 
or  in  some  instances  inflammation  of  the  mastoid  cells. 

(5)  Sexual  Function. — Impotence  is  common,  and  may  bo  an  early 
8ym])tom. 

Course. — In  children  the  disease  is  rapidly  progressive,  and  may  prove 
fatal  in  a  fcnv  days.  It  may  be  stated,  as  a  general  rule,  that  the  older  tlio 
patient  at  the  time  of  onset  the  slower  the  course.  Cases  without  hered- 
itary influences  are  the  mobt  favorable.  In  stout,  elderly  men  diabetes 
is  a  much  more  hopeful  disease  than  it  is  in  thin  persons.  Middle-ajred 
patients  nuiy  live  for  many  years,  and  persons  are  met  with  who  have  liad 
the  disease  for  ten,  twelve,  or  even  fifteen  years. 

Diagnosis. — Glycosuria,  which  to  all  intents  and  purposes  is  a  mild 
form  of  the  disease,  is  to  be  distinguished  only  by  its  transient  character. 
There  is  no  other  disease  with  which  true  diabetes  can  be  confounded. 
It  must  not  bo  forgotten  that  hysterical  women  sometimes  put  sugar  in 
the  urine  for  the  purposes  of  deception. 

Prognosis. — In  true  diabetes  instances  of  cure  are  rare.  On  the 
other  hand,  the  transient  or  intermittent  glycosuria,  met  with  in  stout 
overfeeders,  or  in  persons  who  have  undergone  a  severe  mental  strain,  is 
very  amenable  to  treatment.  Not  a  few  of  the  cases  of  reputed  cures  bo- 
long  to  this  division.  Personally  I  have  never  seen  recovery  from  a  case  df 
true  diabetes.  Temporary  arrest,  reduction  to  a  minimum  of  the  amount 
of  sugar  excreted,  and  prolonged  periods  of  good  health,  I  have  frequently 
seen,  but  neither  in  any  one  of  my  personal  friends  or  acquaintances  who 
have  suffered  with  the  disease,  nor  in  patients  who  have  come  under  my 
care  in  hospital  or  private  practice,  have  I  known  permanent  and  com- 
plete disa])pearance  of  the  sugar,  so  that  an  ordin.-ny  diet  could  be  taken 
with  impunity.  Cures  are,  however,  reported.  Praotically,  in  cases  under 
forty  years  of  age  the  outlook  is  bad ;  in  older  persons  the  disease  is  less 
serious  and  much  more  amenable  to  treatment.  ' 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease 
the  use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hygiene  of  a  diabetic  patient  is  of  the  first  importance. 


DIABETES  MELLITUS. 


303 


Sources  of  worry  should  bo  avoided,  aud  he  should  lead  an  even,  quii't 
life,  if  possible  in  an  equable  climate.  Flannel  or  silk  should  be  worn 
next  to  the  skin,  and  tlie  greatest  care  should  be  taken  to  promote  its 
action.  A  lukewarm,  or  if  tolerably  robust,  a  cold  batli,  should  be  taken 
every  day.  An  occasional  Turkish  bath  is  useful.  Systematic,  moderate 
excrciso  should  be  taken.  When  this  is  not  feasible,  massage  should  be 
given. 

Diet. — Our  injunctions  to-day  are  those  of  Sydenham :  "  Let  the  patient 
eat  food  of  easy  digestion,  such  as  veal,  mutton,  aud  the  like,  aud  abstain 
from  all  sorts  of  fruit  and  garden  stuff." 

The  carbohydrates  in  the  food  should  bo  reduced  to  a  minimum. 
Under  a  strict  hydrocarbonaccous  aud  nitrogenous  regimen  all  cases  are 
beuetited  and  some  are  cured.  Tlie  most  minute  and  specific  instructions 
should  be  given  in  each  case,  and  tlio  dietary  arranged  witli  scrupulous 
care.  It  is  of  tlie  first  importance  to  give  the  patient  variety  in  the  food, 
olhorwise  the  loatliing  of  certain  essential  articles  becomes  intolerable,  and 
too  often  the  patient  gives  up  in  disgust  or  despair.  It  is  well,  perhai)S, 
not  to  attempt  tlie  absolute  exclusion  of  the  carbohydrates,  but  to  allow 
a  small  proportion  of  ordinary  bread,  or,  better  still,  as  containing  less 
starch,  potatoes.  It  is  best  gradually  to  enforce  a  rigid  system,  cutting  off 
one  article  after  another.  The  following  is  a  list  of  articles  which  diabetic 
patients  may  take : 

Liquids:  Soups  —  ox-tail,  turtle,  bouillon,  and  olher  clear  soups. 
Lemonade,  coffee,  tea,  chocolate,  and  cocoa;  these  to  be  taken  without 
sugar,  but  they  may  be  sweetened  with  saccharin.  Potash  or  soda  water, 
and  the  Apollinaria,  or  the  Saratoga  Vichy,  and  milk  in  moderation,  may 
be  used. 

Of  animal  food  :  Fish  of  all  sorts,  salt  and  fresh,  butcher's  meat  (witli 
the  exception  of  liver),  ])oultry,  and  game.  Eggs,  butter,  buttermilk, 
curds,  and  cream  cheese. 

Of  bread  :  Gluten  and  bran  bread,  and  almond  and  cocoanut  biscuits. 

Of  vegetables:  Lettuce,  tomatoes,  spinach,  chiccory,  sorrel,  rjulishes, 
water-cress,  mustard  and  cress,  cucumbers,  celery,  and  endives.  Pickles 
of  various  sorts. 

Fruits :  Lemons,  oranges,  and  currants.     Nuts  are,  as  a  rule,  allowable. 

Among  prohibited  articles  are  the  following:  Thick  souj)s,  liver,  crabs, 
lobsters,  and  oysters;  though,  if  the  livers  are  cut  out,  oysters  may  be 
used. 

Ordinary  bread  of  all  sorts  (in  quantity):  rye,  whoatcn,  brown,  or 
white.  All  farinaceous  preparations,  such  as  hominy,  rice,  tapioca,  semo- 
lina, arrowroot,  sago,  and  vermicelli. 

Of  vegetables:  Potatoes,  turnips,  parsnips,  squashes,  vegetable  marrow 
of  all  kiiuls,  beets,  corn,  artichokes,  and  asparagus. 

Of  liquids:  Beer,  sparkling  wine  of  all  sorts,  and  the  sweet  aerated 
drinks. 


mmmmmm* 


$04t 


CONSTITUTIONAL  DISEASES. 


The  chief  difficulty  in  arranging  the  daily  inenu  of  a  diabetic  patient 
is  the  bread,  and  for  it  various  substitutes  have  been  advised — bran  bread, 
gluten  bread,  and  almond  biscuits.  Most  of  these  are  unpalatable,  and 
the  patients  weary  of  them  rapidly.  Too  many  of  them  are  gross  frauds, 
and  contain  a  very  much  greater  proportion  of  starch  than  represented. 
A  friend,  a  distinguished  physician,  who  has,  unfortunately,  had  to  make 
trial  of  a  great  many  of  them,  writes :  "  That  made  from  almond  flour  is 
usually  so  heavy  and  indigestible  that  it  can  only  be  used  to  a  limited  ex- 
tent. Gluten  flour  obtained  in  Paris  or  London  contains  about  15  per 
cent  of  the  ordinary  amount  of  starch  and  can  be  well  used.  The  gluten 
flour  obtained  in  this  country  has  from  35  to  45  per  cent  of  starch,  and 
can  be  used  successfully  in  mild  but  not  in  severe  forms  of  diabetes." 

Unless  a  satisfactory  and  palatable  gluten  bread  can  be  obtained,  it  is 
better  to  allow  the  patient  a  few  ounces  of  ordinary  bread  daily.  The 
"  Soya  "  bread  is  not  any  better  than  that  made  from  the  best  gluten  flour. 
As  a  substitute  for  sugar,  saccharin  is  very  useful,  and  is  perfectly  harm- 
less.    Glycerin  may  also  be  used  for  this  purpose. 

It  is  well  to  begin  the  treatment  by  cuttii  ■•  o^  -^icle  after  article 
until  the  sugar  disappears  from  the  urine.  ^\  i  iiiu  a  month  or  two  the 
patient  may  gradually  be  allowed  a  more  liberal  regimen.  An  exclusively 
milk  diet,  either  skimmed  milk,  buttermilk,  or  koumyss,  has  been  recom- 
inended  by  Donkin  and  others.  Certain  cases  seem  to  improve  on  it,  but 
it  is  not,  on  the  whole,  to  be  recommended. 

Medicinal  Treatment. — This  is  most  unsatisfactory,  and  no  one  drug 
appears  to  have  a  directly  curative  influence.  Opium  alone  stands  tlie 
test  of  experience  as  a  remedy  capable  of  limiting  the  progress  of  the  dis- 
ease. Diabetic  patients  seem  to  have  a  special  tolerance  for  this  drug. 
Codeia  is  preferred  by  Pavy,  and  has  the  advantage  of  being  less  consti- 
pating than  morphia.  A  patient  may  begin  with  half  a  grain  three  times 
a  day,  which  may  be  gradually  increased  to  six  or  eight  grams  in  the 
twenty-four  hours.  Mitchell  Bruce,  from  a  series  of  elabniitc  observa- 
tions, concludes  that  morphia  is  decidedly  more  powerful,  -v  a  patient 
at  the  University  Hospital,  Philadelphia,  on  whom  I  made  <  .  t/  rt  mber 
of  observations  on  the  comparative  value  of  these  drugs,  mo  [  .ii\  ap- 
peared to  be  much  more  potent.  PaUt  iits  take  with  beneflt  up  to  hvo  or 
six  grains  in  the  twenty-four  hours.  The  expense,  tc,  must  somotimes 
be  taken  into  consideration :  the  cost  of  six  grains  of  codeia  daily  woiiM 
be  twenty-live  cents,  whereas  the  same  amount  of  morphia  would  cost  only 
ten  cents.  Not  much  effect  is  noticed  unless  the  patient  is  on  a  rigid 
diet.  When  the  sng.ir  is  reduced  to  a  minimum,  or  is  absent,  the  opium 
should  be  gradually  withdrawn.  The  patients  not  onlv  bear  well  those 
large  doses  of  moiphia,  but  they  stand  if s  gradual  red;  ■■iujv  Potassium 
bromide  is  often  a  useful  adjunct.  The  arsenite  of  bron  ii  a  ■  oUkiou  of 
arsenious  acid  with  bromine  in  f;lycerin  (dose,  three  to  five  minims  after 
meals),  has  been  very  highly  recommerie-'',  but  it  is  by  no  means  so  cor- 


DIABETES  INSIPIDUS. 


305 


tain  as  opinm.  Arsenic  alone  may  be  used.  Antipyrin  may  be  given  in 
(loses  of  ten  grains  three  times  a  day,  and  iu  cases  with  a  marked  neurotic 
constitution  is  sometimes  satisfactory.  1'he  salicylates,  iodoform,  nitro- 
glycerin, jambul,  lithium  salts,  strychnine,  creasote,  and  lactic  acid  have 
been  employed. 

Of  the  complications,  tho  ])riirit is  and  eczema  are  best  treated  by  cool- 
ing lotions  of  boric  acid  or  hyposulphite  of  soda  (1  ounce;  water,  1 
quart). 

The  coma  is  an  almost  hopeless  complication.  Inhalations  of  oxygen 
have  been  recommended,  and  lately  the  intravenous  injections  of  a  saline 
solution,  as  practised  by  Hilton  Fagge.  The  three  per  cent  solution  of  the 
sodium  bicarbonate  has  generally  been  employed.  The  treatment  has  not, 
however,  been  satisfactory.  Of  seventeen  cases,  collected  by  Chadbourne, 
in  only  one  was  it  successful ;  in  seven  there  was  temporary  improvement ; 
aiitl  the  best  that  can  be  said  for  it  is  that  it  may  give  the  patient  a  few 
liours  of  complete  consciousness.  Injections  should  be  made  as  soon  as 
possible  after  the  appearance  of  the  coma. 


VIII.  DIABETES   INSIPIDUS. 

Definition. — A  chronic  affection  characterized  by  the  passage  of 
lurtro  quantities  of  normal  urine  of  low  specific  gravity. 

The  condition  is  to  be  distinguished  from  diuresis  or  polyuria,  which 
is  a  frequent  symptom  in  hysteria,  in  Bright's  disease,  and  occasionally 
in  (;erobral  or  other  affections.  Willis,  in  1074,  first  recognized  the  dis- 
tinction between  a  saccharine  and  non-saccharine  form  of  diabetes. 

Etiology. — The  disease  is  most  common  in  young  persons.  Of  the 
85  oases  collected  by  Strauss,  9  were  under  five  years ;  1:^  between  five  and 
ten  years ;  J3G  between  ten  and  twenty-five  years.  Males  are  more  fre- 
quently attacked  than  females.  The  affection  may  be  congenital.  A 
iieieditary  tendency  has  been  noted  in  many  cases,  the  most  extraordinary 
of  whitih  has  been  reported  by  Woil.  Of  91  members  in  four  generations, 
23  had  persistent  polyuria  without  any  deterioration  in  health.  Injury  to 
tlie  nervous  system  has  been  present  in  certain  instances,  and  the  disease 
has  followed  sunstroke,  or  a  violent  emotion,  such  as  fright.  Traumatism 
has  oecasionally  been  the  exciting  cause.  The  injury  may  have  been  to 
the  head,  but  in  other  cases  the  lesion  has  been  to  the  trunk  or  to  the 
hiiil)s,  Tlio  disease  has  followed  rapidly  the  copious  drinking  of  cold 
water,  or  a  drinking-bout;  or  has  set  in  during  the  convalescence  from  an 
iieure  disease.  Tumors  of  the  brain  and  lesions  of  the  medulla  have  been 
uiet  with  in  a  few  instances.  Cases  of  polyuria  have  been  accompanied  by 
iwralysis  of  the  sixth  nerve.  Maguiro  has  seen  an  instance  after  menin- 
gitis ill  which  paralysis  of  the  sixth  pair  occurred  with  it.  Bernard,  it 
will  be  remembered,  discovered  a  spot  in  the  floor  of  the  fourth  ventricle 


i 


'JiiM!,.l 


*^-^*iil 


mm 


306 


CONSTITUTIONAL  DISEASES. 


of  animals  which,  when  punctured,  produced  polyuria.  Lesions  of  the 
organs  of  the  abdomen  may  bo  associated  with  an  excessive  flow  of  uriiio, 
wliich,  however,  should  not  be  regarded  as  true  diabetes  insipidus.  Dick- 
enson mentions  its  occurrence  in  abdominal  tumors;  Kalfe,  in  abdominal 
aneurism.     I  have  noted  it  in  several  cases  of  tuberculous  peritonitis. 

The  nature  of  the  disease  is  unknown.  It  is,  doubtless,  of  nervous 
origin.  The  most  reasonable  view  is  that  it  results  from  a  vaso-motor  dis- 
turbance of  the  renal  vessels,  due  either  to  local  irritation,  as  in  a  case  of 
abdominal  tumor,  or  to  central  disturbance  in  cases  of  brain-lesion,  or  to 
functional  irritation  of  the  centre  in  the  medulla,  giving  rise  to  continu- 
ous renal  congestion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions. 
The  kidneys  have  been  found  enlarged  and  congested.  The  bladder  has 
been  found  hypertrophied.  Dilatation  of  the  ureters  and  of  the  pelves  of 
the  kidneys  has  been  present.     Death  has  not  infrequently  resulted  from 

.ronic  pulmonary  disease.     Very  varied  lesions  have  been  met  with  in 

ie  nervous  system. 
Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or 
an  injury.  More  commonly  it  develops  slowly.  A  copious  secretion  of 
urine,  with  increased  thirst,  are  the  prominent  features  of  the  disease. 
The  amount  of  urine  in  the  twenty-four  hours  may  range  from  twenty  to 
forty  pints,  or  even  more.  The  specific  gravity  is  low,  1-001  to  I'OOS;  the 
color  is  extremely  pale  and  watery.  The  total  solid  constituents  may  not 
be  reduced.  The  amount  of  urea  has  sometimes  been  found  in  excess. 
Abnormal  ingredients  are  rare,  jyiuscle  sugar,  inosite,  has  been  occasionally 
found.  Albumen  is  rare.  Traces  of  sugar  have  been  met  with.  Naturally, 
with  the  passage  of  such  enormous  quantities  of  urine,  there  is  a  propor- 
tionate tiiirst,  and  the  only  inconvenience  of  the  disease  is  the  necessity 
for  frequent  micturition  and  frequent  drinking.  The  ajipetite  is  usually 
good,  rarely  excessive  as  in  diabetes  mellitus.  The  patients  may  be  well 
nourished  and  healthy-looking.  The  disease  in  many  instances  does  not 
appear  to  interfere  in  any  way  with  the  general  health.  The  perspiration 
is  naturally  slight  and  the  skin  is  harsh.  The  amount  of  saliva  is  small 
and  the  mouth  usually  dry.  Cases  have  been  described  in  which  the  toler- 
ance of  alcohol  has  been  remarkable,  and  patients  have  been  known  to 
take  a  couple  of  pints  of  brandy,  or  a  dozen  or  more  bottles  of  wine,  in 
the  day. 

The  course  of  the  disease  depends  entirely  upon  the  nature  of  the  pri- 
mary trouble.  Sometimes,  with  organic  disease,  either  cerebral  or  abdomi- 
nal, the  general  health  is  much  impaired ;  the  patient  becomes  thin,  and 
rapidly  loses  strength.  In  the  essential  or  idiopathic  cases,  good  health 
may  be  maintained  for  an  indefinite  period,  and  the  affection  has  ht'cn 
known  to  persist  for  fifty  years.  Death  usually  results  from  some  inter- 
current affection.     Spontaneous  cure  may  take  place. 

Diagnosis. -T- A  low  specific  gravity  end  the  absence  of  sugar  in  the 


RICKETS. 


307 


urine  distinguish  the  disease  from  diabetes  mellitus.  Hysterical  polyuria 
nmy  sometimes  simulate  it  very  closely.  The  amount  of  urine  excreted 
may  be  enormous,  and  only  the  development  of  other  hysterical  manifes- 
tiitious  may  enable  the  diagnosis  to  be  made.  This  condition  is,  however, 
always  transitory. 

In  certain  cases  of  chronic  Bright's  disease  a  very  large  amount  of 
urine  of  low  specific  gravity  may  be  passed,  but  the  presence  of  albumen 
and  of  hyaline  casts,  and  the  existence  of  heightened  arterial  tension,  stiff 
vessels,  and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — The  treatment  is  not  satisfactory.  No  attempt  should 
be  made  to  reduce  the  amount  of  liquid.  Opium  is  highly  recommended, 
but  is  of  doubtful  service.  The  preparations  of  valerian  may  be  tried ; 
cither  the  powdered  root,  beginning  with  five  grains  three  times  a  day,  and 
increasing  until  two  drachms  are  taken  in  the  day,  or  the  valerianate  of 
zinc,  in  fifteen-grain  doses,  gradually  increased  to  thirty  grains,  three  times 
a  day.  Ergot  is  recommended  by  DaCosta.  Ergotin  may  be  employed, 
liiu'go  doses  are  required.  Antipyrin,  the  salicylates,  arsenic,  strychnine, 
turpentine,  and  the  bromides  have  been  recommended.  The  constant 
current  may  be  used — one  pole  on  the  loins,  the  other  on  the  nape  of  the 
neck. 

IX.    RICKETS. 

Definition. — A  disease  of  infants,  characterized  by  impaired  nutrition 
and  alterations  in  the  growing  bones. 

Glisson,  the  anatomist  of  the  liver,  described  the  disease  accurately  in 
tlic  seventeenth  century. 

Etiology. — The  disease  exists  in  all  parts  of  the  world,  but  is  par- 
ticularly marked  among  the  poor  of  the  larger  cities,  who  are  badly  housed 
and  ill  fed.  It  is  much  more  common  in  Europe  than  in  America.  In 
the  colored  race  it  is  frequently  seen.  It  is  a  comparatively  rare  disease  in 
Canada.  In  the  larger  cities  of  this  continent  it  is  frequently  seen  at  the 
clinics,  but  in  comparison  with  Vienna  and  London  the  contrast  is  very 
striking.  In  these  cities  from  50  to  80  per  cent  of  all  the  children  at  the 
clinics  present  signs  of  rickets.  Want  of  sunlight  and  impure  air  are  im- 
ixu'tunt  factors.  A  starchy  diet,  too  much  cows'  milk,  and  the  indiscrimi- 
nate feeding,  so  common  in  the  children  of  the  poor,  are  important 
aireiits ;  but  something  is  required  beyond  these,  for  children  of  healthy 
parents,  who  have  an  ample  quantity  of  the  proper  food,  may  become 
rii^kety.  It  seems  probable,  however,  that  the  combination  of  defective 
fowl  iind  bad  air  plays  the  most  important  role.  Prolonged  lactation  or 
!*u(kling  a  child  during  pregnancy  are  accessory  etiological  factors. 

Thoro  is  no  evidence  that  the  disease  is  hereditary,  but  there  is  prob- 
ahly  a  form  of  foetal  rickets.  It  is  doubtful,  however,  whether  the  changes 
met  with  in  this  are  identical  with  the  post-natal  disease.    In  these  babies, 


■ii 


808 


CONSTITUTIONAL  DISEASES. 


.:,  P.V 


which  are  generally  still-born,  the  limbs  are  short,  the  curves  of  the  bones 
are  exaggerated,  and  at  the  junction  of  the  epiphyses  there  is  no  prolifer- 
ating zone  of  cartilage.  This  condition,  which  Parrot  calls  achonilruplnsi/, 
is  really  more  like  a  fcetal  cretinism. 

Rickets  affects  male  and  female  children  equally.  It  is  a  disease  of  tlic 
first  and  second  years  of  life,  rarely  beginning  before  the  sixth  month. 
Jenner  has  described  a  late  rickets,  in  which  form  the  disease  may  not  ap- 
pear until  the  ninth  or  even  until  the  twelfth  year.  It  has  been  held  that 
rickets  is  only  a  manifestation  of  congenital  syphilis  (Parrot),  but  this  is 
certainly  not  correct.  Syphilitic  bones  rarely,  if  ever,  present  the  spongy 
tissue  peculiar  to  rickets,  and  rachitic  bones  never  show  the  multiple  oste- 
ophytes of  syphilis.     It  has  been  regarded  as  an  effect  of  malaria. 

Morbid  Anatomy. — The  bones  show  the  most  important  changes, 
particularly  the  ends  of  the  long  bones  and  the  ribs.  Between  the  shaft 
and  epiphyses  a  slight  bulging  is  apparent,  and  on  section  the  zone  of  })ro- 
liferation,  which  normally  is  represented  by  two  narrow  hands,  is  greatly 
thickened,  bluish  in  color,  more  irregular  in  outline,  and  very  much 
softer.  The  width  of  this  cushion  of  cartilage  varies  from  five  to  fifteen 
millimetres.  The  line  of  ossification  is  also  irregular  and  more  sjjongy 
and  vascular  than  normal.  The  periosteum  strips  off  very  readily  from 
the  shaft,  and  beneath  it  there  may  be  a  spongioid  tissue  not  unlike  de- 
calcified bone.  The  practical  outcome  of  these  changes  is  a  delay  in,  and 
imperfect  performance  of,  the  ossification,  so  that  the  bone  has  neither 
the  natural  rate  of  growth  nor  the  normal  firmness.  In  the  cranium 
there  may  be  large  areas,  particularly  in  the  parieto-occipital  region,  in 
which  the  ossification  is  delayed,  producing  the  so-called  cranio-tabes,  so 
that  the  bone  yields  readily  to  pressure  with  the  finger.  There  are  local- 
ized depressed  spots  of  atrophy,  which,  on  pressure,  give  the  so-called 
"  parchment  crackling."  Flat  hyperostoses  develop  from  the  outer  table, 
particularly  on  the  frontal  and  parietal  bones,  and  produce  the  character- 
istic broad  forehead  with  prominent  frontal  eminences,  a  condition  some- 
times mistaken  for  hydrocephalus. 

The  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in 
the  calcareous  salts,  which  may  be  as  low  as  from  25  to  35  per  cent. 

The  liver  and  spleen  are  usually  enlarged,  and  sometimes  the  mesen- 
teric glands.  As  Gee  suggests,  these  conditions  2>i'obably  result  from  the 
general  state  of  the  health  associated  with  rickets.  It  is  interesting  to 
note  that  Beneke  describes  a  relative  increase  in  the  size  of  the  arteries  in 
rickets. 

Kassowitz,  who  may  be  considered  the  leading  authority  on  the  anat- 
omy of  rickets,  regards  the  hyperfemia  of  the  periosteum,  the  marrow,  the 
cartilage,  and  of  the  bone  itself  as  the  primary  lesion,  out  of  which  all  the 
others  develop.  This  disturbs  the  normal  development  of  the  growing 
bone,  and  excites  changes  in  the  bone  already  formed.  The  cartilage  cells 
in  consequence  proliferate,  the  matrix  is  softer,  and  the  bone  which  is 


i.<  i 


RICKETS. 


309 


formed  from  this  uiiliealthy  cartilage  is  lacking  in  firmness  and  solidity. 
In  tlie  bono  already  formed  this  excessive  vascularity  favors  tlie  normal 
processes  of  absor})tion,  so  that  the  relation  between  removal  and  deposi- 
tion is  disturbed,  absorjjtion  taking  place  more  rapidly.  The  new  material 
is  poor  in  lime  salts.  Kassowitz  seems  to  have  proved  experimentally 
that  hypera'mia  of  bono  results  in  defective  deposition  of  lime  salts.  Bar- 
low and  Bury*  have  given  an  elaborate  analysis  of  the  changes  described 
by  tliis  author.  It  is  interesting  to  note  that  Glisson  attributed  rickets  to 
disturbed  nutrition  by  arterial  blood,  and  believed  the  changes  in  the  long 
bones  to  be  due  to  excessive  vascularity. 

Symptoms. — The  disease  comes  on  insidiously  about  the  period  of 
(loutition,  before  the  child  begins  to  walk.  In  many  cases  digestive  dis- 
turbances precede  the  appearance  of  the  characteristic  lesions,  and  tho 
nutrition  of  the  child  is  markedly  impaired.  There  is  usually  slight 
fever,  the  child  is  irritable  and  restless,  and  sleeps  badly.  If  the  child 
lias  already  walked,  it  shows  a  marked  disinclination  to  do  so,  and  seems 
feeble  and  unsteady  in  its  gait.  Sir  William  Jennc  has  called  attention 
to  tlu'ce  general  symptoms  which  are  present  in  many  cases  of  rickets. 
Tiiore  is  first  a  diffuse  soreness  of  the  body,  so  that  the  child  cries  when 
iui  attempt  is  made  to  move  it,  and  prefers  to  keep  perfectly  still.  This 
tenderness  is  often  a  marked  and  suggestive  symptom.  Associated  with 
tliis  are  slight  fever  and  a  tendency  at  night  to  throw  off  tho  bedclothes. 
This  may  be  partly  due  to  the  fact  that  the  general  sensitiveness  is  such 
that  even  their  weight  may  be  distressing.  And,  third,  there  is  such 
profuse  sweating,  ])articularly  about  the  head  and  neck,  that  in  the  morn- 
ing the  pillow  is  found  soaked  with  perspiration. 

The  tissues  become  soft  and  flabby ;  the  skin  is  pale ;  and  from  a 
lioaltliy,  plump  condition,  the  child  becomes  puny  and  feeble.  It  is  in 
tliis  stage  of  th,;  disease  that  we  sometimes  find  such  a  degree  of  disability 
iu  tho  muscles,  particularly  of  the  legs,  that  paralysis  may  be  suspected. 
This  so-called  pseudo  paresis  of  rickets  results  in  part  from  the  flabby, 
weak  condition  of  tlie  legs  and  in  part  from  the  pain  associated  with  the 
movements.  Such  cases  are  by  no  means  uncommon,  but  they  are  readily 
distinguished  from  infantile  paralysis.  Coincident  with,  or  following 
closely  upon,  the  general  symptoms  the  characteristic  skeletal  lesions  are 
ohservod.  Among  tho  first  of  these  to  appear  arc  the  changes  in  tho  ribs, 
at  the  junction  of  the  bone  with  the  cartilage,  forming  the  so-called 
liekety  r(>sary.  "When  the  child  is  thin  these  nodules  may  be  distinctly 
seen,  and  in  any  case  can  bo  easily  made  out  by  touch.  They  very  rarely 
iiitjiear  before  the  third  month.  They  may  increase  in  size  up  to  the  sec- 
ond year,  and  are  rarely  seen  after  the  fifth  year.  The  thorax  undergoes 
inii)ortant  changes.  Just  outside  the  junction  of  the  cartilages  with  the 
ribs  there  is  an  oblique,  shallow  depression  extending  downward  and  out- 


Wi  I 


*  Cyclopa.>diu  of  the  Diseases  of  Children,  vol.  u. 


Hi 


■H 


If;  f . 


.«.ifl  if   1! 


f,      '•. 


] 


If 


I  I 

'  i 


i 


if-"' 


310 


CONSTITUTIONAL  DISEASES. 


ward.  A  transverse  curve,  sometimes  called  Harrison's  groove,  passes  out- 
ward from  the  level  of  the  ensiform  cartilage  toward  the  axilla  and  may 
be  deepened  at  each  insi)iration.  It  is  rendered  more  prominent  by  the 
eversion  and  prominence  of  the  costal  border.  Tlie  sternum  projects, 
particularly  in  its  lower  half,  forming  the  so-called  pigeon  or  chicken 
breast.  These  changes  in  the  thorax  are  not  peculiar,  however,  to  rickets, 
and  are  much  more  commonly  associated  with  hypertrophy  of  the  tonsils, 
or  any  trouble  which  interferes  with  the  free  entrance  of  air  into  the 
lungs.  Posteriorly  the  spine  is  usually  curved,  the  processes  are  promi- 
nent, and  lateral  curvature  may  be  produced. 

The  head  of  a  rickety  child  usually  looks  large,  and  the  fontanellea 
remain  open  for  a  long  time.  There  are  areas,  particularly  in  the  parieto- 
occipital regions,  in  which  ossification  is  imperfect ;  and  the  bone  may 
yield  to  the  pressure  of  the  finger,  a  condition  to  which  the  term  cranio- 
tabes  has  been  given.  The  relation  of  this  condition  to  rickets  is  still 
somewhat  doubtful,  as  it  is  very  often  associated  with  syphilis — in  47  of 
100  cases  recently  studied  by  George  Carpenter.  Coincidently  with  this, 
hyperplasia  proceeds  in  the  frontal  and  parietal  eminences,  so  that  these 
portions  of  the  skull  increase  in  thickness,  and  may  form  irregular  bosses. 
In  one  type  the  skull  may  be  large  and  elongated,  with  the  top  considera- 
bly flattened.  In  another,  and  perhaps  more  common  case,  the  shape  of 
the  skull,  when  seen  from  above,  is  rectangular — the  caput  qnadratum. 
The  skull  looks  large  in  proportion  to  the  face.  The  forehead  is  broad 
and  square,  and  the  frontal  eminences  marked.  The  anterior  fontanelle 
is  late  in  closing  and  may  remain  open  until  the  third  or  fourth  year. 
The  skin  is  thin,  the  veins  are  perceptible,  and  the  hair  is  often  rubbed 
from  the  back  of  the  skull.  In  contradistinction  to  the  cranio-tabes  is 
the  condition  of  cranio-sclerosis,  which  has  also  been  ascribed  to  rickets. 

On  placing  the  car  over  the  anterior  fontanelle,  or  in  the  temporal 
region,  a  systolic  murmur  may  frequently  be  heard.  This  condition,  first 
described  by  Fisher,  of  Boston,  was  believed  by  him  to  be  peculiar  to 
rickets.  While  unquestionably  heard  with  the  greatest  frequency  in  this 
disease,  its  presence  and  persistence  in  perfectly  healthy  infants  have  been 
amply  demonstrated.*  The  murmur  is  rarely  heard  after  the  fifth  year. 
A  knowledge  of  the  existence  of  this  systolic  brain  murmur  may  prevent 
errors.  A  case  in  which  it  was  well  marked  was  reported  as  an  instance 
of  supposed  gummy  tumor  of  the  brain,  in  which  the  murmur  was  thought 
to  be  due  to  pressure  on  the  vessels  at  the  base. 

Changes  occur  in  the  bones  of  the  face,  chiefly  in  the  maxilla),  which 
are  reduced  in  size.  The  normal  process  of  dentition  is  much  disturbed; 
indeed,  late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth 
Avhich  appear  may  be  small  and  badly  formed. 

*  Osier,  On  the  Systolic  Brain  Murmur  of  Children,  Boston  Medical  and  Surgical 
.Tournal,  1880. 


\i-' 


Ill 


RICKETS. 


311 


In  tho  upper  limbs  changes  in  the  scapulae  are  not  common.  The 
claviclo  may  be  thickened  at  the  sternal  end,  and  there  may  be  tliickening 
near  tlio  attachment  of  tho  sterno-cleido  muscle.  Tlie  most  noticeable 
I'hanges  are  at  the  lower  ends  of  the  radius  and  ulna.  Tho  enlargement 
is  at  tho  junction-area  of  tho  shaft  and  epiphysis.  Less  evident  enlarge- 
ments may  occur  at  the  lower  end  of  the  humerus.  In  severe  cases  the 
natural  shape  of  the  bones  of  the  arm  may  be  much  altered,  having  to 
support  the  weight  of  the  child  in  crawling  on  the  floor.  The  changes  in 
the  pelvis  are  of  special  importance,  particularly  in  female  children,  as  in 
extreme  cases  tliey  lead  to  great  deformity  and  narrowing  of  tho  outlet. 
In  the  legs,  the  lower  end  of  tho  tibia  first  becomes  enlarged ;  and  in 
sliglit  cases  it  may  alone  bo  affected.  In  the  severe  forms  the  upper  ent^ 
of  the  bone,  the  corresponding  parts  of  the  fibula,  and  tho  lower  end  of 
the  femur  become  greatly  thickened.  If  the  child  walks,  slight  bowing 
of  tlie  tibite  inevitably  results.  In  more  advanced  cases  the  tibia?  and 
even  the  femora  may  bo  arched  forward.  In  other  cases  the  condition  of 
knock-knee  occurs.  Unquestionably  the  chief  cause  of  these  deformi- 
ties is  the  weight  of  the  body  in  walking,  but  muscular  action  takes 
part  in  it.  The  green-stick  fracture  is  not  uncommon  in  the  soft  bones 
of  rickets. 

These  changes  in  the  skeleton  proceed  slowly,  and  the  general  symp- 
toms vary  a  good  deal  with  their  progress.  The  child  becomes  more  or 
loss  emaciated,  though  "  fat  rickets  "  is  by  no  means  uncommon.  Fever 
is  not  constant,  but  in  actively  progressing  changes  in  the  bono  there  is 
usually  a  slight  pyrexia.  The  abdomen  is  large,  due  partly  to  flatulent 
distention,  partly  to  enlargement  of  the  liver,  and  in  severe  cases  to 
diminution  of  the  volume  of  the  thorax.  The  spleen  is  often  enlarged  and 
readily  palpable.  The  urine  is  stated  to  contain  an  excess  of  lime  salts, 
but  Jacobi  and  Barlow  say  this  has  not  been  proved.  No  special  or 
peculiar  changes,  indeed,  have  as  yet  been  described.  Many  rickety  chil- 
dren show  marked  nervous  symptoms  ;  irritability,  peevishness,  and  sleep- 
lessness are  constantly  present.  Jenner  called  attention  to  the  close  w  •- 
tionship  which  existed  between  rickets  and  infantile  convulsions,  par- 
ticularly to  the  fits  which  occur  after  the  sixth  month.  Tetany  is  by  no 
means  uncommon.  It  involves  most  frequently  the  arms  and  hands ;  oc- 
casionally the  legs  as  well.  Laryngismus  stridulus  is  a  common  complica- 
tion, and  though  not,  as  some  state,  invariably  associated  with  this  disease, 
yet  it  is  certainly  much  more  frequent  in  rickety  than  in  other  children. 
Severe  rickets  interfere  seriously  with  the  growth  of  a  child.  Extreme 
examples  of  rickety  dwarfs  are  not  uncommon.  The  disease  known  as 
acute  rickets  is  in  reality  a  manifestation  of  scurvy  and  will  be  described 
with  that  disease. 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition 
f'f  tl.o  cliild  is  such  that  it  is  readily  carried  off  by  intercurrent  affections, 
particularly  those  of  the  respiratory  organs.     Spasm  of  the  larynx  and 
21 


(• 


si 


Ml 


812 


CONSTITUTIONAL  DISKASES. 


nmt 


Vlif,     , 


convulsions  occasionally  cause  dontli.  In  females  the  deformity  of  the 
pelvis  is  serious,  us  it  may  lead  to  dillieulties  in  parturition. 

Treatment. — The  bettor  the  condition  of  the  mother  during  projr- 
nancy  tlie  less  likelihood  is  there  of  the  development  of  rickets  in  the 
child.  Kapidly  repeated  pregnancies  and  suckling  a  >  luld  during  preg- 
nancy seem  important  factors  in  the  ])roducti()n  of  the  disease.  Of  llie 
general  treatment,  attention  to  the  feeding  of  the  child  is  the  first  con- 
sideration. If  the  mother  is  unhealthy,  or  cannot  from  any  cause  nurse 
the  child,  a  suitable  wet-nurse  should  be  provided,  or  the  child  must  bo 
artificially  fed.  Cows'  milk,  diluted  according  to  the  age  of  the  child, 
should  constitute  the  chief  food.  Care  should  be  taken  to  examine  the 
condition  of  the  stools,  and  if  curds  are  present  the  child  is  taking  too 
much,  or  it  is  not  sufficiently  diluted.  Barley-Avater  or  carefully  strained 
and  well-boiled  oatmeal  gruel  form  excellent  additions  to  the  milk. 

The  child  should  bo  warndy  clad  and  should  bo  in  the  fresh  air  and 
sunshine  the  greater  part  of  the  day.  It  is  a  "  vulgar  error  "  to  suppose  that 
delicate  children  cannot  stand,  when  carefully  wrapped  up,  an  even  low  tem- 
perature. The  child  should  be  bathed  daily  in  warm  water.  Careful  friction 
with  sweet  oil  is  very  advantageous,  and,  if  properly  performed,  allays  rather 
than  ai^gravates  the  sensitiveness.  Special  care  should  be  taken  to  pre- 
vent deforraity.  The  child  should  not  be  allowed  to  walk,  and  for  this 
purpose  spliits  applied  so  as  to  extend  beyond  the  feet  are  very  effective. 
Of  medicinci',  phosphorus  has  been  warmly  recommended  by  Kassowitz, 
and  its  use  is  also  advised  by  Jacobi.  The  child  may  be  given  gr.  ^Jj 
two  or  three  times  a  day,  dissolved  in  olive  oil.  Cod-liver  oil,  in  doses 
of  from  a  half  to  one  teaspoonf  ul,  is  very  advantageous.  The  syrup  of  the 
iodide  of  iron  may  be  given  with  the  oil.  The  digestive  disturbances, 
together  with  the  respiratory  and  nervous  complications,  should  receive 
appropriate  treatment. 


X.   SCURVY  {Scorbutus). 


Definition. — A  constitutional  disease  characterized  by  great  debility, 
with  aniBmia,  a  spongy  condition  of  the  gums,  and  a  tendency  to  hemor- 
rhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and 
has  prevailed  particularly  in  armies  in  the  field  and  among  sailors  on  long 
voyages. 

From  the  early  part  of  this  century,  owing  largely  to  the  efforts  of 
Lind  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  de- 
pends, scurvy  has  gradually  disappeared  from  the  naval  service.  In  the 
mercantile  marine,  cases  still  occasionally  occur,  owing  to  neglect  of  proper 
and  suitable  food. 

The  disease  develops  whenever  individuals  have  Bubsisted  for  pro- 


SCUllVY. 


313 


longed  periods  upon  a  diet  in  which  fresh  vegetables  or  their  substitutea 
arc  lacking. 

In  comparison  with  former  times  it  is  now  a  rare  disease.  In  seaport 
towns  sailors  sullcring  with  the  disease  are  occasionally  admitted  to  hos- 
pitals. In  largo  almshouses,  during  the  winter,  cases  are  occasionally 
seen.*  On  several  occasions  in  Philadelphia  characteristic  examples  were 
admitted  to  my  wards  from  tlie  almshouse.  Some  years  ago  it  was  not 
very  uncommon  among  the  lumbermen  in  the  winter  camps  in  the  Ottawa 
Valley.  Among  the  Hungarian,  Bohemian,  and  Italian  mimrs  in  Penn- 
sylvania, cases  of  the  disease  are  not  infrequent.  This  so-called  land 
scurvy  differs  in  no  particular  from  the  disease  in  sailors.  An  insufficient 
diet  ai)pears  to  be  an  essential  element  in  the  disease,  and  all  observers  are 
now  unanimous  that  it  is  the  absence  of  those  ingredients  in  the  food 
which  are  supplied  by  fresh  vegetables.  What  these  constituents  are  has 
not  yet  been  definitely  determined.  Garrod  holds  that  the  defect  is  in  the 
absciu'o  of  the  potassic  salts.  Otliers  believe  that  the  essential  factor  is 
the  absence  of  tlie  organic  ^-Jts  present  in  fruits  and  vegetables.  lialfe, 
wlio  has  made  a  very  careful  study  of  the  subject,  believes  that  the  absence 
from  the  food  of  the  malates,  citrates,  and  lactates  reduces  the  alkalinity 
of  the  blood,  which  depends  upon  the  carbonates  directly  derived  from 
these  salts.  This  diminished  alkalinity,  gradually  produced  in  the  scurvy 
patients,  is,  he  believes,  identical  with  the  effect  which  can  be  artificially 
produced  in  animals  by  feeding  them  with  an  excess  of  acid  salts;  the 
nutrition  is  impaired,  there  are  ecchymoses,  and  profound  alterations  in 
the  characters  of  the  blood.  Tlie  acidity  of  the  urine  is  greatly  reduced 
and  the  alkaline  phosphates  are  diminished  in  amount. 

In  opposition  to  this  chemical  view  it  has  been  urged  that  the  disease 
really  depends  upon  a  specific  micro-organism. 

Other  factors  play  an  important  part  in  the  disease,  particularly  phyei- 
ciil  and  moral  influences;  overcrowding,  dwelling  in  cold,  damp  quarters, 
and  prolonged  fatigue  under  depressing  influences,  as  during  the  retreat 
of  an  army.  Among  prisoners,  mental  depression  plays  an  important 
r(')Jf.  It  is  stated  that  epidemics  of  the  disease  have  broken  out  in  the 
French  convict-ships  en  route  to  New  Caledonia,  even  when  the  diet  was 
amply  sufficient.  Nostalgia  is  sometimes  an  important  element.  It  is  an 
interesting  fact  that  prolonged  starvation  in  itself  does  not  necessarily 
cause  scurvy.  Not  one  of  the  prof essic ' "i,l  fasters  of  late  years  has  dis- 
played any  scorbutic  symptom.  The  disease  attacks  all  ages,  but  the 
old  are  more  susceptible  to  it.  Sex  has  no  special  influence,  but  during 
the  siege  of  Paris  it  was  noted  that  the  males  attacked  were  greatly  in 
excess  of  the  females.  Infantile  scurvy  will  be  considered  in  a  special 
Dote. 

Morbid  Anatomy. — The  anatomical  changes  are  marked,  though 


Henry,  Philadelphia  Hospital  Reports,  vol.  i,  1800. 


I'll .-  "il 


11 '\ 


t     \ 


m  I  ^ 


314 


CONSTITUTIONAL  DISKASES. 


by  no  means  specific,  and  arc  cliiefly  those  associated  witli  hipmorrluipo. 
The  blood  is  dark  and  tluid.  Thoro  arc  no  characteristic  niicroscopicul 
alterations.  The  bacteriological  examination  has  not  yielded  anything 
very  positive.  Practically  there  are  no  changes  in  the  blood,  either  ana- 
tomical or  chemical,  which  can  be  regarded  as  i)cculiar  to  the  disease. 
The  skin  shows  the  ecchymoscs  evident  during  life.  There  are  luvmor- 
rhages  into  the  muscles,  and  occasionally  about  or  even  into  the  jointrf. 
Ilajmorrhages  occur  in  the  internal  organs,  particularly  on  the  serous 
membranes  and  in  the  kidneys  and  bladder.  The  gums  are  swollen  and 
sometimes  ulcerated,  so  that  in  advanced  cases  the  teeth  arc  loose,  and 
have  even  fallen  out.  Ulcers  are  occasionally  met  with  in  the  ileum  and 
colon,  llajmorrhages  are  extremely  common  into  the  mucous  membranes. 
The  spleen  is  enlarged  and  soft,  rarenchymatous  changes  are  constant 
in  the  liver,  kidneys,  and  heart. 

Symptoms. — The  disease  is  insidious  in  its  onset.  Early  symptoms 
are  loss  in  weight,  progressively  developing  weakness,  and  pallor.  Very 
soon  the  gums  are  noticed  to  be  swollen  and  sjjongy,  to  bleed  easily,  and 
in  extreme  cases  to  present  a  fungous  appearance.  The  teeth  may  become 
loose  and  even  fall  out.  Actual  necrosis  of  the  jaw  is  not  common.  The 
breath  is  excessively  foul.  The  tongue  is  swollen,  but  may  be  red  and 
not  much  furred.  The  salivary  glands  are  occasionally  enlarged.*  The 
lesions  of  the  gums  are  rarely  absent.  The  f  "•!  becomes  dry  and 
rough,  and  ecchymoscs  soon  a]>pear,  first  on  t'  '^s  and  then  on  the 
arms  and  trunk.  They  are  petechial,  but  may  ■^.„...iie  larger,  and  when 
subcutaneous  may  cause  distinct  swellings.  In  severe  cases,  particularly 
in  the  legs,  there  may  be  effusion  between  the  periosteum  and  the  bone, 
forming  irregular  nodes,  which,  in  the  case  of  a  sailor  from  a  whaling 
vessel,  who  came  under  my  observation,  had  broken  down  and  formed  foul- 
looking  sores.  The  slightest  bruise  or  injury  causes  hemorrhage  into  the 
injured  part.  Q^.dema  about  the  ankles  is  common.  Haemorrhages  from 
the  mucous  membranes  are  less  constant  symptoms.  Epistaxis  is,  however, 
frequent.  Iloemoptysis  and  ha^matemesis  are  uncommon.  Ha;maturia 
and  bleeding  from  the  bowels  may  be  present  in  very  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.  A  haemic  murmur  can  usually  be  heard  at 
the  base.  Ilaemorrhagic  infarction  of  the  lungs  and  spleen  has  been  de- 
scribed. Respiratory  symptoms  are  not  common.  The  appetite  is  in- 
paired,  and  owing  to  the  soreness  of  the  gums  the  patient  is  unable  to 
chew  the  food.  Constipation  is  more  frequent  than  diarrhoea.  The  urine 
is  often  albuminous.  The  changes  in  the  composition  of  the  urine  are 
not  constant ;  the  specific  gravity  is  high  ;  the  color  is  deeper ;  and  the 
phosphates  are  increased.  The  statements  with  reference  to  the  inorgaiuc 
constituents  are  contradictory.  Some  say  the  phosphates  and  potash  are 
deficient ;  others  that  they  are  increased. 

There  are  mental  depression,  indifference,  in  some  cases  headache,  and 


SCURVY. 


315 


in  tlie  latter  Htaj^fcs  (luliriiitn.  Cases  of  convulsions,  of  lieniii'lej^ia,  and  of 
niiiiiiigeul  lueinorrliilgo  have  been  descriluMl.  Ueinarkahle  i)cular  symp- 
toms are  occasionally  met  with,  such  as  night-bliiulness  or  day-blindness. 

In  advanced  cases  necn-osis  of  the  bones  may  occur,  and  in  young 
]»crsons  even  scfpariUion  of  the  epiphyses.  There  are  instances  in  which 
the  curtilages  have  sep'U'ated  from  the  sternum.  The  callus  of  a  recently 
n  paired  fracture  has  been  known  to  undergo  destruction.  Fever  is  not 
present,  except  in  the  later  stages,  or  when  secondary  intlanunatioin  in  the 
internal  organs  appear.  The  temperature  may  indeed  be  sometimes  below 
normal. 

Scurvy  in  Children. — In  infants  and  young  children,  fed  upon  impro})er 
fiiod,  a  form  of  cachexia  develops  which  has  been  regarded  as  acute 
rickets,  but  which  Cheadlo  and  Barlow  have  shown  to  be  a  form  of  scurvy. 
The  most  striking  cases  develop  in  infants  reared  on  artificial  food  pre- 
pared with  water,  though  the  disease  has  occuired  when  these  foods  were 
prepared  with  milk.  Kickets  str(mgly  predispose  to  the  condition.  The 
eases  may  occur  in  infants,  or  in  children  up  to  the  ago  of  ten.  Barlow 
thus  summarizes  the  chief  features : 

"  (1)  Predominance  of  lower  limb  alTection  : 

"(«)  Immobility,  going  on  to  })seudo-paralysis ;  (/>)  excessive  tender- 
nosa ;  {c)  general  swelliii':  of  lower  limbs;  (d)  skin  shiny  and  tense,  but 
seldom  pitting,  and  not  characterized  by  undue  local  heat;  (e)  on  subsi- 
dence, revealing  a  deep  thickening  of  the  shaft ;  (/)  liability  to  fracb.no 
near  the  epiphyses. 

"  (:i)  Swelling  of  the  gums,  varying  from  definite  sponginess  down  to 
ii  viinishing-point  of  minute  transient  ecchymoscs.  These  constitute  the 
eliief  diagnostic  ditferentia  between  infantile  scurvy  and  rickets,  properly 
so  called.  But  to  theni  must  bo  added,  as  the  most  imi)ortant  diagnostic 
(if  all,  (3)  definite  and  rapid  amelioration  by  antiscorbutic  regimen." 
According  to  Gee,  lutmaturia  may  be  the  oidy  sign  of  scurvy  in  children. 

Diagnosis. — No  difficulty  is  met  in  the  recognition  of  scurvy  when 
a  luHuber  of  persons  are  affected  together.  In  isolated  cases,  however,  the 
disi'ase  is  distinguished  with  difficulty  from  certain  forms  of  purpura.  The 
association  with  manifest  insufficiency  in  diet,  and  the  rapid  amelioration 
with  suitable  food,  are  points  by  which  the  diagnosis  can  be  readily 
settled. 

Prognosis. — The  outlook  is  good,  unless  the  disease  is  far  advanced 
and  the  conditions  persist  which  lead  to  its  development.  The  mortality 
now  is  rarely  great.  During  the  civil  war  the  death-rate  was  sixteen  per 
cent.  Death  results  from  gradual  heart-failure,  occasionally  from  sudden 
syiu'opc.  Meningeal  haemorrhage,  extravasation  into  the  serous  cavities, 
eutero-colitis,  and  other  intercurrent  affections  may  prove  fatal. 

Prophylaxis. — The  regulations  of  the  Board  of  Trade  require  that  a 
siiHicient  supply  of  antiscorbutic  articles  of  diet  is  taken  on  each  ship;  so 
that  now,  except  as  the  result  of  accident,  the  occurrence  of  scurvy  on 


;  I'l 


1*1  k  t'l 
I'-'  ='    l 


316 


CONSTITUTIONAL  DISEASES. 


board  a  vessel  shculd  lead  to  the  indictment  of  the  captain  or  owners  for 
criminal  negligrnce.  An  outbreak  of  the  disease  in*  an  almshouse  is  evi- 
dence of  cnl})able  neglect  on  the  part  of  the  managers. 

Treatment. — The  juice  of  two  or  three  lemons  daily  and  a  varied 
diet,  with  plenty  of  fresh  vegetables,  suffice  to  cure  all  cases  of  scurvy, 
unless  far  advanced.  When  the  stomach  is  much  disordered,  small  quan- 
titios  of  scraped  meat  and  milk  should  be  given  at  short  intervals,  and  the 
lemon-juice  in  gradually  increasing  quantities.  'A  bitter  tonic,  or  a  stool 
and  bark  mixture,  may  be  given.  As  the  patient  gains  in  strength,  the 
diet  may  be  more  liberal  and  he  may  eat  freely  of  potatoes,  cabbage, 
water-cresses,  and  lettuce.  The  stomatitis  is  tluj  symptom  which  causes 
the  greatest  distress.  The  permanganate  of  potash  or  dilute  carbolic  acid 
forms  the  best  mouth-wash.  Pencilling  the  swollen  gums  with  a  tolerably 
strong  solution  of  nitrate  of  silver  is  very  useful.  The  solution  is  better 
than  the  solid  stick,  as  it  roaches  to  the  crevices  between  the  granulations. 
The  constipation  which  is  so  common  is  best  treated  with  large  enemata. 
For  other  conditions,  such  as  haemorrhages  and  ulcerations,  suitable 
measures  must  be  employed. 


XI.  PURPURA. 


Ilk 


It  - : 


Strictly  speaking  this  is  a  symptom,  not  a  disease ;  but  under  this 
term  are  conveniently  anunged  a  number  of  affections  characterize'!  by 
extravasations  of  the  blood  into  the  skin.  The  purpuric  spots  vary  liom 
one  to  three  or  four  millimetres  in  diameter.  When  small  and  pin-point- 
like  they  are  called  i)etechia3 ;  when  large,  they  are  known  as  ecchymnsos. 
At  first  bright  red  in  color,  they  become  darker,  and  gradually  fade  to 
brownish  stains.     They  do  not  disappear  on  pressure. 

It  is  extremely  difficult  to  make  a  satisfactory  classification  of  purpura. 
Perhaps  as  good  a  division  as  can  be  made  i.s  the  following : 

Symptomatic  Purpura. — (n)  Infectious. — In  pyaemia,  scpticaMiiia, 
malignant  endocarditis  (particularly  in  the  latter  affection),  ecchyniosos 
may  be  very  abundant.  In  typhus  fever  the  rash  is  always  purpiivic. 
Measles,  scarlet  fever,  and  more  particularly  small-pox,  have  each  a  variety 
characterized  by  an  extensive  ])urpuric  rash. 

(/>)  Toxic. — The  virus  of  siuikes  produces  with  groat  rapidi  y  extrava- 
sation of  blood  ;  a  condition  which  has  been  very  carefully  studied  by 
Weir  Mitchell.  Certain  medicines,  particularly  copaiba,  q'  inine,  bella- 
donna, mercury,  ergot,  and  the  iodides  occasionally,  arc  ollowed  by  h 
petechial  rash.  Under  this  division,  too,  comes  the  j,ur])ura  associated 
with  jaundice. 

(c)  Cachectic. — Under  this  heading  are  best  described  the  instances  nf 
purpura  which  develop  in  the  constitutional  disturbance  of  cancer,  tuber- 
culosis, Ilodgkin's  disease,  Bright's  disease,  scurvy,  and  in  the  debility  of 


PURPURA. 


317 


old  age.  In  these  cases  the  spots  are  usually  confined  to  the  extremities. 
They  may  be  very  abi'rdant  in  the  lower  limbs  and  about  the  wrists  and 
hands.  This  constitutes,  probably,  the  commonest  variety  of  the  disease, 
and  many  examples  of  it  can  be  seen  in  tl:    .  .irds  of  any  large  hospital. 

{(l)  Neurotic. — One  variety  is  met  with  in  cases  of  organic  disease. 
It  is  the  so-called  myelopathic  pu*-'  u  .,  which  is  seen  occasionally  in 
locomotor  ataxia,  particularly  follow!; -^  attacks  of  the  lightning  pains 
and,  as  a  rule,  involving  the  area  of  the  skin  in  which  the  pains  have  been 
most  intense.  Cases  have  been  met  with  also  in  acute  myelitis  and  in 
transverse  myelitis,  and  occasionally  in  severe  neuralgia.  Another  form 
is  the  remarkable  hysterical  condition  in  which  stigmata,  or  bleeding 
points,  appear  upon  the  skin. 

(e)  Mechanical. — This  variety  is  most  frequently  seen  in  venous  stasis 
of  any  form,  as  in  the  paroxysms  of  whooping-cough  and  in  epilepsy. 

Arthritic. — This  form  is  characterized  by  involvement  of  the  joints. 
It  is  usually  known,  therefore,  as  rheumatic,  though  in  reality  the  evi- 
dence upon  which  this  view  is  based  is  not  conclusive.  For  the  present 
it  seems  more  satisfactory  to  use  the  designation  arthritic.  Three  groups 
of  cases  may  be  recognized  : 

(a)  A  mild  form,  often  known  as  Purpura  simplex,  seen  most  com- 
monly in  children,  in  whom,  with  or  without  articular  pain,  a  crop  of 
purpuric  spots  appears  upon  the  legs,  less  commonly  upon  the  trunk  and 
arms.  As  pointed  out  by  Graves,  this  form  is  not  infrequently  associated 
with  diarrhoia.  The  disease  is  seldom  severe.  There  may  be  loss  of  ap- 
petite, and  slight  anaemia.  Fever  is  not,  as  a  rule,  present,  and  the  pa- 
tients get  well  in  a  week  or  ten  days.  These  cases  are  usually  regarded 
as  rheumatic,  and  are  certainly  associated,  in  some  instances,  with  un- 
doubted rheumatic  manifestations  ;  yet  in  a  majority  of  the  patients  which 
I  have  seen  the  arthritis  was  slighter  than  in  the  ordinary  rheumatism  of 
cliildren,  and  no  other  manifestations  were  present. 

{b)  Peliosis  Rheumatica  (Schoidein's  Disease). — This  remarkable  affec- 
tion is  characterized  by  multiple  arthritis,  and  an  eruption  which  varies 
greatly  in  characters,  sometimes /)«/7?«rtV,  more  commonly  associated  wiih 
urticaria  or  with  erythema  e.rndativiim.  The  disease  is  most  common  in 
iiiiih's  between  the  ages  of  twenty  and  thirty.  It  not  infrequently  sets  in 
with  sore  throat,  a  fev.^;-  from  101°  to  103°,  and  articular  pains.  The 
purpuric  rash  nuikes  it"^  appearance  first  on  the  legs  or  about  the  affected 
joints.  It  may  be  a  simple  purpura  or  ordinary  urticarial  wheals.  In 
other  instances  there  are  nodular  infiltrations,  not  to  be  distinguished 
from  erythema  nodosum.  The  combination  of  wheals  and  purpura,  the 
purpura  nrficans,  is  very  distinctive.  Much  more  rarely  vesication  is  met 
with,  the  t^o-cvbWaA  pemphigoid  purpura.  The  amount  of  oedema  is  vari- 
ii!»lo ;  occasionally  it  is  excessive.  In  one  case,  which  I  saw  in  Montreal 
with  Molson,  the  chin  and  lower  lip  were  enormously  swollen,  tense, 
glazed,  and  deeply  ecchymotic.     The  ej'elids  were  swollen  and  purpuric, 


wmmi^'mmm 


818 


CONSTITUTIONAL  DISEASES. 


;!;.;; 


IJI 


while  scattered  over  the  cheeks  and  about  the  joints  were  numerous  spots 
of  purpura  urticans.  These  are  the  cases  which  have  been  described  as 
febrile  purjniric  oedema.  The  temperature  range,  in  mild  cases,  is  not 
high,  but  may  reach  103°  or  103°. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous. 
The  joint  aflections  are  usually  slight,  though  associated  with  much  pain, 
particularly  as  the  rash  comes  out.  Relapses  may  occur  and  the  disease 
may  return  at  the  same  time  for  several  years  in  succession. 

The  diagnosis  of  Schonlein's  disease  oilers  no  difliculty.  The  associa- 
tion of  multiple  arthritis  with  purpura  and  urticaria  is  very  characteristic. 
In  a  case  which  I  saw  with  Musser  there  was  endo-pericarditis,  and  the 
question  at  first  arose  whether  the  i:)atient  had  malignant  endocarditis 
with  extensive  cutaneous  infarcts. 

Schonlein's  poliosis  is  thought  by  most  writers  to  bo  of  rheumatic 
origin,  and  certainly  many  of  the  cases  have  the  charactors  of  ordinary 
rheumatic  fever,  plus  purpura.  By  many,  however,  it  is  regarded  as  a 
special  affection,  of  which  the  arthritis  is  a  manifestation  analogous  to 
that  which  occurs  in  htemophilia.  The  frequency  with  which  sore  throat 
precedes  the  attack,  and  the  occasional  occurrence  of  endocarditis  or  peri- 
carditis, are  certainly  very  suggestive  of  true  rheumatism. 

The  cases  usually  do  well,  and  a  fatal  event  is  extremely  rare.  The 
throat  sy)nptoms  nuiy  persist  and  give  trouble.  In  two  instances  I  have 
seen  necrosis  and  sloughing  of  a  portion  of  the  uvula. 

{c)  There  is  r.n  arthritic  purpura  which  presents  marked  gastro-in- 
testinal  and  renal  symptoms.  This  not  uncomr«ion  but  little  recognized 
form  is  met  with  most  frequently  in  children  and  sets  in  usually  with 
pains,  but  rarely  much  swelling  in  the  joints.  Purpura  or  purpura  urti- 
cans develops  about  them,  and  the  case  at  first  looks  like  one  of  so-called 
rheumatic  purpura.  Soon  other  symptoms  develop :  the  child  has  attacks 
of  severe  colic  with  vomiting  and  diarrhani,  true  gastro-intestinal  crises  ; 
which  may  recur  with  great  frequency,  particularly  at  night.  I'here  may 
be  haemorrhage  from  the  bowels  and  soon  renal  symptoms.  There  are 
albumen  and  tube-casts,  often  blood,  and  sometimes  all  the  symptoms  of 
an  intense  ha3morrhagic  nephritis.  The  cases  may  drag  on  for  montli.«. 
Death  may  occur  from  the  nephritis,  or  from  the  severe  gastro-intestinal 
disturbance.  Couty,  who  has  given  the  best  deso'iption  of  this  affection, 
regards  it  as  a  form  of  nervous  purpura.  This  )rm  has  an  interesting 
connection  with  the  angio-neurotic  (rdema,  which  is  also  characterizid 
by  severe  gastro-intestinal  crises.  Of  four  cases  which  have  been  undt! 
my  care  one  died  of  the  nephritis.* 

Purpura  HsBmorrliagica. — Under  this  heading  may  be  consid- 
ered the  cases  of  very  severe  })urpura  with  haemorrhages  from  the  mucou? 
membranes.     The  affection,  known  as  the  morbus  macvlosus  of  Werlliof, 


*  New  York  Medical  Journal,  1889. 


PURPURA. 


319 


is  most  commonly  met  with  in  young  and  delicate  individuals,  particu- 
larly in  girls ;  but  cases  are  described  in  which  the  disease  has  attacked 


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BLACK,  RED  CORPUSCLES  BED,  HAEMAOLOBIN.  BLUE,  C0L0BI.ES8  CORPUSCLES. 

CiiAHT  XIV.— lUni^trat.      ho   rapidity  with  which  anaemia  is  produced  in  purpura 
haBmoiThiij,'ica  and  itie  grachial  recovery. 

adults  in  full  vigor.  After  a  few  davs  of  weaki.  ss  and  debility,  purpuric 
spots  appear  on  tlie  skin  and  rapidly  mcroase  in  niimb<'rs  and  size.  Blet'd- 
iiig  from  the  mucous  surfaces  sets  in,  and  tbo  epist  is,  li;vm;ituria,  and 
hasmoptysis  may  cause  profound  angemia.  Clint  X IV  illustrates  the  rapid- 
ity with  which  anaemia  is  produced  and  the  ladual  recovery.  Death  may 
tiiko  place  from  loss  of  blood,  or  from  iuumon-liago  into  the  brain.  Slight 
fever  usually  accompanies  the  disease.  In  favomble  cases  tiie  affection 
termiuutes  in  from  ten  days  to  two  weeks.  TIk  r.  av  instances  of  purpura 
iiii'morrhagica  of  great  malignancy,  which  muv  juove  fatal  within  twenty- 
foiu-  honra— purpura  fulminam.  This  form  is  most  commonly  met  with 
m  children,  and  is  characterized  by  cutaneous  hjiemorrhages,  which  develop 
with  great  rapidity.  Death  may  occur  before  any  bleeding  takes  place 
from  the  mucous  membranes. 

In  the  diagnosis  of  purpura  haemorrhagica  it  is  important  to  exclude 
scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health, 


'  i 


320 


CONSTITUTIONAL   DISEASES. 


the  circumstances  under  which  the  disease  develops,  and  by  the  absence 
of  swelling  of  the  gums.  The  malignant  forms  of  the  fevers,  particularly 
small-pox  and  measles,  are  distingished  by  the  prodromata  and  the  higher 
temperature. 

Treatment. — In  symptomatic  })urpura  attention  should  be  paid  to 
the  conditions  under  which  it  develops,  and  measures  should  be  employed 
to  increase  the  strength  and  to  restore  a  normal  blood  condition.  Tonics, 
good  food,  and  fresh  air  meet  these  indications.  In  the  simple  purpura  of 
children,  or  that  associated  with  slight  articular  trouble,  arsenic  in  full 
doses  should  be  given.  No  good  is  obtained  from  the  small  doses,  but  the 
Fowler's  solution  should  be  pushed  freely  until  physiological  ell'ects  are 
obtained.  In  poliosis  rheumatica  the  sodium  salicylates  may  be  given,  but 
with  discretion.  I  confess  not  to  have  seen  any  special  control  of  the  hiem- 
orrhages  by  this  remedy.  We  are  still  without  a  trustworthy  medicine 
which  can  always  be  relied  upon  to  control  purpura. 

Aromatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic 
and  gallic  acids,  may  be  used,  and  in  some  instances  they  seem  to  check 
the  bleeding.  In  other  cases  the  whole  series  of  haemostatics  may  be  tried 
in  succession  without  any  benefit. 


XII.   HvtMOPHILIA. 


Definition. — An  hereditary,  constitutional  fault,  characterized  by  a 
tendency  to  uncontrollable  bleeding,  either  spontaneous  or  from  slight 
wounds.     It  is  sometimes  associated  with  a  form  of  arthritis. 

Early  in  the  century  several  physicians  of  this  country  called  attention 
to  the  occurrence  of  profuse  hajmorrhage  from  slight  causes.  '^I'ho  fact 
that  fatal  lueniorrhagc  might  occur  from  slight,  trilling  wounds  had  been 
known  for  centuries.  The  recognition  of  the  family  nature  of  the  disease 
is  due  to  the  writings  of  Buel,  Otto,  Ilay,  Coates,  and  others  in  this  coun- 
try. The  disease  has  been  elaborately  treated  in  the  monographs  of  Logg 
and  Grand  id  ier. 

Etiology.-  In  a  majority  of  cases  the  disposition  is  hereditary.  The 
fault  may  be  ac((uired,  however,  but  nothing  is  known  of  the  conditions 
under  which  the  disease  may  thus  arise  in  healtiiy  stock. 

The  hereditary  transmission  m  this  disease  is  remarkable.  In  the 
Appleton-Swain  family,  of  Reading,  Mass.,  there  have  been  cases  for 
nearly  two  centuries ;  and  P.  F.  Brown,  of  that  town,  tells  me  that  in- 
stances have  already  occurred  in  the  seventh  generation.  The  usual  iiio'lc 
of  transmission  is  through  the  mother,  who  is  not  herself  a  bleeder,  luii 
the  daughter  of  one.  Atavism  through  the  female  alone  is  almost  the 
rule,  and  the  daughters  of  a  bleeder,  though  healthy  and  free  from  any 
tendency,  are  almost  certain  to  transmit  the  disposition  to  the  male  otT- 
spring.     The  affection  is  much  more  common  in  males  than  in  females. 


HEMOPHILIA. 


891 


the  proportion  being  estimated  at  eleven  to  one,  or  even  thirteen  to  one. 
The  tendency  usually  appears  within  the  first  two  years  of  life.  It  is  rare 
for  manifestations  to  bo  delayed  until  the  tenth  or  twelfth  year.  Families 
ill  all  conditions  of  life  are  affected.  The  bleeder  families  are  usually 
largo.    The  members  arc  healthy-looking,  and  usually  have  fine,  soft  skins. 

Morbid  Anatomy. — No  special  peculiarities  have  been  described. 
Ill  some  instances  changes  have  been  found  in  the  smaller  vessels ;  but 
in  others  careful  studies  have  been  negative.  An  unusual  thinness  of  the 
vessels  has  been  noted.  Haemorrhages  have  been  foand  in  and  about  the 
cupsules  of  the  joints,  and  in  a  few  instances  inflammation  of  the  synovial 
surfaces.  The  nature  of  the  disease  is  undetermined,  and  we  do  not  yet 
know  whether  it  depends  upon  a  peculiar  frailty  of  the  blood-vessels  or 
some  peculiarity  in  the  constitution  of  the  blood,  which  prevents  the  nor- 
mal thrombus  formation  in  a  wound. 

Symptoms. — Usually  haemophilia  is  not  noted  in  the  child  until  a 
trilling  cut  is  followed  by  serious  or  uncontrollable  haemorrhage,  or  spon- 
taneous blooding  occurs  and  presents  insuperable  difliculties  in  its  arrest. 
The  symptoms  may  bo  grouped  under  three  divisions :  external  bleedings, 
spontaneous  and  traumatic ;  interstitial  bleedings,  petechiio  and  ecchy- 
moses;  and  the  joint  affections.  The  external  bleedings  may  be  spon- 
taneous, but  more  commonly  they  follow  cuts  and  wounds.  In  334  ciises 
((irandidier)  the  chief  bleedings  were  epistaxis,  109;  from  the  mouth,  43; 
stomach,  15;  bowels,  36;  urethra,  Ki;  lungs,  17;  and  in  a  few  instances 
blooding  from  the  skin  of  the  head,  the  tongue,  finger-tips,  tear-papilla, 
oyolitls,  external  ear,  vulva,  navel,  and  scrotum. 

Traumatic  bleeding  may  result  from  blows,  cuts,  scratches,  etc.,  and 
the  blood  may  be  diffused  into  the  tissues  or  discharged  externally.  Trivial 
oporations  have  proved  fatal,  such  as  the  extraction  of  teeth,  circumcision, 
or  venesection.  It  is  possible  that  there  may  be  local  defects  which  make 
blooding  from  certaiii  parts  of  the  body  more  dangerous.  I).  Hayes  Agnew 
moiitioned  to  me  the  case  of  a  bleeder  who  had  always  bled  from  cuts  and 
l)ruisos  above  the  neck,  never  from  those  below.  The  bleeding  is  a  capil- 
lary oozing.  It  may  last  for  hours,  or  even  many  days.  E])istaxis  may 
pidve  fatal  in  twenty-four  hours.  In  the  slow  blooding  from  the  mucous 
surfaces  large  blood  tumors  may  form  and  project  from  the  nose  or 
month,  forming  remarkable-looking  structures,  and  showing  thiit  the 
blood  has  tlie  power  of  coagulation.  The  interstitial  htipmorrhagcs  may 
bo  spontaneous,  or  may  result  from  injury.  Petechiic  or  largo  extravasa- 
tions— ho^matomata — may  occur,  the  latter  usually  following  blows. 

The  joint  affections  of  haemophilia  are  remarkable.  There  may  simply 
bo  pain,  or  attacks  which  come  on  suddenly  with  fever,  and  closely  rosem- 
Itlo  acute  rheumatism.  The  larger  joints  are  usually  atfected.  Arthritis 
may  iislier  in  an  attack  of  haemorrhage. 

So  far  as  the  examination  of  the  blood  goes,  no  changes  of  special 
niomont  have  been  noted.     When  the  bleedini;  has  been  severe  it  is  thin 


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322 


CONSTITUTIONAL  DISEASES. 


and  watery,  but  at  the  beginning  of  the  bleeding  the  blood  is  rich  in 
corpuscles  and  coagulatos  firmly. 

Diagnosis. — In  the  diagnosis  of  the  condition  the  family  tendency 
is  important.  A  single  uncontrollable  haemorrhage  in  child  or  adult  is 
not  to  be  ranked  as  haemophilia ;  but  it  is  only  when  a  person  shows  a 
marked  tendency  to  multiple  hfcmorrhages,  spontaneous  or  traumatic, 
which  tendency  is  not  transitory  but  persists,  particularly  if  there  have 
been  joint  affections,  that  we  may  consider  the  condition  haemophilia. 
Peliosis  rheumatica  is  an  affection  which  touches  haemophilia  very  closely, 
particularly  in  the  relation  of  the  joint  swelling.  It  may  also  show  itself 
in  several  members  of  a  family.  The  diagnosis  from  the  various  forms 
of  purpura  is  usually  easy. 

Prognosis.  —  The  patients  rarely  die  in  the  first  bleeding.  The 
younger  the  individual  the  worse  is  the  outlook,  though  it  is  rarely  fatal 
in  the  first  year.  Grandidier  states  that  of  152  boy  subjects,  81  died  before 
the  termination  of  the  seventh  year.  The  longer  the  bleeder  survives  the 
greater  the  chance  of  his  outliving  the  tendency ;  but  it  may  persist  to 
old  age,  as  shown  in  the  case  of  Oliver  Appleton,  the  first  reported  Ameri- 
can bleeder,  who  died  at  an  advanced  ago  of  haemorrhage  from  a  bed-sore 
and  from  the  urethra.  The  prognosis  is  graver  in  a  boy  than  in  a  girl. 
In  the  latter  menstruation  is  sometimes  early  and  excessive,  but  fortunate- 
ly, in  the  female  members  of  haemophilic  families,  neither  this  function 
nor  the  act  of  parturition  brings  with  it  special  dangers. 

Treatment. — Members  of  a  bleeder's  family,  particularly  the  boys, 
should  be  guarded  from  injury,  and  operations  of  all  sorts  should  be 
avoided.  The  daughters  should  not  marry,  as  it  is  through  them  that  the 
tendency  is  propagated. 

When  an  injury  or  wound  has  occurred,  absolute  rest  and  compression 
should  first  be  tried,  and  if  these  fail  the  styptics  may  be  used.  In  epis- 
taxis  ice, tannin,  and  gallic  acid  maybe  tried  before  resorting  to  plugging. 
Internally  ergot  seems  to  have  done  good  in  several  cases.  Legg  advises 
the  perchloride  of  iron  in  half-drachm  doses  every  two  hours  with  a 
purge  of  sulphate  of  soda.  Venesection  has  been  tried  in  several  cases. 
Transfusion  has  been  employed,  but  without  success.  During  convales- 
cence, iron  and  arsenic  should  be  freely  used. 


SECTION  III. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


I.  DISEASES  OF  THE  MOUTH. 


STOMATITIS. 

(1)  Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  tlie  com- 
monest form  of  inflammation  of  the  mouth,  results  from  the  action  of 
irritiuits  of  various  sorts.  It  is  frequent  at  all  ages.  In  children  it  is 
ifU'Ti  associated  with  dentition  and  with  gastro-intestinal  disturbance, 
particularly  in  ill-nourished,  unhealthy  subjects.  .  In  adults  it  follows  the 
ovornse  of  tobacco  and  the  use  of  too  hot  or  too  highly  seasoned  food.  It 
U  a  frequent  concomitant  of  indigestion,  and  is  met  with  in  the  acute  spe- 
fific  fevers. 

The  affection  may  be  limited  to  the  gums  and  lips  or  may  extend  over 
tlu!  whole  surface  of  the  mouth  and  include  the  tongue.  There  is  at  first 
su])prficial  redness  and  dryness  of  the  membrane,  followed  by  increased 
socrction  and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the 
teeth.  'J'here  is  rarely  any  constitutional  disturbance,  but  in  children 
there  may  l)e  slight  elevation  of  temperature.  The  condition  is  sufficient 
to  cause  consiilcrablo  discomfort,  sometimes  amounting  to  actual  distress 
and  pain,  p;u'ticularly  in  mastication. 

Ill  infants  the  mouth  should  be  carefully  sponged  after  each  feeding. 
A  month-wash  of  borax  or  the  glycerine  of  borax  may  be  used,  and  in  se- 
vere cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of 
silver  (three  or  four  grains  to  the  ounce)  may  be  applied. 

i'i)  Aphthous  Stomatitis. — This  form,  also  knovfnas  folh'riilnr  or  ve- 
vi'ular  stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised 
f^pots,  from  two  to  four  millimetres  in  diameter,  surrounded  by  reddened 
areola;.  The  spots  appear  first  as  vesicles,  which  rupture,  leaving  small 
ulcers  with  grayish  bases  and  bright-red  margins.  They  are  seen  most 
fre'inently  on  the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and 
tile  cheeks.  They  are  seldom  present  on  the  mucous  membrane  of  the 
pliarynx.  This  form  is  met  with  most  often  in  children  under  three  years. 
It  may  occur  either  as  an  independent  affection  or  in  association  with  any 


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DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


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one  of  the  febrile  diseases  of  cliildhood  or  with  an  attack  of  indigestion. 
Tlic  crop  of  vesicles  conies  out  with  great  rapidity  and  the  little  ulcere 
may  bo  fully  formed  within  twenty-four  hours,  '.riio  child  complaiuH  of 
soreness  of  the  mouth  and  takes  food  with  reluctance.  The  buccal  .secre- 
tions are  increased,  and  the  breath  is  heavy,  but  not  foul.  The  constitu- 
tional sym])toms  are  usually  those  of  the  disease  with  which  the  aphllia' 
are  associated.  Tlio  disease  must  not  bo  confounded  with  thrush.  Xo 
Ljpecial  parasite  has  been  found  in  connection  witli  it.  It  is  not  a  seriouH 
condition,  and  heals  rapidly  with  tho  improvement  of  the  constitutional 
state.  In  severe  cases  it  nuiy  extend  to  the  pillars  of  the  fauces  and  to 
the  pharynx,  and  produce  ulcers  which  are  irritating  and  diflicult  to 
heal. 

Each  ulcer  should  be  touched  with  nitrate  of  silver  and  tho  moutli 
should  be  thoroughly  cleansed  after  taking  food.  A  wash  of  (ihloiute  of 
potash,  or  of  borax  and  glycerine,  may  be  used.  Tho  constitutional  symp- 
toms should  receive  careful  attention. 

(3)  Ulcerative  Stomatitis. — This  form,  which  is  also  known  by  tho 
names  of  fetid  sloinaiilis,  or  putrid  sore  mouth,  occurs  particularly  in 
children  after  the  first  dentition.  It  may  prevail  as  a  wide-spread  epi- 
demic in  institutions  iu  which  the  sanitary  conditions  are  defective.  It 
has  been  met  with  in  jails  and  camps.  Insufficient  and  unwholesome 
food,  improper  ventilation,  and  prolonged  damp,  cold  weather  seem  to 
be  special  predisposing  causes.  Lack  of  cleanliness  of  the  mouth,  tlic 
presence  of  carious  teeth,  and  the  collection  of  tartar  around  them  favor 
the  development  of  the  disease.  The  affection  spreads  like  a  specific  dis- 
ease, but  the  microbe  has  not  yet  been  isolated.  It  has  been  held  that 
the  disease  is  the  same  as  the  foot-and-mouth  disea'se  of  cattle,  and  that 
it  is  conveyed  by  tho  milk,  but  there  is  no  positive  evidence  on  these 
points.  Payne  suggests  that  the  virus  is  identical  with  that  of  conta- 
gious impetigo. 

The  morbid  process  begins  at  tho  margin  of  the  gnms,  which  beconio 
swollen  and  red,  and  bleed  readily.  Ulcers  form,  the  bases  of  which  are 
covered  with  a  grayish-white,  firmly  adherent  membrane.  In  severe  cases 
the  teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may 
occur.  Tho  ulcers  extend  along  the  gum-line  of  the  upper  and  lower 
jaws;  the  tongue,  lips,  aiul  mucosa  of  the  cheeks  are  usually  swollen,  l)iit 
rarely  ulcerated.  There  is  salivation,  the  breath  is  foul,  and  mastication 
is  painful.  The  submaxillary  lymph  glands  are  enlarged.  The  constitu- 
tional symptoms  are  often  severe,  and  in  institutions  deatii  sometimes  re- 
sults in  the  case  of  debilitated  children. 

In  the  treatment  of  this  form  of  stomatitis  chlorate  of  potash  has 
been  found  to  be  almost  specific.  It  should  be  given  in  doses  of  ten 
grains,  three  times  a  day,  to  a  child,  and  to  an  adult  double  that  amount. 
Locally  it  may  bo  used  as  a  mouth-wash,  or  the  powdered  salt  may  he  ap- 
plied directly  to  the  ulcerated  surfaces.     When  there  is  much  fetor  a 


STOMATITIS. 


ass 


porm.anjjaimto-of-potash  wasli  may  be  used,  and  an  application  of  nitrate 
of  silver  nuiy  bo  made  to  tlio  ulcers. 

There  are  several  other  varieties  of  ulcerative  soro  mouth,  which  difTor 
entirely  from  this  form.  Ulcers  of  the  mouth  are  common  in  nursing 
women,  and  are  usually  seen  on  the  mucous  membianc  of  the  lijjs  and 
cheeks.  They  develop  from  the  mucous  follicles,  and  are  from  three  to 
five  millimetres  in  diameter.  They  may  cause  little  or  no  inconvenience  ; 
l)ut  in  some  instances  they  are  very  painful  and  interfere  seriously  with  the 
takiuj:;  of  food  and  its  mastication.  As  a  rule  they  heal  readily  after  the 
iili|)lication  of  nitrate  of  silver,  and  the  condition  is  an  indication  for 
tonics,  fresh  air,  and  a  better  diet. 

Parrot  describes  the  occasional  appearance  in  the  new-born  of  small 
ulcers  symmetrically  placed  on  the  hard  palate  on  either  side  of  the  mid- 
dle line.  They  are  met  with  in  very  debilitated  children.  The  ulcers 
rarely  heal ;  usually  they  tend  to  increase  in  size,  and  may  involve  the 
bf)iie. 

(4)  Parasitic  Stomatitis  {Thrush;  Soar;  Mnguct). — This  affection, 
most  eonimonly  seen  in  children,  is  dependent  upon  a  fungus,  the  sac- 
rh(iroin>/ces  albicans,  called  by  Robin  the  o'idinm  albicans.  It  belongs  to 
the  order  of  yeast  fungi,  and  consists  of  branching  filaments,  from  the  ends 
of  which  ovoid  torula  cells  develop.  The  disease  does  not  arise  appar- 
ently in  a  normal  mucosa.  The  use  of  an  improper  diet,  uncleanliness  of 
the  mouth,  the  acid  fermentation  of  remnants  of  food,  or  the  development, 
fnini  any  cause,  of  catarrhal  stomatitis  predispose  to  the  growth  of  the 
fungus.  In  institutions  it  is  frequently  transmitted  by  unclean  feeding- 
bottles,  spoons,  etc.  It  is  not  confined  to  children,  but  is  met  with  in 
iidults  in  the  final  stages  of  fever,  in  chronic  tuberculosis,  diabetes,  and  in 
caclieetic  states.  The  parasite  develops  in  the  upper  layers  of  the  mucosa, 
and  the  filaments  form  a  dense  felt-work  among  the  epithelial  cells.  The 
disease  begins  on  the  tongue  and  is  seen  in  the  form  of  slightly  raised, 
pearly-white  spots,  which  increase  in  size  and  gradually  coalesce.  The 
nitiinhrane  thus  formed  can  be  readily  scraped  off,  leaving  an  intact  mu- 
cosa, or,  if  the  process  extends  deeply,  a  bleeding,  slightly  ulcerated  sur- 
face The  disease  spreads  to  the  cheeks,  lips,  and  hard  palate,  and  may 
involve  the  tonsils  and  pharynx.  In  very  severe  cases  the  entire  buccal 
mucosa  is  covered  by  the  grayish-Avhitc  membrane.  It  may  even  extend 
into  the  o'sophagus  and,  according  to  Parrot,  to  the  stomach  and  caecum. 
It  is  occasionally  met  with  on  the  vocal  cords.  Robust,  well-nourished 
children  are  sometimes  aiTected,  but  it  is  usually  met  Avith  in  enfeebled, 
emaciated  infants  with  digestive  or  intestinal  troubles.  In  such  cases  the 
disease  may  persist  for  months. 

'I'he  affection  is  readily  recognized,  and  must  not  be  confounded  with 
aphthous  stomatitis,  in  which  the  ulcers,  preceded  by  the  formation  of 
vesicles,  are  perfectly  distinctive.     In  thrush  the  microscopical  examina- 


-■''   V!  .     ' 


>''*t'EJ  ^i-j^ 


326 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tion  hIiows  tho  proscnco  of  the  characteristic  fiingiiH  tlirougliout  the  nu-in- 
bruno.  In  tliis  eoiKJition,  too,  the  moutli  is  usually  dry — a  striking  contrast 
to  the  salivation  accompanying  aphthie. 

Thrusli  is  more  readily  prevented  than  removed.  Tho  child's  moutli 
should  he  kept  8(;riipulously  el<?an,  and,  if  artificially  fed,  the  botlji'-! 
should  he  thoroughly  sterilized.  Lime-water  or  any  other  alkiiline  fluid, 
such  as  the  bicarbonate  of  soda  (a  drachm  to  a  tumbler  of  water),  may  l>c 
cm{>loycd.  When  the  patches  are  present  these  alkaline  mouth-waslics 
may  be  cojitinued  after  each  feeding.  A  spray  of  borax  or  of  sulpliito 
of  soda  (a  drachm  to  the  ounce)  or  the  black  wash  with  glycerine  may 
be  employed.  The  pernuinganate  of  potassium  is  also  useful.  The  c(m- 
stitutional  treatment  is  of  equal  importance,  and  it  will  often  be  found 
that  the  thrush  })ersists,  in  spite  of  all  local  measures,  until  the  gencnil 
health  of  the  infant  is  improved  by  change  of  air  or  the  relief  of  the  diar- 
rhcca,  or,  in  obstinate  cases,  the  substitution  of  a  natural  for  the  artiiiciul 
diet. 

(5)  Gangrenous  Stomatitis  {Cancrnm  Oris;  Xotnn). — An  alToction 
characterized  by  a  rapidly  progressing  gangrene,  starting  on  tho  gums  or 
cheeks,  and  leading  to  extensive  sloughing  and  destruction.  This  terrible 
but  fortunately  rare  disease  is  seen  only  in  children  under  very  insanitary 
conditions  or  during  convalescence  from  the  acute  fevers.  It  is  more 
common  in  girls  than  in  boys.  It  is  met  with  between  the  ages  of  two 
and  five  years.  In  at  least  one  half  of  the  cases  the  disease  has  develojiod 
during  convalescence  from  measles.  Cases  have  been  seen  also  after  scar- 
let fever  and  typhoid.  The  mucous  membrane  is  first  affected,  usually  of 
tho  gums  or  of  one  cheek.  It  begins  insidiously,  and  when  first  seen  there 
is  a  sloughing  ulcer  of  the  mucous  membrane,  which-  si)reads  rapidly  and 
leads  to  brawny  induration  of  the  skin  and  adjacent  parts.  The  sloughing 
extends,  and  in  severe  cases  the  cheek  is  perforated.  The  disease  may  spread 
to  the  tongue  and  chin ;  it  may  invade  the  bones  of  the  jaws  and  even  in- 
volve the  eyelids  and  ears.  In  mild  cases  an  ulcer  forms  on  the  inner 
surface  of  the  cheek,  which  heals  or  may  perforate  and  leave  a  fistulous 
opening.  Naturally  in  such  a  severe  affection  the  constitutional  disturb- 
ance is  very  great,  the  pulse  is  rapid,  the  prostration  extren:  %  and  death 
usually  takes  place  within  a  week  or  ten  days.  The  temperature  may  reach 
lO'J"  01  104°.  Diarrhoea  is  usually  present,  and  aspiration  pneumonia 
often  develops.  II.  R.  Wharton  has  described  a  case  in  which  there  Mas 
extensive  colitis.  Lingard  has  found  in  cases  of  noma  a  thread-like 
bacillus,  but  its  precise  relation  to  the  disease  is  doubtful.  Tho  highly 
refractive  bodies  described  by  Sansom  in  the  blood  were  probably  blood- 
plates. 

The  treatment  of  the  disease  is  unsatisi  actory.  In  many  cases  tlu' 
onset  is  so  insidious  that  there  is  an  extensive  sloughing  sore  when  the  case 
first  comes  under  observation.  Destruction  of  the  sore  by  the  can  lory, 
either  tho  Paqueliu  or  fuming  nitric  acid,  is  the  most  effectual.     Antisep- 


STOMATITIS. 


327 


tio  applioiitions  should  bo  made  to  di'Htroy  tho  fi'tor.    The  child  shouUl 
111'  ciirefiiUy  nourinhed  uiid  stirrmhmts  given  fri'i'ly. 

((>)  Mercurial  Stomatitis  {/'/i/alism). — An  inllammation  of  lh(!  rnoutli 
and  salivary  glands  caust'd  by  niurcury,  which  occurs  chictly  in  persons  who 
have  a  special  Busceptil)ility,  and  rarely  now  as  a  result  of  the  excessive 
use  of  the  drug.  It  is  met  with  also  in  persons  whose  occupation  neces- 
sitates the  constant  handling  of  mercury.  It  often  follows  the  adminis- 
tration of  repeated  small  doses.  Thus,  a  patient  with  heart  disease  who 
was  ordered  an  eighth  of  a  grain  of  calomel  every  three  hours  for  diu- 
retic purposes  had,  after  taking  eiglit  or  ten  doses,  a  severe  stomatitis, 
which  persisted  for  several  weeks.  1  have  known  it  to  follow  also  the  admin- 
istration of  small  doses  of  gray  powder.  'J'he  ])atient  complains  lirst  of  a 
nu'tallic  taste  in  the  mouth,  the  gums  become  swollen,  red,  and  sore,  mas- 
tication is  ditlicult,  and  soon  there  is  a  great  ijicrease  in  the  secretion  of 
the  saliva,  which  ilows  freely  from  the  mouth.  The  tongue  is  swollen, 
the  breath  has  a  foul  odor,  and,  if  the  alTection  progresses,  there  nuiy  be 
ulceration  of  the  mucosa,  ami,  in  rare  instances,  necrosis  of  the  jaw.  Al- 
though troublesome  and  distressing,  the  disease  is  rarely  serious,  and  re- 
covery usually  takes  place  in  a  couple  of  weeks.  Instaiu-es  in  which  the 
teeth  ])ocome  loosened  or  detached  or  in  which  the  inllamnuition  extends 
to  tlie  pharynx  and  Eustachian  tubes  are  rarely  seen  now. 

The  administration  of  mercury  should  be  suspended  so  soon  as  the 
gums  are  "touched."  Mild  cases  of  the  alfection  subside  within  u  few 
(lays  and  require  oidy  a  simple  mouth-wash.  In  severer  cases  the  chlorate 
of  potash  may  be  given  internally  and  used  to  rinse  the  mouth.  The 
bowels  should  be  freely  oiiened ;  the  patient  should  take  a  hot  bath  every 
evening  and  should  drink  plentifully  of  alkaline  mineral  waters.  Atropine 
is  sometimes  serviceable,  and  may  be  given  in  doses  of  one  one  hundredth 
i)f  a  grain  twice  a  day.  lotline  is  also  recommended.  When  the  .salivation 
is  severe  and  protracted  the  patient  becomes  much  debilitated,  anaemia  de- 
velops, and  a  supporting  treatment  is  indicated.  The  diet  is  necessarily 
liquid,  for  the  patient  finds  the  chief  difficulty  in  taking  food.  If  the  pain 
is  severe  a  Dover  powder  may  be  given  at  night. 

Here  may  be  appropriately  mentioned  the  influence  of  stomatitis,  par- 
ticularly the  mercurial  form,  upon  the  develoj)ing  teeth  of  children.  'J'he 
coiulition  known  as  erosion,  in  whicli  the  teeth  are  honeycombed  or 
liitttil  owing  to  defective  fornuition  of  enamel,  is  indicative  as  a  rule  of 
infantile  stomatitis.  Such  teeth  must  be  distinguished  carefully  from 
tliose  of  congenital  syphilis,  which  may  of  course  coexist,  but  the  two 
eouditions  are  distinct.  The  honeycombing  is  frequently  seen  on  the 
UKisors;  but,  according  to  Jonathan  Hutchinson,  the  test  teeth  of  infan- 
tile stomatitis  are  the  first  permanent  molars,  then  the  incisors, "  which  are 
almost  as  constantly  pitted,  eroded,  and  of  bad  color,  often  showing  the 
transverse  furrow  which  crosses  all  tlie  teeth  at  the  same  level."  Magitot 
regards  these  transverse  furrows  as  the  result  of  infantile  convulsions  or 


t 


ill'     i 


14 


m.v^''immnmm 


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328 


DISEASKS  OF  THE    DIGESTIVE  SYSTEM. 


of  severe  illncHses  duriiif^  eiirly  life.     He  thinks  they  are  analogous  to  the 
furrows  on  the  nails  which  so  often  follow  u  serious  disease. 


■IS,/ 


II.  DISEASES  OF  THE  SALIVARY  GLANDS. 

1.  Hypersecretion  {Pfi/nlism). — The  normal  amount  of  saliva  varies 
from  two  to  three  pints  in  the  twenty-four  hours.  The  seeretioi  is  in- 
creased during  tlie  taking  of  food  and  in  the  physiological  processes  of 
dentition.  A  great  iiu-rease,  to  which  the  term  pfydl ism  is  applied,  is  met 
with  under  numy  circumstances.  It  occurs  occasionally  in  mental  and 
nervous  affections  and  in  rahies.  Occasionally  it  is  seen  in  the  acute 
fevers,  particularly  in  small-pox.  It  has  been  met  with  during  gestation, 
usually  early,  tlK)Ugh  it  nuiy  persist  througliout  the  entire  course.  It  lias 
been  known  to  occur  at  each  menstrual  period ;  aiul,  lastly,  it  is  a  com- 
mon etfect  of  certain  drugs.  Mercury,  gold,  co])j)er,  the  iodine  com- 
pounds, and  (among  vegetable  remedies)  jaborandi,  muscarin,  and  tobacco 
excite  the  salivary  secretion.  Of  these  we  most  frequently  see  the  ctTcct 
of  mercury  in  producing  ptyalism.  The  salivation  may  be  i)resent  with- 
out any  inllamnuition  of  the  mouth. 

2.  Xerostomia  {Arrest  of  the  Salivary  and  Buccal  Secretions ;  Dry 
Month). — In  this  condition,  first  described  by  Jonathan  Hutchinson,  the 
secretions  of  the  mouth  and  salivary  glands  are  suppressec'  'i'lie  tongue 
is  red,  sometimes  cracked,  ami  (juitedry;  the  mucous  memt  ;aiie  of  the 
cheeks  and  of  the  palate  is  smooth,  shining,  and  dry;  and  mastication, 
deglutition,  and  arti(!ulation  are  very  difficult.  The  condition  is  not  com- 
mon. A  majority  of  the  cases  are  in  women,  and  in  several  instances  have 
been  associated  with  nervous  phenomeiui.  The  general  health,  as  a  rule, 
is  unimpaired.  Iladden  suggests  that  it  is  due  to  involvement  of  soinc 
centre  which  controls  the  secretion  of  the  salivary  and  buccal  glands.  A 
well-marked  case  came  under  my  observation  in  a  man  aged  thirty-two, 
who  was  sent  to  me  by  Donald  Baynes  on  account  of  a  peculiar  growth 
along  the  gums.  This  proved  to  be  the  remnants  of  food  which,  owing  to 
the  absence  of  any  salivary  or  buccal  secretions,  collected  along  the  gums, 
became  hardened,  and  adhered  to  them.  The  condition  lasted  for  three 
weeks,  and  was  cured  by  the  f^alvanic  current.* 

3.  Inflammation  of  the  Salivary  Glands. 
{a)  Specific  Parotitis.     (See  Mumps.) 

{b)  Symptomatic  parotitis  or  parotid  btibo  occurs: 

(1)  In  the  course  of  the  infectious  fevers— typhus,  typhoid,  pneumo- 
nia, pyaemia,  etc.  In  ordinary  practice  it  occurs  of  tenest,  perhaps,  in  typhoid 
fever.    It  is  the  result  either  of  septic  infection  through  the  blood,  or  the  in- 

*  Canada  Medical  and  Surgical  Journal,  vol.  v,  p.  4^9,  1877. 


Mlii,  i^ 


DISEASES  OF  THE   rilAIlYNX. 


320 


fliiiiimation,  in  many  casoa,  passes  wyt  tlie  salivary  duct  ami  so  roaches  tho 
gliind.  Tho  process  is  usually  very  intense  and  leud-s  rapidly  to  suppura- 
tion.    It  is,  as  a  rule,  an  unfavorable  indication  in  the  course  of  a  fever. 

(2)  In  connection  with  injury  or  disease  of  the  abdonuni  or  pelvis,  a 
condition  to  which  Stephen  Pa<]fet  has  called  special  attention.  Of  101 
ciiscs  of  ihh  kind,  "  10  followed  injury  or  disease  of  the  uriiuiry  tract, 
18  were  due  to  injury  or  disease  of  the  alimentary  canal,  and  '^'.]  were  duo 
to  injury  or  disease  of  the  abdominal  wall,  tho  ])eritona!um,  or  the  pelvic 
cellular  tissue.  Tho  remaining  50  were  duo  to  injury,  disease,  or  tempo- 
rary derangement  of  tho  genital  organs."  By  teni])()rary  derangement  is 
meant  slight  injuries  or  natural  jjroccsses — a  slight  blow  on  the  testis,  the 
introduction  of  a  pessary,  menstruation,  or  j»regna!icy.  lie  states  that 
this  form  of  parotitis  is  not,  as  a  rule,  associated  with  signs  of  eepticwmia 
or  pyfpwiia.  It  may  occur  in  connection  with  gastric  ulcer.  Of  tho  101 
casos  37  died,  tho  majority  of  them  not  from  the  jjarotitis,  but  from  the 
primary  lesion  with  which  it  was  associated.  After  an  operation  it  occurs 
usually  within  tho  first  week,  often  on  tho  seventh  day.  There  may  bo 
pyrexia,  but  many  cases  are  afebrile.  One  gland  is  usually  attacked,  but 
both  may  bo  involved.  In  78  cases  in  which  tiio  termination  was  noted 
45  suppurated  and  33  resolved  without  suppuration.  Tho  etiology  of  this 
form  of  parotitis  is  obscure.     Many  of  tho  cases  are  undoubtedly  septic. 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  described  by  Gowors. 

In  tho  treatment  of  parotid  bubo  the  application  of  half  a  dozen 
leeches  will  sometimes  reduce  tho  inflammation  and  promote  resolution. 
When  suppuration  seems  inevitable  hot  fomentations  should  be  applied. 
A  free  incision  should  bo  made  early. 


I 


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li 


HI.  DISEASES  OF  THE  PHARYNX. 

(1)  Circulatory  Disturbances. — («)  Hypcrcemia  is  a  common  condition 
ill  acute  and  chronic  affections  of  tho  throat,  and  is  frequently  seen  as  a 
result  of  the  irritation  of  tobacco  smoke.  Venous  stasis  is  seen  in  valvular 
disease  of  the  heart,  and  in  mechanical  obstruction  of  the  superior  vena 
cava  by  tumor  or  aneurism.  In  aortic  insufficiency  tho  capillary  pulse 
may  sometimes  be  seen  and  the  intense  throbbing  of  the  internal  carotid 
may  bo  mistaken  for  aneurism. 

{h)  Ilwmorrhage  is  found  in  association  with  bleeding  from  other 
mucous  surfaces,  or  it  is  due  to  local  causes  in  tho  pharynx  itself.  In 
the  latter  case  it  may  be  mistaken  for  haemorrhage  from  the  lungs  or 
stoinaoh.  The  bleeding  may  come  from  granulations  or  vegetations  in 
the  naso-pharynx.  Sometimes  tho  patient  finds  the  pillow  stained  in  tho 
moruiug  with  bloody  secretion.     Tho  condition  is  rarely  serious,  and  only 


Ill 


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330 


DISEASES  OP  TUK  DIGESTIVE  SYSTEM. 


it  I 
»-■»■( 

i*g..*i  , 


requires  suitaMo  local  treatment  of  the  pharynx.  Occasionally  a  hajmor- 
rhago  takes  place  into  the  mucosa,  producing  a  pharyngeal  ha3matoma.  I 
have  thrice  seen  a  condition  of  the  uvula  resembling  hainiorrhagic  infarc- 
tion. One  was  in  a  ])atient  with  acute  rheumatism,  to  whom  largo  doses 
of  salicylic  acid  had  been  given ;  the  other  two  were  instances  of  peliosis 
rheumatica,  in  both  of  which  partial  sloughing  of  the  uvula  took  place. 

(<•)  O'Jdcmn. — An  infiltrated  anlematous  condition  of  the  uvula  and 
adjacent  i)arts  is  ii'>t  very  iinconimon  in  conditions  of  debility,  in  pro- 
found ana?niia,  and  in  Bright's  disease.  The  uvula  is  sometimes  from  this 
cause  enormously  enlarged,  and  may  lead  to  didiculty  in  swallowing  or  in 
breathing. 

(2)  Acute  Pharyngitis  {Sore.  Throat;  Angina  Simplex). — The  entire 
pharyngeal  structures,  often  with  the  tonsils,  arc  involved.  The  condi- 
tion may  follow  cold  or  exposure.  In  other  instances  it  is  associated  with 
constitutional  states,  such  as  rheumatism  or  gout,  or  with  digestive  dis- 
orders. The  patient  complains  of  uneasiness  and  soreness  in  swallowing, 
of  a  feeling  of  tickling  and  dryness  in  the  throat,  together  Avith  a  con- 
stant desire  to  hawk  and  cough.  Frequently  the  ir  flammation  extends 
into  the  larynx  and  produces  hoarseness.  Not  uncommonly  it  is  only 
part  of  a  geiu'ral  naso-pharyngeal  catarrh.  The  process  may  pass  into 
the  Eustachian  tubes  and  cause  slight  deafness.  There  is  stiffness  (f 
the  neck,  the  lymph  glands  of  Avhich  may  be  enlarged  and  painful.  Th  • 
constitutional  synqitoms  are  rarely  severe.  The  disease  sets  in  witli  a 
chilly  feeling  and  slight  fever,  and  the  pulse  is  increased  in  frequency. 
Occasionally  the  febrile  symptoms  are  more  se\ere,  particularly  if  the 
tonsils  are  specially  involved.  The  examination  of  the  throat  shows  gen- 
eral congestion  of  the  mucous  membrane,  Avhi-h  is  dry  and  glistening, 
and  in  places  covered  wijth  sticky  secretion.  The  uvula  may  be  much 
swollen. 

Acute  pharyngitis  lasts  only  a  few  days  and  requires  mild  measures. 
If  the  tonsils  are  involved  and  tlie  fevor  is  high,  aconite  or  sodium  salic\  lute 
may  be  given.  fJuaiacum  also  is  beneficial;  but  in  a  Piajority  of  the 
cases  a  calomel  purge  or  a  saline  aperient  and  inhalations  with  steam 
meet  the  indications. 

(3)  Chronic  PharyT»gitis. — This  may  follow  repeated  acute  attacks.  It 
is  very  common  in  persons  who  snioko  or  drink  to  excess,  and  in  thoFO 
who  use  the  voice  very  i-iuch,  such  as  clergymen,  hucksters,  and  otl'.er3. 
It  is  frequently  met  witi.  in  chronic  nasal  catarrh.  The  naso-])harynx 
and  the  posterior  wall  are  *ho  parts  most  frequf^ntly  affected.  Tho 
mucoiis  membrane  in  relaxed,  the  venules  are  dilated,  and  roundish 
bodies,  from  two  to  four  millimetres  in  diameter,  reddish  in  color,  pro- 
ject to  a  variable  distance  beyond  tho  mucous  membrane.  These  repro- 
Bont  the  j)roliferations  of  lymph  tissue  about  i,he  mucous  glands.  Tlioy 
may  be  very  abundant,  forming  elongated  rows  in  tho  lateral  walls 
of  <hc  pliarynx.    AVith  this  there  mLy  bo  a  dry  glistening  etate  of  tho 


DISEASES  OF  THE  PHAIIYNX. 


89rt 


]ihiiryngpal  mucosa,  sometimes  known  as  phary7igilis  sicca.  The  pillars 
of  the  fauces,  and  the  uvula  are  often  much  relaxed.  The  secretion 
forms  at  the  back  of  the  pharynx  and  the  patient  may  feel  it  drop  down 
from  the  vault,  or  it  is  tenacious  and  adherent,  and  is  only  removed  by  re- 
]H'atcd  efforts  at  hawking. 

In  the  ireafment,  special  attention  must  be  paid  to  tlvo  general  health. 
If  possible,  the  cause  should  be  ascertained.  The  condition  is  almost 
constant  in  smokers,  and  cannot  be  cured  without  stopping  the  use  of 
tobacco.  The  use  of  food  either  too  hot  or  too  much  spiced  should  be  for- 
liiiUlen.  "When  it  depends  upon  excessive  exercise  of  the  voice,  rest  should 
l)t'  oiijoined.  In  many  of  these  cases  change  of  air  and  tonics  help  very 
iiuu'h.  In  the  local  treatment  of  the  throat  gargles,  washes,  and  pastilles 
(if  various  sorts  give  temporary  relief,  but  when  the  hypertrophic  condi- 
lioh  is  miirked  the  spots  should  be  thoroughly  destroyed  by  the  galvano- 
cuutcry.  In  many  instances  this  affords  great  and  ])ermanent  relief,  but 
in  others  the  condition  persists,  and  as  it  is  not  unbearable,  the  patient 
gives  up  all  hope  of  permanent  relief. 

(4)  niceratlon  of  the  Pharynx. — (a)  Follicular.  The  ulcers  are  usu- 
ally small,  superficial,  and  generally  associated  with  chronic  catarrh. 

(h)  Syphilitic  ulcers  are  usually  painless,  and  most  frequently  situated 
on  tlic  posterior  wall  of  the  i)haryiix.  They  occur  in  the  secondary  stage 
as  small,  shallow  excavations  with  the  mucous  patches.  In  the  tertiary 
stage  the  ulcers  are  due  to  erosion  of  gummata,  and  in  healing  they  leave 
whitish  cicatri'   s. 

{(■)  'J'uberculous  ulceration  is  not  very  uncommon  in  advanced  cases 
of  plitlu.-is,  and,  if  extensive,  is  one  of  the  most  distressing  features  of  the 
later  stages  of  the  disease.  The  ulcers  are  irregular,  with  ill-defined  edges 
and  grayish-yellow  bases.  The  posterior  wall  of  the  pharynx  may  have  an 
(Todi'd,  worm-eaten  appearance.  Those  ulcers  arc,  as  a  rule,  intensely 
painful. 

{(I)  Ulcers  occur  in  connection  with  pseudo-membranous  inflamma- 
tion, i)articularly  the  diphtheritic.  In  cancer  and  in  lupus  ulcers  are  also 
present. 

(' )  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typhoid. 
In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is 
vo  ,  (liflicult.  The  tuberculous  and  cancerous  varieties  are  readily  recog- 
iiiz.  1,  bnt  it  liappens  not  infrequently  that  a  doubt  arises  as  to  the 
syphilitic  character  of  an  ulcer.  In  many  instances  the  local  condi- 
tions may  be  uncertain.  Then  other  evidences  of  syphilis  should  be 
Roug^u  for,  and  the  patie  it  should  bo  placed  on  mercury  and  iodide  of 
pota,s,-:iiim,  under  which  remedies  syphilitic  ulcers  usually  heal  with  great 
I'apitlity. 

(■')  Acute  Infectious  Phlegmon  of  the  Pharynx.— Under  this  term 
i^onator  has  described  cases  in  which,  along  with  ditticulty  in  swallowing, 
soreness  of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the 


a 


il 


332 


x^SEASES  OB'  THE  DIGESTIVE  SYSTEM. 


Ill  M    *'" 


pharyngeal  mucosa  becomes  swollen  and  injected,  tlio  fever  is  high,  the 
constitutional  symptoms  are  severe,  and  the  inflammation  passes  on  rap- 
idly to  suppuration.  The  symptoms  are  very  intense.  The  swelling  of  tlio 
pharyngeal  tissues  early  reaches  such  a  grade  as  to  impede  respiration. 
Very  similar  symptoms  may  bo  produced  by  the  lodgment  of  foreign 
bodies  in  the  i)harynx. 

(6)  Retro-pharyngeal  Abscess. — This  may  occur  as  a  sequel  to  one  of 
the  fevers,  but  more  commonly  results  from  caries  of  the  cervical  vertebrae. 
It  is  accompanied  with  pain  in  swallowing,  sometimes  with  cough,  dysp- 
noea, and  alterations  in  the  character  of  the  voice. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  bo  seen,  and 
felt  with  the  finger  on  the  posterior  wall  of  the  pharynx. 

(7)  Angina  Ludovici  {Ludwig^s  Anffina;  CeUulitis  of  the  Kcrl').—h\ 
medical  practice  this  is  seen  as  a  secondary  inflammation  in  tlio  spooific 
fevers,  particularly  diphtheria  and  scarlet  fever.  It  may,  however,  occur 
idiopathieally  or  result  from  trauma.  It  is  probably  always  a  streptococ- 
cus infection  which  spreads  rapidly  from  the  glands.  The  swelling  at  first 
is  most  marked  in  the  submaxiUary  region  of  one  side.  The  symptoms 
are,  as  a  rule,  intense,  and,  unless  early  and  thorough  surgical  measures  ara 
employed,  there  is  great  risk  of  systemic  infection. 


IV.  DISEASES  OF  THE  TONSILS. 

Apart  from  the  affection  of  these  glands  already  described  in  connec- 
tion with  diphtheria,  scarlet  fever,  and  syphilis,  an  acute  and  a  chronic 
tonsillitis  may  be  recognized. 

ACUTE  TONSILLITIS. 

(1)  Follicular  or  Lacunar  Tonsillitis. — For  practical  purposes,  under 
this  name  may  be  described  the  various  forms  which  have  been  called  ca- 
tarrhal, erythematous,  ulcero-membranous,  and  lieri)etic. 

Etiology. — The  disease  is  met  with  most  frequently  in  young  per- 
sons, but  in  children  under  ten  it  is  less  common  than  the  chronic  form. 
It  is  rare  in  infants.  Sox  has  no  special  influence.  Exposure  to  wot  and 
cold,  and  bad  hygienic  surroundings  appear  to  liavo  a  direct  etiologioul 
connection  with  the  disease.  In  so  many  instances  defective  drainage  lias 
been  found  associated  with  outbreaks  of  follicular  tonsillitis  tluit  scwcr-gas 
is  regarded  as  a  common  exciting  cause.  One  attack  renders  a  i)atieiit 
more  liable  to  sul)sequent  infection.  Special  stress  is  laid  by  some  writers 
upon  the  coexistence  of  tonsillitis  with  rheumatism.  Cheadle  doscrilx's  it 
as  one  of  the  phases  of  rheumatism  in  childhood  with  which  articular  at- 
tacks may  alternate.     I  cannot  say  that,  in  my  experience,  the  conuoction 


Ml!  Hi     / 


ACUTE  TONSILLITIS. 


m 


between  the  two  affections  has  been  very  striking,  excejit  in  one  point,  viz., 
that  an  attack  of  acute  rlietimatism  is  not  infrequently  preceded  by  in- 
flammation of  the  tonsils.  The  existence  of  pains  in  the  limbs  is  no  evi- 
dence of  the  connection  of  the  affection  with  rheumatism.  A  disease  so 
connnon  and  wide-spread  as  acute  tonsillitis  necessarily  attacks  many  per- 
sons in  whose  families  rheumatism  prevails  or  who  may  themselves  have 
had  acute  attjicks. 

Mackenzie  gives  a  table  showing  that  in  four  successive  years  more 
cases  occurred  in  September  than  in  any  other  month ;  in  October  nearly 
as  many ;  with  July,  August,  and  November  next.  In  this  country  it  seems 
more  i)revalcnt  in  the  spring.  So  many  cases  develop  within  a  short  time 
that  the  disease  may  be  almost  epidemic.  It  spreads  through  a  family  in 
such  a  way  that  it  must  be  regarded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definite  relation  between  the 
tonsils  and  the  testes  and  ovaries.  F.  J.  Shepherd  has  called  attention  to 
the  circumstance  that  acute  tonsillitis  is  a  very  common  affection  in  newly 
married  persona.  That  view  is  probably  correct  which  regards  tonsillitis 
as  a  local  disease  with  severe  constitutional  manifestations,  although  tho 
fever  is  often  high  in  proportion  to  the  local  symptoms.  The  commonest 
organism  found  in  tonsillitis  is  a  streptococcus.  Staphylococci  also  occur. 
In  some  oases  organisms  closely  resembling  the  bacillus  diphiherite  of 
Loofflor  have  been  found,  but  they  do  not  seem  to  possess  tho  same  malig- 
nancy. 

Morbid  Anatomy.— The  lacunas  of  the  tonsils  become  filled  with 
exudation  products,  which  form  cheesy-looking  masses,  projecting  from 
tiie  orifices  of  the  crypts.  Not  infrequently  the  exudations  of  contiguous 
liuinia!  coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-red  in 
color,  and  may  present  herpetic  vesicles  or,  in  some  instances,  oven  mem- 
branous exudation,  in  which  case  it  may  be  difticult  to  distinguish  tho 
condition  from  diphtheria.  The  creamy  contents  of  the  crypt  are  made 
up  of  micrococci  and  epithelial  debris. 

Symptoms.— Chilly  feelings,  or  even  a  definite  chill,  and  aching 
liiiiiis  in  the  Ijack  and  linijs  may  precede  the  onset.  The  fever  rises  rap- 
idly, and  in  the  case  of  a  young  child  may  reach  U)")°  on  the  evening  of 
the  first  day.  Tho  patient  comjdains  of  soreness  of  the  throat  and  dith- 
'ulty  in  swallowing.  On  examination,  tho  tonsils  are  seen  to  be  swollen 
and  tlie  crypts  present  the  characteristic  creamy  exudate.  The  tongue  is 
the  breath  is  lieavy  and  foul,  and  the  nrine  is  highly  colored  and 


furr 


I'll 


loaded  with  urates.  In  children  the  respirations  are  usually  very  hurried, 
and  the  pulse  is  greatly  increased  in  rapidity.  Swallowing  is  painful,  and 
the  voice  often  becomes  nasal.  Slight  swelling  of  the  cervical  glands  is 
in-esent.  In  severe  cases  the  symptoms  increase  and  the  tonsils  become 
i^till  more  swollen.  The  inflammation  gradually  subsides,  and,  as  a  rule, 
\vitlun  a  week  the  fever  departs  and  the  local  symptoms  greatly  improve. 
Ihe  tonsils,  however,  remain  somewhat  swollen.     The  prostration  and 


I  !) 


mmi'^ 


334 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


I  ...  I 


M::^ 


constitutional  disturbance  are  often  out  of  jiroportion  to  tlio  intensity  of 
the  local  disease. 

There  are  complications  which  occasionally  excite  uneasiness.  Febrile 
albuminuria  is  not  uncommon,  as  Ilaig-Brown  luis  pointed  out.  Cases  of 
endo(.'arditi.s  or  pericarditis  have  been  found.  It  is  to  be  borne  in  mind 
that  in  children  an  apex  systolic  murmur  is  by  no  means  uncommon  at 
the  height  of  any  fever.  The  disease  may  extend  to  the  middle  ear. 
The  development  of  paralytic  symptoms,  local  or  general,  after  an  attack 
which  has  been  regarded  as  follicular  tonsillitis  indicates  an  error  in  diag- 
nosis. 

Diagnosis. — It  may  be  difficult  to  distinguish  follicular  tonsillitis 
from  diphtheria.  It  would  seem,  indeed,  as  if  there  were  intermediate 
forms  between  the  mildest  lacunar  and  the  severer  pseudo-membranous 
tonsillitis.  In  the  follicular  form  the  individual  yellowish-gray  masses, 
separated  by  the  reddish  tonsillar  tissue,  are  very  characteristic ;  whereas 
in  diphtheria  the  membrane  is  of  ashy  gi'ay,  and  uniform,  not  patchy.  A 
point  of  the  greatest  importance  in  diphtheria  is  that  the  membrane  is  not 
limited  to  the  tonsils,  but  creeps  up  the  pillars  of  the  fauces  or  appears  on 
the  uvula.  The  di]:)htheritic  membrane  when  removed  leaves  a  bleeding, 
eroded  surface ;  whereas  the  exudation  of  lacunar  tonsillitis  is  easily  sepa- 
rated, and  there  is  no  erosion  beneath  it.  In  all  doubtful  cases  cultures 
should,  if  possible,  be  made  to  determine  the  presence  of  Loeffler's  bacillus. 

(2)  Suppurative  Tonsillitis. 

Etiology. — This  arises  under  conditions  very  similar  to  those  men- 
tioned in  the  lacunar  form.  It  may  follow  exposure  to  cold  or  wet,  and  is 
particularly  liable  to  recur.  It  is  most  common  in  adolescence.  The  in- 
flammation is  here  more  deeply  seated.  It  involves  the  stroma,  and  tends 
to  go  on  to  suppuration. 

Symptoms. — The  constitutional  disturbance  is  very  great.  The 
temperature  rises  to  104°  or  105°,  and  the  pulse  ranges  from  110  to  130. 
Nocturnal  delirium  is  not  uncommon.  The  prostration  may  be  extreme. 
There  is  no  local  disease  of  similar  extent  which  so  rapidly  cxliausts  the 
strength  of  a  patient.  Soreness  and  dryness  of  the  throat,  with  pain  in 
swallowing,  are  the  symptoms  of  which  the  patient  first  complains.  One 
or  both  tonsils  may  be  involved.  They  are  enlarged,  firm  to  the  touch, 
dusky  red  and  oedematous,  and  the  contiguous  parts  arc  also  much  swol- 
len. The  swelling  of  the  glands  may  be  so  great  that  they  meet  in  the 
middle  line,  or  one  tonsil  may  even  push  the  uvula  aside  and  almost  touch 
the  other  gland.  The  salivary  and  buccal  secretions  are  increased.  The 
glands  of  the  neck  enlarge,  the  lower  jaw  is  fixed,  and  the  patient  is  un- 
able to  open  his  mouth.  In  from  two  to  four  days  the  enlarged  glaml 
becomes  softer,  and  fluctuation  can  be  distinctly  felt  by  placing  one  finger 
on  the  tonsil  and  the  other  at  the  angle  of  the  jaw.  The  abscess  usually 
points  toward  the  mouth,  but  it  may  point  toward  th'e  pharynx.  It  may 
burst  spontaneously,  affording  instant  and  great  relief.     Suffocation  has 


CHRONIC  TONSILLITIS. 


335 


followed  the  rupture  of  a  large  abscess  and  the  entrance  of  the  pus  into  the 
liiryux.  When  the  supj)uration  is  peritonsillar  and  extensive,  the  internal 
carotid  artery  may  be  opened  ;  but  these  are,  fortunately,  very  rare  accidents. 

Treatment. — In  the  follicular  form  aconite  may  be  given  in  full  doses. 
It  acts  very  beneficially  in  children.  The  salicylates,  given  freely  at  the 
outset,  arc  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of 
such  prompt  aiui  decisive  action.  At  night,  a  full  dose  of  Dover's  pow- 
der may  be  given.  The  use  of  guuiacum,  in  the  form  of  two-grain  loz- 
enges, is  warmly  recommended.  In^n  and  quinine  should  be  reserved 
until  the  fever  has  subsided.  A  pad  of  s])ongio-piline  or  thick  flannel 
dipped  in  ice-cold  water  may  be  applied  around  the  lu^ck  and  covered 
vith  oiled  silk.  More  convenient  still  is  a  siiuxU  ice-bag.  Locally  the 
tonsils  may  bo  treated  witli  the  dry  sodium  bicarbonate.  The  moistened 
linger-tip  is  dipped  into  the  soda,  which  is  then  rubbed  gently  on  tho 
gland  and  rejieated  every  hour.  Astringent  preparations,  such  as  iron 
and  glycerine,  alum,  zinc,  and  nitrate  of  silver,  may  be  tried.  To  cleanse 
and  disinfect  the  throat,  solutions  of  borax  or  thymol  in  glycerine  and 
water  may  bo  used. 

In  suppurative  tonsillitis  hot  applications  in  the  form  of  poultices  and 


fomentations  are 


more   comfortable  and  better  than  the  ice-bag. 


The 


gland  should  bo  felt — it  cannot  always  be  seen — from  time  to  time,  and 
should  be  opened  when  fluctuation  is  distinct.  The  progress  of  tho  dis- 
ease may  be  shortened  and  the  patient  spared  several  days  of  great  suffer- 
ing if  the  gland  is  scaritied  early.  The  curved  bistoury,  guarded  nearly 
to  the  point  with  jdaster  or  cotton,  is  tho  nu)st  satisfactory  instrument. 
The  incision  shoidd  be  nuidc  from  above  downward,  parallel  with  tho  an- 
terior pillar.  There  are  cases  in  which,  before  suppuration  takes  place, 
the  parenchy  mil  tons  swelling  is  so  great  that  the  paticsnt  is  threatened 
witli  suffocation.  In  such  instances  the  tonsil  must  cither  be  excised  or 
tracheotomy  or,  possibly,  intubation  performe<l.  Delavan  refers  to  two 
cases  in  which  ho  states  that  tracheotomy  would,  under  these  circum- 
stances, have  saved  life.  Patients  with  this  affection  require  a  nourishing 
liiiuid  diet,  and  during  convalescence  iron  in  full  doses. 


CHRONIC  TONSILLITIS. 

(Chronic  Kasii-pharynijeal  Obstruction;  Month- Breathing ;  Aprosexia.) 

Tuder  this  heading  will  be  considered  also  hypertrophy  of  tho  adenoid 
tissiu!  in  the  vault  of  the  pharynx,  sometimes  known  as  the  pharyngeal 
t'tnsil,  as  the  affection  usually  involves  both  the  tonsils  proper  and  this 
tissue,  and  the  symptoms  are  not  to  be  differentiated. 

Clironic  enlargement  of  the  tonsillar  tissues  is  an  affection  of  great  im- 
portance, and  may  influence  iu  an  extraordinary  waj  tlio  mental  and  bodily 
development  of  children. 


;  :|fgp-V  I 


,  r'-v 


4^ 


336 


DISfJASES  OP  THE  DIGESTIVE  SYSTEM. 


Etiology. — Ilypcrtroiiliy  of  the  tonsillar  Btructures  is  occasionally 
congenital.  Cases  are  perhaps  most  frequent  in  children,  during  the  third 
hemi-decade.  The  condition  also  occurr,  in  young  adults,  more  rarely  in 
the  middle-aged.  The  enlargement  may  follow  diphtheria  or  the  eruptive 
fevers.  The  frerpiency  of  the  occurrence  of  adenoid  growths  in  the  naso- 
pharynx  has  been  variously  stated.  Meyer,  to  whom  the  profession  is  in- 
debted for  calling  attention  to  the  subject,  found  them  in  about  one  per 
cent  of  the  children  in  Copenhagen,  while  Chappell  found  sixty  cases  in 
the  examination  of  two  thousand  children  in  New  York.  These  figures 
give  a  very  moderate  estimate  of  the  prevalence  of  the  trouble.  It  occurs 
eqi;ally  in  boys  and  girls,  according  to  some  writers  with  greater  preva- 
lence in  the  former. 

Morbid  Anatomy. — The  tonsils  proper  present  a  condition  of 
chronic  hypertrophy,  due  to  muUiplicatiou  of  all  the  constituents  of  the 
glands.  The  lymphoid  elements  may  be  chiefly  involved  without  much 
development  of  the  stroma.  In  other  instances  the  fd)rous  matrix  is  in- 
creased, and  the  organ  is  then  harder,  smaller,  firmer,  and  is  cut  with 
much  greater  difficulty. 

,  The  adenoid  growths,  which  spring  from  the  vault  of  the  pharynx, 
form  masses  varying  in  size  from  a  small  pea  to  an  almond.  They  may 
be  sessile,  with  broad  bases,  or  pedunculated.  They  arc  reddish  in  color, 
of  moderate  firmness,  aiul  contain  numerous  blood-vessels.  "  Abundant, 
as  a  rule,  over  the  vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube, 
the  growths  may  lie  posterior  to  the  fossa — namely,  in  the  depression 
known  as  the  fossa  of  Kosenmiillcr,  or  upon  the  parts  which  are  parallel 
to  tiio  posterior  wall  of  the  i)harynx.  The  growths  appear  to  spring  in 
the  main  from  the  nnicous  membrane  covering  the  localities  where  the 
connective  tissue  fills  in  the  inequalities  of  the  base  of  the  skull "  (Har- 
rison Allen).  The  growths  are  most  frequently  papillomatous  with  a 
lymphoid  parenchyma.  Hypertrophy  of  the  pharyngeal  adenoid  tissue 
may  be  present  without  great  enlargement  of  the  tonsils  proper.  Chronic 
catarrh  of  the  nose  usually  coexists. 

Symptoms. — The  direct  effect  of  chronic  toncillar  hypertrophy  is 
the  establishment  of  mouth-breathing.  The  indirect  effects  arc  deforma- 
tion of  the  thorax,  changes  in  the  facial  expression,  and  sometimes  marked 
alteration  in  the  mental  condition.  The  establishment  of  mouth-brciitli- 
ing  is  the  symptom  which  first  attracts  the  attention.  It  is  not  so  notiec- 
able  by  day,  although  the  child  may  present  the  vacant  expression  charac- 
teristic of  this  condition.  At  night  the  child's  sleep  is  greatly  disturbed  ; 
the  respirations  are  loud  and  snorting,  and  there  are  sometimes  prolonged 
pauses,  followed  by  deep,  noisy  inspirations.  The  child  may  wake  up  in  a 
paroxysm  of  shortness  of  breath.  Some  of  these  nocturnal  attacks  may  be 
due  to  reflex  spasm  of  the  glottis. 

When  the  mouth-breathing  has  persisted  for  a  long  time  definite 
vohangcs  are  brought  about  in  the  face,  mouth,  and  chest.     The  facies  is 


CHRONIC  TONSILLITIS. 


337 


BO  peculiar  and  distinctivo  tlmt  the  condition  may  bo  evident  at  a  glance. 
The  expression  is  dull,  heavy,  and  aimthotic,  duo  in  part  to  the  fact  that 
the  mouth  is  habitually  left  open.  In  long-standing  cases  the  child  is 
very  stupid-looking,  responds  slowly  to  questions,  and  may  be  sullen  and 
itross.  'J'he  lips  are  thick,  the  nasal  orifices  small  and  pinched-in  look- 
ing, and  in  the  mouth  the  superior  dental  arch  ia  narrowed  and  the  roof 
considerably  raise<# 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection  with 
enlarged  tonsils  were  first  studied  by  Dupuytren  and  J.  Mason  Warren. 
Tlioy  are  liable  to  be.  mistaken  for  those  of  rickets.  It  is  the  commonest 
i-ause  of  chest  deformity  in  this  country.  "  Anteriorly  the  ribs  arc  promi- 
nent, the  stermim  is  angulated  forward  at  the  nmnubrio-gladiolar  junction 
and  grooved  at  the  gladiolo-xiphoid  junction.  A  saucer-sha])ed' depres- 
sion is  often  found  at  the  lower  costal  cartilages.  The  lower  angle  of  the 
scapula  projects.  While  the  ribs  are  separated  far  from  each  other  ante- 
riorly they  are  so  closely  pressed  together  posteriorly,  especially  at  the 
lower  part  of  the  chest,  as  to  have  the  intercostal  spaces  practically  oblit- 
erated "  (Harrison  Allen).  The  jirominent  sternum  (chicken  breast) 
with  tlie  circular  depression  in  the  lateral  zones  corresponding  to  the  at- 
tachment of  the  diaphragm  are  the  most  characteristic  features.  Dur- 
ing sleep,  in  a  chronic  mouth-breather,  with  each  inspiration  the  dia- 
phragm may  be  seen  to  draw  in  the  lower  and  lateral  thoracic  regions. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation 
of  certain  letters  is  changed,  and  there  is  inability  to  pronounce  the  nasal 
consonants  n  and  m.  IMoch,  in  his  monogrsiph,*  lays  great  stress  upon 
the  association  of  mouth-breathing  with  stuttering. 

The  hearing  is  impaired,  usuady  owing  to  the  extension  of  inflamma- 
tion along  the  Eustachian  tube  and  its  obstruction  with  mucus  or  the 
narrowing  of  its  orifice  by  pressure  of  the  adenoid  vegetations.  In  some 
instances  it  may  be  due  to  retraction  of  the  drums,  as  the  upper  pharynx 
is  insuf!ioiently  supplied  with  air.  Xaturally  the  senses  of  taste  and  smell 
arc  much  impaired.  With  these  symptoms  there  may  be  little  or  no  nasal 
catarrh  or  discharge,  but  the  pharyngeal  secretion  of  mucus  is  always  in- 
creased. Children,  however,  do  not  notice  this,  as  the  mucus  is  usually 
swallowed,  but  older  persons  expectorate  it  with  ditliculty. 

Among  other  symptoms  may  be  mentioni'd  headache,  which  is  by  no 
means  uncommon,  general  listlessnesa,  and  an  indisposition  for  physical 
or  mental  exertion.  Habit-spasm  of  the  face  has  been  described  in  con- 
nection with  it.  I  have  known  several  instances  in  which  permanent 
relief  has  been  afforded  by  the  removal  of  the  adenoid  vegetations.  Enu- 
resis is  occasionally  an  associated  symptom.  The  influence  upon  the  men- 
tal development  is  striking.  Mouth-breathers  are  usually  dull,  stupid, 
and  backward.    It  is  impossible  for  them  to  fix  the  attention  for  long  at  a 

*  Die  Pathologic  und  Therapie  der  Slundathmung.    Wiesbaden,  1889. 


>X 


Ml 

1 ,  r 


m 


<i 


r   f. 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


time,  ami  to  this  impairment  of  tlio  mental  function  Ouyc,  of  Amsterdam, 
has  given  the  name  aprosexia.  Headaches,  forgetfuhiess,  inability  to 
study  witliout  discomfort,  are  frequent  symptoms  of  this  condition  in  stu- 
dents. The  i)ractitioner  must  bear  in  mind  that  all  of  these  symptoms 
may  be  found  in  connection  with  adenoid  growths  in  the  vault  of  the 
pharynx  without  especial  enlargement  of  the  tonsils,  and  that  both  in 
diagnosis  and  treatment  ])arti(nihir  attention  must  be  j^Wd  to  the  former. 

A  symptom  si)ecially  associated  witli  enlarged  tonsils  is  fetor  of  the 
breath.  In  the  tonsillar  crypts  the  inspissated  secretion  undergoes  de- 
composition and  an  odor  not  unlike  that  of  llocliefort  or  Limburger  cheese 
is  produced.  The  little  cheesy  masses  may  sometimes  be  squeezed  from 
the  crypts  of  the  tonsils.  Though  the  odor  may  not  apparently  be  very 
Btrong,  yet  if  the  mass  bo  squeezed  between  the  fingers  its  intensity  will  at 
once  be  appreciated.  In  some  cases  of  chronic  enlargement  the  cheesy 
masses  may  be  deep  in  the  tonsillar  crypts;  and  if  they  remain  for  a 
prolonged  period  lime  salts  arc  deposited  and  a  tonsillar  calculus  in  this 
way  produced. 

Children  with  enlarged  tonsils  arc  especially  prone  to  take  cold  and  to 
recurring  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  features  in  scarlet  fever  are  always  more 
serious. 

Diagnosis. — Enlarged  tonsils  are  readily  seen  on  inspection  of  the 
pharynx.  There  nuiy  be  no  great  enlargement  of  the  tonsils  and  nothing 
apparent  at  the  back  of  the  throat  even  when  the  naso-pharynx  is  com- 
pletely blocked  with  adenoid  vegetjitions.  In  children  the  rhinoscopic 
examination  is  rarely  practicable.  Digital  examination  is  the  most  satis- 
factory. The  growths  can  then  be  felt  either  as  small,  flat  bodies  or,  if 
extensive,  as  velvety,  grape-like  papillomata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evi- 
dently influenced  by  them  they  should  be  at  once  removed.  Applications 
of  iodine  and  iron,  or  pencilling  the  crypts  with  nitrate  of  silver,  are  of 
service  in  the  milder  grades,  but  it  is  waste  of  time  to  apply  them  in  very 
enlarged  glands.  There  is  a  condition  in  which  the  tonsils  are  not  much 
enlarged,  but  the  crypts  are  constantly  filled  with  cheesy  secretions  and 
cause  a  very  bad  odor  in  the  breath.  In  such  instances  the  removal  of 
the  secretion  and  thorough  pencilling  of  the  crypts  with  chromic  acid 
may  be  practised.  The  galvano-cautery  is  of  great  service  in  many  cases 
of  enlarged  tonsils  when  there  is  any  objection  to  the  more  radical  surgi- 
cal procedure. 

The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  great- 
est importance,  and  should  be  thoroughly  carried  out.  Parents  should 
be  frankly  told  that  the  affection  is  serious,  one  which  impairs  the  men- 
tal not  less  than  the  bodily  development  of  the  child.  In  spite  of  the 
thorough  ventilation  of  tlxis  subject  by  specialists,  practitioners  do  not 
appear  to  have  grasped  as  yet  the  full  importance  of  this  disease.    They 


ACUTE  lESOPIlAOITIS. 


339 


are  far  too  apt  to  temporize  and  to  postpone  unncrcssarily  radical  mcaa- 
urc3.  The  child  must  bo  etherized,  when  the  growths  can  be  removed 
either  with  the  finger-nail,  which  in  most  instances  is  sufKcient,  or  with 
u  suitable  curette.  Considerable  haemorrhage  may  follow,  but  it  is  usually 
cljecked  quickly.  The  good  effects  of  the  operation  are  often  ajjparent 
within  a  few  days,  and  the  child  begins  to  breathe  through  the  nose.  In 
some  instances  tlio  habit  of  mouth-breathing  persists.  As  soon  as  the 
child  goes  to  sleep  the  lower  jaw  drojjs  and  the  air  is  drawn  into  the 
mouth.  In  these  cases  a  chin  strap  can  bo  readily  adjusted,  which  the 
ciiild  may  wear  at  night.  In  severe  cases  it  nnvy  take  months  of  careful 
tniining  before  the  child  can  speak  jiropcrly. 

Throughout  the  entire  treatment  attention  should  bo  paid  to  hygiene 
and  diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  bo  administered 
with  benefit. 


V.  DISEASES  OF  THE  CESOPIIAGUS. 


I.  ACUTE  CESOPHAGITIS. 

Etiology. — Acute  inflammation  occurs  (a)  in  the  catarrhal  processes 
of  the  specific  fevers ;  more  rarely  as  an  extension  from  catarrh  of  the 
])h!irynx.  {b)  As  a  result  of  intense  mechanical  or  chemical  irritation, 
])r()duced  by  foreign  bodies,  by  very  hot  liquids,  or  by  strong  corrosives, 
(t)  In  the  form  of  pseudo-membranous  inflammation  in  diphtheria,  and 
occiisionally  in  pneumonia,  typhoid  fever,  and  pysBmia.  (d)  As  a  pustular 
inflammation  in  small -pox,  and,  according  to  Laennec,  as  a  result  of  a  pro- 
longed administration  of  tartar  emetic,  (e)  In  connection  with.  local  dis- 
ease, particularly  cancer  either  of  the  tube  itself  or  extension  to  it  from 
witliout.  And,  lastly,  acute  oesophagitis,  occasionally  with  ulceration,  may 
occur  spontaneously  in  sucklings. 

Morbid  Anatomy. — It  is  extremely  rare  to  see  redness  of  tho 
mucosa,  except  when  chemical  irritants  have  been  swallowed.  More  com- 
monly the  epithelium  is  thickened  and  has  desquamated,  so  that  the  sur- 
face is  covered  with  a  fine  granular  substance.  The  mucous  follicles  are 
swollen  and  occasionally  there  may  be  seen  small  erosions.  In  the  pseudo- 
membranous inflammation  there  is  a  grayish  croupous  exudate,  usually 
limited  in  extent,  at  the  upper  portion  of  tho  gullet.  This  must  not  be 
confounded  with  the  grayish-white  deposit  of  thrush  in  children.  The 
pustular  disease  is  very  rare  in  small-pox.  In  the  phlegmonous  inflamma- 
tion the  mucous  membrane  is  greatly  swollen,  and  there  is  purulent  infil- 
tratitm  in  the  submucosa.  This  may  bo  limited  as  about  a  foreign  body, 
or  extremely  diffuse.  It  may  even  extend  throughout  a  large  part  of  the 
gullet.    Gangrene  occasionally  supervenes.    Birch-IIirschfeld  describes  a 


i 


i 


■''nr^' 


340 


DISEASES  OF  THK   DIOKSTIVE  SYSTEM. 


4**    1. 1  ti 

T      ' 

1  |;|t^||]>'^ 


'   f 


■r.  ]  t"' 


remarkable  case  in  an  liyHterical  woman,  who  vomited  a  long  mcmljranous 
tube  which  })roved,  on  examination,  to  bo  the  (k-tached  ('i>itlielial  lining  of 
the  ccsoi)hagn8.  I'raetically,  in  posi-njortem  work,  tlnTc  is  no  ])ortion  f  f 
the  alimentary  canal  wliieh  more  rarely  shows  Higns  of  ilisease. 

Symptoms. — I*ain  in  deglutition  is  always  jiresent  in  severe  inllain- 
mation  of  the  uisojdiagua,  and  in  the  form  which  follows  the  swallowing 
of  strong  irritants  may  prevent  the  talking  of  food.  A  dull  pain  beneath 
the  sternum  is  also  present.  In  the  milder  forms  of  catarrhal  inllamnia- 
tion  there  arc  usually  no  sym[)toms.  The  })resencc  of  a  foreign  body  is 
indicated  by  dysphagia  luul  spasm  with  the  regurgitation  of  portions  of 
the  food.  Later,  blood  and  jjus  may  be  ejected.  It  is  surprising  how  ex- 
tensive the  diseas(^  nuiy  be  in  the  (esophagus  without  j)roducing  much  j)ain 
or  great  discomfort,  ex<'ept  in  swallowing.  The  intense  infiainnuitiou 
which  follows  the  swallowing  of  corrosives,  when  not  fatal,  gradually  sub- 
sides, and  often  leads  to  cicatricial  contraction  and  stricture. 

The  trcalmc7it  of  acute  inllammation  of  the  a'sc)phagU3  is  extremely 
unsatisfactory,  particularly  in  the  severer  forms.  The  slight  catarrhal 
cases  require  no  sj)ecial  treatment.  When  the  dysphagia  is  intense  it  is 
best  not  to  give  food  by  the  mouth,  but  to  feed  entirely  by  enemata.  Frag- 
ments of  Wii  may  be  given,  and  as  the  pain  and  distress  subside,  demulcent 
drinks.     External  appl      tionsof  cold  often  give  relief. 

A  chronic  form  of  cesophagitis  is  described,  but  it  results  usually  from 
the  prolonged  action  of  the  causes  which  produce  the  acute  form. 

Associated  with  chronic  heart  disease  and  more  frequently  with  the 
senile  and  the  cirrhotic  liver,  the  rosophageal  veins  nuiy  be  enormously 
distended  aiul  varicose,  particularly  toward  the  stomacdi.  In  these  cases 
the  mucous  membrane  is  in  a  state  of  chronic  catarrh,  and  the  patient  has 
frequent  eructations  of  mucus.  Ilupture  of  these  trsojjhageal  veins  niuy 
cause  fatal  haemorrhage.  Two  cases  of  the  kind  have  occurred  in  my  ex- 
perience. ,      . 


II.  SPASM  OF  THE  CESOPHACUS  {(Esophagismua). 

This  so-called  spasmodic  stricture  of  the  gullet  is  met  Avith  in  hysteri- 
cal ])atients  and  hypochondriacs,  also  in  chorea,  epilepsy,  and  especially 
hydrophobia.  It  is  sometimes  associated  also  with  the  lodgment  of 
foreign  bodies.  The  idiopathic  form  is  found  in  females  of  a  marktil 
neurotic  habit,  but  may  also  occur  in  elderly  men.  It  may  be  pres- 
ent only  during  pregiuincy.  Of  three  cases  which  have  come  under  my 
observation,  two  were  in  men,  one  a  hypochondriac  over  sixty  years  of 
age  who  for  many  months  had  taken  only  liquid  food,  and  Avith  great 
difficulty,  owing  to  a  spasm  which  accompanied  every  attempt  to  swallow. 
The  readiness  with  which  the  bougie  passed  and  the  subsequent  history 
showed  the  true  nature  of  the  case.     The  patient  complains  of  inability  to 


STRK'TUUE  OP  THE  (KSOPIIAOUS. 


841 


swiillow  solid  fond,  and  in  pxtromo  instaiioos  oven  liquids  aro  rojoctod. 
Tiio  attack  may  ooino  on  ahriiptly,  and  be  associatnl  with  emotional  dis- 
turbances and  with  sub.steriud  pain.  Tho  bougi(>,  when  j)aH.s«>d,  may  bo 
arrested  temporarily  at  the  seat  of  the  spasm,  which  {gradually  yields,  or  it 
may  slip  throujjfh  without  the  slij^htest  effort.  The  condition  is  rarely  seri- 
ous.    Death  has  however  follow^'d. 

The  (li((f/notiis  is  not  difficult,  particularly  in  ynung  j)erson8  with 
marked  nervous  manifestations.  In  i  Idorly  j)erson3  a'sophajfismus  is  almost 
;ihvays  connected  with  hypochondriasis,  but  great  caro  must  bo  taken  to 
exclude  cancer. 

In  some  cases  a  cure  is  at  onco  effected  by  the  jiassago  of  a  bougjo. 
'I'lie  general  neurotic  condition  also  requires  spt^'ial  attention. 

Paralysis  of  the  a^sophagus  scarcely  denumds  separate  consideration. 
It  is  a  very  rare  condition,  due  moat  often  to  central  disease,  particularly 
liulliar  paralysis.  It  may  bo  peripheral  in  origin  as  in  diphtheriti(f  paraly- 
sis. Occasiomilly  it  occurs  also  in  hysteria.  Tho  essential  symptom  is 
dysphagia. 


III.  STRICTURE  OF  THE  CESOPKAGUS. 


This  results  from  :  {a)  Congenital  narrowing.  (/>)  The  cicatricial  con- 
traction of  healed  ulcers,  usually  duo  to  corrosive  j)oison3,  occasionally 
to  syphilis,  (f)  The  growth  of  tumors  in  the  walls,  as  in  tho  so-called 
cancerous  stricture.  Occasionally  polypoid  tumors  projecting  from  tho 
mucosa  produce  great  narrowing,  {d)  p]xternal  pressure  by  aneurism,  en- 
larged lymph  glands,  enlarged  thyroid,  other  tumors,  and  sometimes  by 
pi'vicardial  effusion. 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  ex- 
tri'inc  cases  may,  indeed,  involve  tho  whole  tube,  but  in  a  majority  of  in- 
stances it  is  found  either  high  up  near  tho  pliarynx  or  low  down  toward 
the  stonmch.  The  mirrowing  may  be  extreme,  so  that  only  small  quanti- 
ties of  food  can  trickle  through,  or  the  obstruction  nuiy  be  quite  slight. 
There  is  usually  no  difficulty  in  making  a  diagnosis  of  the  cicatricial  strict- 
ure, as  the  history  of  mechanical  injury  or  tho  swallowing  of  a  corrosive 
lliiid  makes  clear  tho  nature  of  tho  case.  When  tho  stricture  is  low  down 
tlu!  (Esophagus  is  dilated  and  the  walls  are  usually  much  liypertropliied. 
When  it  is  high  in  the  gullet  the  food  is  usually  rejected  at  once,  wherciis 
if  low  it  may  bo  retained  and  a  considerable  quantity  collects  before  it  is 
regurgitated.  Any  doubt  as  to  its  having  reached  the  stomach  is  removed 
hy  the  alkalinity  of  the  materials  ejected  and  the  absence  of  the  character- 
istic gastric  odor.  Auscultation  of  the  oosophagus  nuiy  be  i)ractised  and 
is  wMuetimes  of  service.  Tho  patient  takes  a  mouthful  of  water  and  tho 
iiuscultator  listens  along  the  left  of  the  spine.  During  deglutition  at  tho 
seat  of  the  stricture,  in  place  of  the  normal  oesophageal  bruit,  there  will  bo 


li 


DISEASKS  OP  THE  DKlESTiVE  SYSTEM. 


I'  ^??;pl'.i ' ' 


LKl 


liciinl  a  loud  HiJashinf?,  gurgling  bouikI,  The  passiigo  of  tho  frsophagoal 
bouglo  will  di^termiiio  more  uocuratcly  tho  locality.  Conical  bougies  at- 
tjiclu'(l  to  a  lloxiblo  whalcbono  Htcm  aro  the  must  satisfactory,  but  the 
gum-clasllc  Htornach  tubo  may  be  used  ;  a  large  one  should  bo  tried  lirst. 
Tho  i)atieat  should  bo  placed  on  a  low  chair  with  tho  head  well  thrown 
back.  Tho  index  finger  of  tho  left  hand  is  jiassed  far  into  tho  i)harynx, 
and  in  somo  instancies  this  i)rocedure  al(»no  nuiy  determine  tho  presence  of 
a  new  growth.  Tho  bougie  is  jiassed  beside  tho  finger  until  it  touches 
tho  jxisterior  wall  of  the  i)harynx,  then  along  it,  more  to  one  side  tliaii  iu 
tho  middle  line,  and  so  grailually  j)ushed  into  the  gidlet.  It  is  to  be  boriio 
in  mind  that  in  passing  tho  cricoid  cartilago  there  is  often  a  slight  ob- 
struction. (Jreat  gentleness  should  bo  used,  as  it  has  happened  more  than 
once  that  the  bougie  has  been  i)assed  through  a  cancerous  ulcer  into  the 
mediastinum  or  through  a  diverticulum.  I  have  known  this  accident  to 
happen  twice — onco  iu  the  case  of  a  distinguished  surgeon,  who  performed 
a\sophagotomy  and  jjasscd  tho  tube,  as  ho  thought,  into  tho  stomach.  The 
post-mortem  on  the  next  day  showed  that  tho  tube  had  entered  a  diverticu- 
lum and  through  it  tho  left  pleura,  in  which  the  milk  injected  throusrh 
the  tubo  was  found.  In  tho  otiier  instance  the  tube  passed  thnnigli  a 
cancerous  ulcer  into  the  lung,  whicli  was  adherent  aiul  inflamed.  For- 
tunately these  accidents,  sometimes  unavoidable,  are  extremely  rare.  It 
is  well  always,  as  a  precautionary  measure  before  passing  the  bougie,  to 
examine  carefully  fen*  aneurism,  which  may  ])roduce  all  the  symjjtonis  of 
organic  stricture.  In  cases  in  which  the  stricture  is  extreme  there  is  al- 
ways emaciation. 

The  prognosis  in  these  cases  is  good  so  long  as  the  stricture  is  dilatable. 
Tho  persistent  treatment  of  cicatricial  stricture  by  gradual  dilatation  is 
very  beneficial,  and  ])atient3  improve  remarkably  uiuler  this  metluid. 
When  extreme,  the  treatment  by  bougie  is  not  possible,  and  the  questictn 
of  oosophagotomy  or  gastrotomy  mns+  be  considered.  Kectal  alimentation 
should  be  employed  whenever  the  patient  is  unable  to  take  sufficient  food 
by  the  mouth. 


IV.  CANCER  OF  THE  CESOPHACUS. 


This  is  usually  epithelioma.  It  is  not  an  uncommon  disease,  and  oc- 
curs more  frequently  in  males  than  in  females.  The  common  situation  is 
in  tho  upper  third  of  tho  tube.  At  first  confined  to  tho  mucous  niciii- 
brane,  tho  cancer  gradually  increases  and  soon  ulcerates.  The  lumen  of 
tho  tubo  is  narrowed,  but  when  ulceration  is  extensive  in  the  later  stagi's 
the  stricture  may  be  less  marked.  Dilatation  of  the  tubo  and  hypcrtroj)liy 
of  the  walls  usually  take  place  above  the  cancer.  The  cancerous  ulcer 
may  perforate  the  trachea  or  a  bronchus,  the  lung,  the  mediastinum,  tlie 
aorta  or  one  of  its  larger  branches,  the  pericardium,  or  it  may  erode  tlie 


RUl'TUIlK  OF  THE  CKSOPIIAOUS. 


343 


vertebral  column.  In  my  oxiwricncc  jK'rfoniti(tii  of  llu'  lung  has  boon  the 
iinist  frcfiiient,  producing,  as  a  rule,  local  gangrene. 

Symptoms. — The  earliest  symptom  is  tlysi)hagia,  which  is  progre.s8- 
ivo  and  may  become  extreme,  so  that  the  patient  emac.'iates  ra{)id!y.  Ue- 
fur'^tation  nuiy  take  place  at  once ;  or,  if  the  caiu'cr  is  situated  near  the 
stomach,  it  nuiy  be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if 
the  tul)o  id  much  dilated.  The  rejected  nuiterials  may  bo  mixed  with 
blood  and  may  contain  cancerous  fragments.  In  persons  over  fifty  years 
of  age  persistc^nt  difliculty  in  swallowing  accompanied  by  rapid  emaciation 
usually  indicates  (esophageal  eaiuxu*.  The  cervical  lymph  glands  aro  frc- 
(|Mcutly  enlargcid  and  nuiy  give  early  indication  of  the  nature  of  the  trouble. 
I'aiu  nuiy  bo  persistent  or  is  present  only  when  food  is  taken.  In  certain 
instances  the  pain  is  very  great.  I  saw  an  autopsy  on  a  case  of  cancer  of  the 
oesophagus  in  which  the  patient  gradually  became  emaciated,  but  had  no 
special  symptoms  to  call  attention  to  the  disease.  These  latent  cases  aro, 
however,  very  rare. 

The  prot/nosis  is  hopeless,  and  the  patients  usually  become  progressive- 
ly emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  tho  ulcer. 

In  the  diaffnodis  of  the  condition  it  is  important,  in  the  first  place,  to 
exclude  pressure  from  without,  as  by  aneurism  or  other  tumor.  Tho 
history  enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The 
souiul  may  bo  passed  and  the  presence  of  the  stricture  determined.  As 
mentioned  above,  great  care  should  bo  exercised. 

Treatment. — In  most  cases  milk  and  liquids  can  bo  swallowed,  but 
8upi)lementary  nourishment  should  bo  given  by  tho  rectuin.  It  may  be 
advisable  in  some  instances  to  pass  a  tube  into  the  stomach  and  attempt 
to  feed  in  this  way.  If  the  patient  is  willing  to  take  the  risk,  cosopha- 
gotomy  or  gastrotomy  may  be  performed  in  order  to  prolong  life. 


I 


\ 


V.  RUPTURE  OF  THE  CESOPHAGUS. 

This  may  occur  in  a  healthy  organ  as  a  result  of  prolonged  vomiting. 
Bocrhaave  described  the  first  case  in  Baron  Wasscnnar,  who  "  broke  asun- 
der the  tube  of  the  oesophagus  near  the  diaphragm,  so  that,  after  tho 
most  excruciating  pain,  the  elements  which  he  swallowed  passed,  together 
with  tho  air,  into  the  cavity  of  the  thorax,  and  he  expired  in  twenty-four 
hours."  Fitz  has  reporte  I  a  case  and  has  analyzed  the  literature  on  the 
subject  up  to  1877.  Tho  accident  has  usually  occurred  during  vomiting 
after  a  full  meal  or  when  intoxicated.     It  is,  of  course,  invariably  fatal. 

Much  more  common  is  the  post-mortem  digestion  of  the  cosophagus, 
which  was  first  described  by  King,  of  Guy's  Hospital.  It  is  not  very 
mfreriuent.  In  one  instance  I  found  the  contents  of  tho  stomach  in  the 
left  jileura.  The  erosion  is  in  the  posterior  wall,  and  may  be  of  consider- 
able extent 


;   >•.'■*», 


lit- 


344 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


VI.  DILATATIONS  AND   DIVERTICULA. 


Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  tlio  tube 
above  the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dila- 
tation is  extremely  rare.  The  tube  nuiy  attain  extraordinary  dimensions — 
30  cm.  in  circ\  mference  in  Lusclika's  case.  Regurgitation  of  food  is  the 
most  common  symptom.  There  may  also  bo  difliculty  in  breathing  from 
pressure. 

Diverticula  are  of  two  forms :  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which 
is  gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouch,  (b)  The  traction  diverticula  situated  on  the  anterior  wall  near 
the  bifurcation  of  the  trachea,  result,  lus  a  rule,  from  the  extension  of 
inflammation  from  the  lyini>h  glands  with  adhesion  and  subsequent  cica- 
tricial coatraction,  by  which  the  wall  of  the  gullet  is  druwu  out 


VI.  DISEASES  OF  THE   STOMACH. 

I.  METHODS  OF  CLINICAL  EXAMINATION. 

The  stomach  normally  occupies  the  loft  ujjjier  qaadrajit  of  the  abdo- 
men, one  quarter  of  the  organ  only  lying  to  the  riglit  of  the  median 
line;  it  is  bordered  above  by  the  diaphragm  anil  liver,  below  by  the 
intestine  and  transverse  colon ;  on  tlie  left  it  reac^hes  the  spleen,  and  nii 
the  right  it  touches  the  gall-bladder;  anteriorly  it  lies  against  the  rilisi 
and  the  abdoniinal  wall.  The  longitudinal  axis  extends  from  the  loft 
above  downward  and  batskward  to  the  right. 

The  cardiac  oriiice  is  about  opp')t-Ho  the  sternal  border  of  the  sixili  or 
seventh  left  costal  cartilage.  The  highest  jtoint  of  the  fundus  rciulii'S 
the  level  of  the  fifth  rib,  or  even  that  of  tlie  fourth  interspace,  while  the 
lowest  point  is  3  or  4  cm.  above  the  navel.  The  pylorus  lies  on  a  level 
with  the  ti]>  of  the  xiphoid  cartilage  at  a  point  midway  between  the  rijrlit 
sternal  and  parasternal  lines;  it  is  normally  covered  by  the  left  lohc  (if 
the  liver.  With  the  stomach  moderately  filled  with  air  the  upper  limit  of 
resoiumcc  reaches  the  fifth  interspace  in  the  left  mamnuiry  liiie,  while  the 
lower  limit  is  several  cm.  above  the  navel. 

The  greatest  vertical  dianu^ter  of  gastric  resonance  varies,  according 
to  Pacanowski,  from  10  to  J 4  cm.  in  the  nude,  and  is  about  10  cm.  in  llie 
female. 

Methods  for  determining  the  Position  and  Size  of  the  Stomach.  - 
(1)  Inflation  by  bicarbonate  of  soda  a)ul  tartaric  a(;id.  Dissolve  a  tcii- 
spoonrul  of  each  separately  in  as  snndl  a  tpiantity  of  water  as  possible, 


METHODS  OP  CLINICAL  EXAMINATION. 


345 


and   let  the    patient    drink    the    one    solution    ininit'diaiely   after   tlie 
other. 

(2)  Inflation  by  means  of  a  bulb-syringe  apparatus  v.liich  can  be  at- 
tached to  a  stomach  tube  already  introduced. 

(3)  As  a  makeshift  the  patient  may  be  given  250  to  500  c.  c.  of  water 
on  an  empty  stomach  in  divided  doses  atid  the  lower  limit  of  the  stomach 
tk'tcrnuued  by  j)ercu8sion  after  each  drink.  The  normal  stonuxch  sinks 
gradually  to  a  point  a  little  above  the  navel,  while  the  dilated  and  atonic 
stomach  falls  rapidly  to  a  much  lower  level. 

The  first  method  is  the  simplest  and  most  practical,  and  is  generally 
one  of  the  first  steps  in  the  physical  examination ;  tlie  tube  is  not  intro- 
duced until  the  test-meal  has  been  given.  The  method  has  the  objection 
that  the  amoun*,  of  air  introduced  caniuit  be  so  well  regulait'  d  and  that 
one  may  not  in  ;.  given  case  fdl  the  stomach  to  the  entire  cajiacity,  Avhile 
occasionally  a  spasmodic  contraction  of  the  cardia  and  j)ylorus  may  give 
the  patient  for  a  time  some  discomfort. 

Auscultation  of  the  Deglutatory  Murmurs.— On  listening  at  the  tip 
of  the  xiphoid  cartilage  as  the  i)iitient  swallows  a  mouthful  of  water  one 
hears  normally  two  murmurs.  (1)  The  jtriniary  murmur  is  heard  syn- 
chronously with  the  act  of  deglutition  and  sounds  as  if  water  were  in- 
jected into  a  space  containing  air.  ("i)  TIk-  secondary  murmur  is  heard 
up  to  twelve  seconds  later  and  is  a  coarser  gurgling  sound.  It  is  well 
while  listening  to  place  one  hand  on  the  trachea,  as  the  first  murmur  may. 
be  al)sent.  In  esophageal  and  cardiac  stenosis  the  second  sound  is  de- 
layed and  altered  in  character. 

The  following  description  of  methods  is  merely  a  rough  summary. 
For  fuller  particulars  see  the  works  of  Ewnid,  IJoas,  IjOo,  Wesencr,  etc. 

Examination  of  the  Contents  of  the  Stomach.— ^^arious  forms  of  test- 
meiiN  have  been  projuxsed.  The  sinn)l('st  and  most  satisfactory  is  that 
"f  J'lwald.  His  test  breakfast  {Prvhcfrnhstikk)  consists  of  one  roll 
{livixlrltcn) — about  thirty  grammes  of  white  bread — and  one  glass  of  water 
or  ii  I'up  of  tea  without  milk  or  sugar.  One  hour  later  the  contents  are 
to  !)('  cN  pressed. 

Tlie  contents  should  not  be  more  than  :;M)  to  40  c.  c.  The  filtrate 
should  1)0  a  clear  yellow  or  yellowish-brown  lliiid.  The  fluid  should  (;on- 
taiti  free  hydrochloric  acid  ;  it  should  not  contain  sullicicnt  lactic  acid  to 
he  recognized  by  the  ordinary  tests.  Pepsin  and  pepsinogen,  the  curdling 
ferment  and  its  zymogen,  should  be  present. 

Alhiuniiioids  should  be  almost  entirely  converted  into  jieptoius;  pro- 
poptones,  if  present  at  all,  should  be  recognizable  only  in  traces.  Starcho 
should  be  80  far  converted  into  achroodextrin,  dextrose,  or  maltose  ti.at 
the  reaction  for  starch  or  erythrodextrin  with  LugoPs  solution  should  bo 
HO  liiiii,'cr  present. 

Chemical  Examination  of  the  Gastric  Contents. 
(I)  Acidify  may  be  determined  by  litmuB  paper. 
2.3 


346 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


liiil'iM 


(2)  Presence  of  Free  Acid. — {a)  Tropa^olin  0.  0.  The  brownish- 
yellow  color  of  the  alcoholic  solution  is  turned  by  the  addition  of  a  fluid 
contiiining  free  acid  to  a  dcoj)  niahoj^any  brown  or  brown-red  or  deep 
red,  accordin<;f  to  tlic  strent^th  of  the  acid.  This  is  most  commonly  used 
as  tropaMjlin  paper — strijjs  of  fdter  i)aper  soaked  for  some  time  in  an  alco- 
holic solution.  The  })aper  must  not  be  kept  too  long.  It  is  best  to  uuiko 
up  a  new  (pumtity  monthly  at  least. 

{!))  Congo  red.  Solutions  of  Congo  red  of  a  brick-red  color  are  turned 
blue  by  the  addition  of  a  fluid  c(mtaining  pure  acid.  This  is  best  iised  us 
Congo  ])aper,  which  is  a  very  delicate  reagent,  and,  on  the  whole,  the  most 
satisfactory.  Many  other  reagents  have  been  used  (methyl  violet,  fuch- 
sin,  nudachite  green,  benzopur})urin),  but  the  two  above-mentioned  testa 
are  ])robably  as  satisfactory  as  any. 

(;j)  Presence  of  Free  HCl. — The  best  and  simplest  test  is  that  of  Giinz- 
burg:  Phloroglucin,  2;  vanillin,  1;  absolute  alcohol,  30.  To  a  drop  of 
the  gastric  contents  (better  filtered)  add  a  similar  (juantity  of  the  reagent 
on  a  porcelain  plate.  On  evaporation  gradually  to  dryness  over  a  ilanie,  a 
beautiful  rose-red  color  begins  to  appear  at  the  edges  if  IICI  is  present. 
Tliis  is  merely  a  test  for  a  free  mineral  acid,  but  IICI  is  the  only  one  pres- 
ent in  tliy  gastric  juice. 

(4)  Presence  of  Lactic  Acid. — The  best  test  is  that  of  FfTeltiumn. 
Add  1  to  'I  drojjs  of  tinctura  ferri  chloridi  to  10  to  20  c.  c  of  a  5-per- 
cent solution  of  carbolic  acid  and  dilute  with  water  till  it  assuitu-s  im 
amethyst-blue  color.  On  the  addition  of  a  few  drops  of  a  solution  con- 
taining lactic  acid  to  about  1  c.  c.  of  this  solution  the  color  changes  to  a 
clear  lemon-yellow.  The  test  nuiy  be  simulated  in  tlie  presence  of  plios- 
ph.'ites,  mineral  acids  in  concentration,  gra])e  sugar,'  alcohol,  etc. ;  licnee 
in  cases  of  doubt  it  is  always  prudent  to  shake  20  c.  c.  of  gastric  juice  with 
10  c.  c.  of  ether  three  times  and  then  evaporate  the  et'ner  to  dryness  over  u 
water  bath..  To  the  ether  residue,  which  contains  any  lactic  aci<l  present, 
add  several  drops  of  water.  On  the  addition  to  this  of  an  e<pial  (piautity 
of  the  reagent  a  reliable  test  for  lactic  acid  nniy  be  obtaineil. 

(5)  Butyric  acid  gives  with  infelmann's  reagent  a  result  very  similar 
to  tlKit  with  lactic  acid.  The  color  is,  however,  more  brownish,  'i'lie 
odor  is  siiflicient  evidence  of  its  presence  for  practical  purposes,  whi(!li  is 
also  true  of 

(0)  Acetic  Acid. 

Qunntitaiive  Tests.— (a)  Test  for  the  total  acidity.  This  test  is  prac- 
tically a  test  for  tlie  IICI,  where  tiiis  is  present  to  any  extetit,  as,  umler 
these  circumstances,  oth»^r  acids  are  i)rcscnt  usually  in  unapi)rccial)l(M|iian- 
tities.  To  T)  to  10  c.  c.  of  filtered  gastric!  contents,  a  on( -tenth  normal 
solution  of  sodic  hydrate  is  added  from  a  burette  till  neutnilization.  Tliis 
point  can  be  determined  by  adding  a  drop  of  an  alcoholic  solution  of  jdie- 
nolphthalein  to  the  gastric;  juice.  The  solution  remains  colorless  in  aciil  'T 
neutral  solution,  but  turns  red  in  alkaline.    This  test  estinmtes  not  only  iho 


MKXnODS  OF  CLINICAL  EXAMINATION. 


317 


froo  IICl,  but  that  in  combiiuation.  Xormally  4  to  C  to  do  of  the  one-tenth 
Ki)hition  is  re(|uirocl.     Eucii  o.  c.  of  tins  on(>-tenth.  sohition  =  -OCt^O-iG  IICI. 

(b)  Test  for  Free  IICI. — If  ono  desires  to  estiniuto  inoro  accurately  the 
free  IICI,  the  Bimj)lest  method  in  Hous's  mollification  of  that  of  Jllintz. 
From  10  c.  o.  of  the  gastric  coiitcnts  all  organic  acids  arc  removed  hy 
sliaking  with  100  c.  c.  of  ether,  and  then  the  test  performed  as  above  until 
Congo  shows  no  longer  a  grayish-blue  discoloration. 

Quantitative  testa  for  organic  acids  are  complicated  and  in  practice 
unnecessary. 

Tcffs  for  Pepsin  and  Curtlling  Ferment  and  their  Zi/nm/en.<f. — In  tho 
presence  of  free  IICI  it  is  unnecessary  to  examine  for  theso  (slemeuts,  us 
they  may  bo  safely  assumed  to  be  present. 

(1)  7\'st  for  Pepsin  and  Pepsinogen. — («)  In  presence  of  IICI  tlio 
presence  of  pepsin  may  be  determined  l)v  adding  to  5  to  10  c.  c.  of  the  gas- 
tric contents  a  small  piece  of  egg  albu  ./)en  and  observing  digestion  at  3T° 
to  40"  during  several  hours. 

(b)  In  the  absence  of  IICI,  pepsinogen  alone  is  found.  Add  to  10  c.  c. 
of  the  filtered  gastric  conti'uts  1  to  2  drojts  of  a  2.>  per  cent  HCI  solution  ; 
ailil,  as  before,  a  small  shaving  of  egg  albumen,  and  see  if  ii  is  dissolvd. 
The  IICI  turns  the  j)cpsinogen  into  pej)sin. 

(2)  Test  for  the  Ciirdltnf/  Ferment  and  its  Zijmo(jen. — {a)  Test  for  the 
curdling  ferment.  Meutralize  cxiu^tly  5  to  10  c.  c.  of  the  filtered  gastric 
contents  witii  one  tenth  nornud  NaOII  solution  and  mix  with  an  eipuil 
(luantity  of  neutral  or  ami)hoterii!  milk.  If  tlie  ferment  is  jircsent  curd- 
ling will  occur  in  from  ten  to  fifteen  minutes  at  3V°  to  40"^.  (Mie  nuiy 
proceed  more  simply  by  adding  3  to  5  dro{)s  of  the  filtered  gastric  juice 
to  10  c.  c.  of  milk,  when  curdling  will  occur  as  above. 

{h)  Test  for  tiie  zymogen.  To  10  c.  c.  of  lilt  red  gastric  jnicc  add 
CaOjlI,  till  slightly  alkaline.  This  .-ets  the  zymogen  free,  and,  on  mixing 
with  an  equal  (pumtity  of  milk,  coagulation  will  occur  as  above. 

These  tests  are  of  much  value  in  the  absencH^  of  IICI  to  determiiu^  the 
condition  of  the  mucous  mcmhraiu>.  For  IICI  alone  nuiy  be  absejit  for  a 
grcaU'p  or  less  length  of  limi;  from  various  nervous  causes,  while  the  ab- 
wnci-  of  jH'psin  and  its  curdling  ferment  at  tho  wuiie  limo  would  suggest  a 
sirioiis  impairment  of  the  secretory  functions. 

Texts  for  the  condition  of  t lie  albuminoids  in  digestion  are  complicated, 
aucj  not  neci'ssary  in  an  ordinary  clini(;al  cxjaaiia:!':  (ilinct.MTi-  .  an  be 
found  in  the  books  of  Kwald,  Jioas,  Leo,  vt>n  Jach.-  n.  \Vt-4ncr.  itc). 

Tests  for  the  Condition  of  the  Starch. — If,  aftt^  an  hour  of  digesUon, 
dio  addition  of  a  dror.  of  Lugol's  solution  to  the  liltered  gastric  juice  is 
lOllowt'd  l)y  the  rea.c.ion  for  standi  (blue)  or  erythnnlextrin  (purple),  v.c 
iiaiy  know  that  the  iligestion  of  stareli  has  been  hindered.     This  is  usuail; 
(hie  to  a  hyperacidity. 

Tests  for  t/ie  Motive  Power  of  the  Stomach. — There  are  various  meth- 
«i8.  but  practically  perfectly  good  results  can  bo  obtained  by  observation 


348 


DlSEAfiES  OP  THE  DIGESTIVE  SYSTEM. 


of  the  amount  of  fluid  obtained  after  a  test  breakfast.  More  than  40  c.  c. 
is  a  sure  indieation  of  motor  insufficiency.  Large  quantities  are  always 
suggestive  of  dilatation. 

Tent  for  the  Absorptive  Power  of  the  Stomach. — Kali  iodidi  (pure),  0  •* 
gramme,  is  taken  in  a  perfectly  clean  capsule  when  the  stomach  is  empty. 
The  sputa,  tested  every  two  or  three  minutes  with  starch  and  UNO,,  giv(> 
the  blue  reaction  inside  of  fifteen  minutes  in  normal  cases.  The  conclu- 
sions to  be  drawn  from  this  test  are,  however,  of  little  value. 


mi' 


m- 


M 


II.    ACUTE    GASTRITIS 

(Simple  Oaatritis;  Acute  Gastric  Catarrh;  Acute  Dyspepsia). 

etiology. — Acute  gastric  catarrh,  one  of  the  most  common  of  coni- 
p'aints,  occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.  It 
may  follow  the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it 
may  result  from  taking  unsuitable  articles,  which  either  themselves  irritahi 
tlie  mucosa  or,  remaining  undigested,  decomj)ose,  and  so  excite  an  aciito 
dyspepsia.  A  frequcuit  cause  is  the  taking  of  food  which  has  begun  to 
decompose,  particularly  in  liot  weather.  In  children  these  fernuM)tativo 
processes  are  very  a])t  to  excite  acute  catarrh  of  the  bowels  as  well.  An- 
other very  common  cause  is  the  abuse  of  alcohol,  and  the  acute  gastriti.'* 
which  follows  u  drinking-bout  is  one  of  the  most  typical  forms  of  the  dis- 
ease. The  tendency  to  acute  indigestion  varies  very  much  in  dilTerorit 
individuals,  and  indeed  in  families.  We  recognize  this  in  using  the  ex- 
pressions a  "delicate  stomach  ''  and  a  "strong  stomach."  Gouty  persons 
are  generally  thought  to  be  more  disi)osed  to  acute  dyspepsia  than  others. 
Acute  catarrh  of  the  stomach  occurs  at  the  outset  of  numy  of  the  infec- 
tious fevers. 

Lcbert  described  a  special  infectious  form  of  gastric  citarih,  occurriiii,' 
in  epidemic  form,  and  only  to  bo  distinguished  from  mild  tyj)hoid  fever  by 
the  abseiu!e  of  rose  spots  atid  swelling  of  the  sjdeen.  Many  practitioners 
still  adhere  to  the  belief  that  there  is  a  form  of  gadric  fever,  but  the  evi- 
dence of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great 
nuijority  of  all  cases  in  this  country  are  examples  of  mild  typhoid. 

Morbid  Anatomy. — Ikaumont's  study  of  St.  Martin's  stoniiu!i 
showed  that  in  acute  catarr'i  the  mucous  membrane  is  reddi  'i  and 
swollen,  less  gastric  juice  is  secreted,  and  mucus  covers  the  surfuco. 
Slight  ha>morrhages  nuiy  occur  or  even  snudl  erosions.  The  Rubp'nco.a 
may  be  somewhat  oedematous.  Microscopically  the  v\y  -.  arc  .i<lly 
noticeable  in  the  mucous  and  ])eptic  cells,  which  are  -den  and  more 
granular,  and  there  is  an  infiltration  of  the  intertubular  tissue  with  Iciicu- 
cytes. 

Symptoms. — In  mild  cases  the  sym])tom8  are  those  cf  sligiit"  in- 
digestion"— uneoml'ortab!.;  feeling  in  the  abdomen,  headache,  depression, 


^^1 


ACUTE  GASTRITIS. 


349 


nausea,  cnictations,  and  vomiting,  which  usually  gives  relief.  Tlie  tongue 
la  heavily  coated  and  the  saliva  is  increased.  In  diildren,  there  are  intes- 
tinal symptoms — diarrhani  and  colicky  pains.  The  pulse  may  be  slightly 
increased,  but  in  sonic  instances  is  less  frequent  than  normal ;  there  is 
usually  no  fever.  The  duration  is  rarely  more  than  twenty-four  hours. 
In  tlie  severer  forms  the  attack  may  set  in  with  a  chill  and  febrile  reac- 
tion, in  which  the  temperature  rises  to  102°  or  103".  The  tongue  is 
furred,  the  breath  heavy,  and  vomiting  is  freciuent.  The  ejected  sub- 
stances, at  nn<t  mixed  ^\'ith  food,  subsequently  contain  much  mucus  and 
bile-stained  fluids.  There  may  be  constipation,  but  very  often  there  is 
tliiirrha>a.  The  urine  presents  the  usual  febrile  characteristics,  and  there 
is  a  heavy  deposit  of  urates.  The  abdomen  may  be  somewliat  distended 
iind  slightly  tender  in  the  epigastric  region.  Ilerjjes  may  appear  on  the 
lips.  The  attack  may  last  from  one  to  three  days,  and  occasionally 
longer.  The  examination  of  the  vomitus  shows,  as  a  rule,  absence  of  the 
liydrochloric  acid,  presence  of  lactic  and  fatty  acids,  and  marked  increase 
in  the  mutnis. 

Diagnosis. — The  ordinary  afebrile  gastric  catarrh  is  readily  recog- 
nized. The  acute  fel)rile  form  is  so  similar  to  the  initial  symptoms  of 
nmny  of  the  infectious  diseases  that  it  is  impossible  for  a  day  or  two  to 
make  a  definite  diagnosis,  particularly  in  the  cases  which  have  come  on, 
so  to  speak,  spontaneously  and  independently  of  un  error  in  diet.  Some 
of  these  resemble  closely  an  acute  infection ;  the  symptoms  may  be  very 
intense,  and  if,  as  sometimes  happens,  the  attack  sets  in  with  severe 
hoaduebe  and  delirium  the  case  nuiy  be  mistaken  for  meningitis.  When 
the  abdominal  pains  are  intensr  tlic  attack  may  be  confounded  with  gall- 
stone colic.  In  discriminating  between  acute  febrile  gastritis  and  the 
abortive  forms  of  typhoid  fever  it  is  to  be  borne  in  mind  that  in  the 
former  the  temperature  rises  abruptly,  the  remissions  are  slighter,  and  the 
drop  is  more  sudilen.  T!»e  initial  bronchitis,  the  well-nuirked  splenic 
enlargement,  and  the  rose  spots  are  not  present.  It  is  a  very  common 
iiror  to  class  under  gastric  fever  the  mild  forms  of  the  various  infectious 
disonlci-';. 

Treatment. — Mild  cases  recover  spontaneously  in  twenty-four  hours, 
and  Kijuire  no  treatment  other  than  a  dose  of  cai^tor  oil  in  chihlreii  or  of 
lihu'  mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  iu  the 
regidu  of  the  stomach,  the  vomiting  should  be  promoted  by  warm  water 
or  the  siiiiplo  emetics.  A  full  dose  of  calomel,  eigli;  I"  ten  graitu.,  should 
he  given,  and  followed  the  next  morning  by  a  dose  of  Ilunyadi-Janos  or 
Carlsbad  water.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda 
and  bi.sniutli  may  be  given.  The  stomatdi  should  have,  if  possible,  abso- 
lute rest,  and  it  is  a  good  plan  in  the  case  of  strong  perbous,  j/articularly 
iu  those  addicted  to  alcohol,  to  cut  oif  all  food  for  a  day  or  two.  The  pa- 
tient juay  be  allowed  soda  water  and  ice  freely.  It  is  wcdl  not  to  attempt 
to  cheek  the  vomiting  unless  it  is  excessive  and  protracted,     llecovery  is 


^r''Ai4:: 


« '»*!;>;•    >'-' 


350 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


usually  complete,  thoiij^h  ropoated  attacks  may  load  to  subacute  gastritis 
or  to  the  establishmout  of  chronic  dy8j)epsia. 

Phlegmonous  Gastritis ;  Acute  Suppurative  Gastritis.— This  is  an  ex- 
cessively rare  disease,  characterized  by  the  occurrence  of  suppurative  ])r(>- 
cesses  in  the  submucosa.  The  affection  is  more  common  in  men  than  in 
women.  The  cause  is  seldom  obvious.  It  has  been  met  with  as  an  idio- 
pathic affection,  but  it  lias  occurred  also  in  j)uerpera]  fever  and  other  sop- 
tic  processes,  and  has  occasiomiUy  followed  trauma.  A)iatonncally  tiicro 
appear  to  be  two  forms,  a  diffuse  j)urulent  infiltration  and  a  localized  ab- 
scess formation,  in  which  case  the  tumor  may  reach  the  size  of  an  egg,  and 
may  burst  into  the  stomach  or  into  the  peritoneal  cavity. 

The  sijwptoins  are  variable.  There  are  usually  pain  in  the  abdomen, 
fever,  dry  tongue,  and  symptoms  of  a  severe  infective  process,  delirium 
and  coma  preceding  death.  Jaundice  has  been  met  with  in  some  in- 
stances. Occasionally,  when  the  abscess  tumor  is  large,  it  has  been  felt 
externally,  in  one  case  forming  a  mass  as  large  as  two  fists,  'J'here  are  in- 
stances which  run  a  more  chronic  course,  with  pains  in  the  abdomen, 
fever,  and  chills. 

The  diagnosis  is  rarely  possible,  even  when  with  abscess  rupture  oc- 
curs, and  the  pus  is  vomited,  as  it  is  not  possible  to  differentiate  this  con- 
dition from  an  abscess  perforating  into  the  stoniuch  from  Mithout.  It  is 
stated,  however,  that  C'hvostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inflamnuition  of  the  stoni 
ach  is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong 
alkalies,  or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  amm  Miia, 
arsenic,  etc.  In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic, 
and  antimony,  the  process  consists  of  an  acute  degcMi'eration  of  the  gland- 
ular elements,  and  liaMuorrhage.  In  the  powerful  coiu'cntrated  poisons 
the  mucous  membrane  is  extensively  destroyed,  and  nmy  be  converted  into 
u  brownish-black  eschar.  In  the  less  severe  grades  there  may  be  areas  of 
necrosis  surrounded  by  inflammatory  reaction,  while  the  subnuicosa  is 
luemorrhagic  and  iidiltrated.  The  jjrocess  is  of  course  more  intense  ut 
the  fundus,  but  the  active  peristalsis  may  drive  the  ])oi8on  through  tlie 
pylorus  into  the  intestine. 

The  symptoma  are  intense  pain  in  the  mouth,  throat,  and  stomadi, 
salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the  vom- 
ited materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  painful  on 
pressure.  In  the  most  acute  eases  symptoms  of  collajise  supervene;  the 
pulse  is  weak,  the  skin  pale  and  covered  with  sweat;  then^  is  restlessness, 
and  sometimes  convulsions.  There  may  be  albumen  or  blood  in  tlie  urine, 
and  pet*>chi!«  mav  develop  on  the  skin.  When  the  poison  is  less  intense, 
the  sloughs  may  separate,  leaving  ulcers,  whifdi  too  often  lead,  in  tlio 
oesophagus,  to  stricture,  and  in  the  stoiiiach  to  chronic  atrophy,  and  finally 
to  death  from  exhaustion. 


CHRONIC  GASTRITIS. 


351 


Tlio  (limjnosis  of  toxic  gastritis  is  usually  easy,  aa  insi)ection  of  the 
mouth  and  idiaryux  showa,  in  many  instances,  corrosive  elTects,  while  the 
(>xaniinati()n  of  the  vomit  may  indicate  the  nature  of  tho  poison. 

In  ])(>isoiiing  by  acids,  nuignosia  should  be  administered  in  milk  or 
with  egg  all)umcn.  When  strong  alkalies  have  been  taken,  the  dilute  acids 
slididd  l)e  administered.  For  the  severe  inllammation  which  follows  tho 
swallowing  of  tho  stronger  poisons  palliative  treatment  is  alono  available, 
aii<l  morphia  may  be  freely  employed  to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis.— This  condition  is  met  with 
occasionally  in  diphtheria,  but  more  commonly  as  a  sccoiulary  process  in 
typhus  or  typhoid  fever,  pneumonia,  pyaemia,  snudl-pox,  and  occasionally 
ill  (Ichilitated  children.  An  instance  of  it  camo  under  my  notice  in  ])neu- 
nidiiia.  The  exudation  nuiy  be  extensive  and  uniform  or  in  patches. 
'I'lic  conditicMi  is  not  recognizable  during  life. 

Mycotic  and  Parasitic  Gastritis.— It  t)ccasiomdly  happens  that  fungi 
develop  in  the  stomach  and  excite  inllammation.  One  of  tho  most  rc- 
iiiiirkalde  cases  of  the  kind  is  that  reported  by  Kundrat,  in  which  tho 
faviis  fungus  developed  in  the  stomach  and  intt  sline. 

Ill  caiu-er  and  in  dilatation  of  the  stomach  the  sarciiue  and  yeast  fungi 
prohatily  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  (•ai)al)le  of  killing  the  ordinary  bacteria.  Orth  states  that  tho 
uiitlirax  bacilli,  in  certain  cases,  produce  sMclling  of  the  mucosa  and  ulcer- 
iitiDii.  Kiclts  has  descrilx'd  a  barillns  (/iisfrin/s  which  develops  in  tlio 
tiil)iil('s  and  produces  numerous  spores,  and  Kug.  Fraonkel  has  reported  a 
ease  of  acute  emphysenuitous  gastritis  probably  of  mycotic  origin.  Tho 
larvie  of  certain  insects  may  excite  gastritis,  as  in  the  cases  reported  by 
(Icrlianlt,  Mescliede,  and  others.  In  rare  instances  tuberculosis  and  syphi- 
lis attack  the  gastric  mucosa. 


III.  CHRONIC  GASTRITIS 

{Chronic  Catarrh  of  the  Stomach;  Chronic  Di/npepsia). 

Definition. — A  coiulition  of  (Msturbed  digestion  associated  with  in- 
creased mucus  formation,  qualitative  or  (juantitativo  changes  in  the  gastric 
juice,  eiifeeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for 
an  aliiiurmal  time  in  the  stomach ;  and,  linuUy,  with  alterations  in  tho 
structure  of  tho  mucosa. 

Etiology. — Tne  causes  of  chronic  gastritis  may  be  classified  as  fol- 
lows: (1)  Dietetic.  Tl)e  use  of  i-nsuitable  or  improperly  prepared  food. 
riif  persiistent  use  of  certain  articles  of  diet,  su(.'h  as  very  fat  substances 
or  fdiMJs  contaiiung  too  much  of  the  carbohydrates.  The  use  in  excess  of 
tea  or  colTce,  and,  above  all,  alcohol  in  its  various  forms.  Under  this  head- 
ing, too,  nuiy  be  mentioned  the  habits  of  eating  at  irregular  hours  or  too 
rapiiJly  and  iiiipcrfcctly  chewing  tho  food.     A  common  cause  of  chronic 


I: 


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I 

352 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


cttttirrh  is  drinking  too  fret-ly  of  ice- water  during  meals,  a  practice  which 
phiys  no  snmll  jjurt  in  tlic  i)revalence  of  dyspepsia  in  America.  Anotlior 
frequent  cause  is  tiie  abuse  of  tobacco.  (2)  Constitutional  causes.  Antrniia 
chlorosis,  chronic  tuberculosis,  gout,  diabetes,  and  Bright's  disease  arc 
often  associated  with  chronic  gastric  catarrh.  (3)  I^ocal  conditions :  («)  of 
the  stomach,  as  in  cancer,  ulcer  and  dilatation,  which  are  invariablv  uc- 
comi)anied  by  catarrh ;  (/>)  conditions  of  the  portal  circulation,  causin;; 
chronic;  engorgement  of  the  mucous  membrane,  as  in  cirrhosis,  chronic 
heart  disease,  aiul  certain  chronic  lung  alfections. 

Morbid  Anatomy. —Anatomically  two  forma  of  chronic  gastritis 
may  be  recognized,  the  simple  and  the  sclerotic. 

,{a)  Simple  Chronic  Gastritis —The  organ  is  usually  enlarged,  the 
mucous  membrane  i)ale  gray  in  color,  and  covered  with  closely  adherent, 
tenacious  mucus.  'J'hc  veins  arc  large,  i)atches  of  ecchymosis  are  not  in- 
frequently seen,  and  in  the  chronic  catarrh  of  portal  obstruction  and  (if 
chronic  heart  disease  small  hiiMnorrhagic  erosions.  Toward  the  pylorus 
the  mucosa  is  not  infrefjuently  irregularly  j)igmentcd,  and  presents  a 
rough,  wrinkled,  nuimmillated  surfacii,  the  clot  vuinwichme  of  the  French, 
u  condition  which  nuiy  sometimes  be  so  prominent  that  writers  have  dc- 
Rcribed  it  as  gasfrifts  polifjwsn.  The  membrane  may  be  thinner  than 
normal,  and  much  firmer,  teariiig  less  readily  with  the  finger-nail.  Ewald 
thus  describes  the  histological  changes:  The  minute  anatomy  shows  the 
picture  of  a  parenchymatous  and  an  interstitial  inflammation.  1'he  gland 
cells  are  in  part  eroded  or  show  cloudy  granular  swelling  or  atrophy. 
The  distinction  between  the  "haupt"  and  "beleg''  cells  cannot  be  recog- 
nizel,  and  ]n  many  places,  ])articularly  in  the  pyloric  region,  the  tubes 
liave  l(jst  their  regular  form  and  show  in  many  places  an  atypical  branch- 
ing, like  the  fingers  of  a  glove.  Individual  glands  are  cut  oflE  toward  tlu^ 
fundus,  but  appear  at  the  border  of  the  Bubmi;cosa  as  cysts,  partly  empty, 
with  a  smooth  nuimbrane,  partly  filled  M'ith  remnants  of  hyaline  and  re- 
fractile  epithelium.  An  abundant  small-celled  infiltration  presses  apart 
the  tubules  and  is  particularly  marked  toward  the  surface  of  the  mucosa, 
and  from  the  submucosa  cxtensicms  of  the  conn*^ctive  tissue  may  be  seen 
passing  between  the  glands.  The  mucoid  transformation  of  the  cells  of 
the  tubules  is  a  striking  feature  in  the  process  and  may  extend  to  the  very 
fundus  of  the  glands. 

(b)  Sclerotic  Gastritis.— As  a  final  result  of  the  parenchymatous  and 
inff  istitial  changes  the  muccms  membrane  may  undergo  complete  atropliy, 
80  that  but  few  traces  of  secreting  substance  remain.  There  appear  td 
be  two  forms  of  this  sclerotic  atrophy — one  with  thinning  of  the  coats  of 
i\xc  stojniich,p}it hi. ■iis  vent riculi,  ami  u  retention  or  even  increase  of  the 
size  of  the  organ;  the  other  with  enormous  thickening  of  the  coats  ami 
great  reduction  in  the  volume  of  the  organ,  the  condition  which  i.^ 
usually  described  as  cirrhmH  ventricnU.  Extreme  atrophy  of  the  mu- 
cous membrane  of  the  stomach  has  been  carefully  studied  by  Fcuwick, 


l\     .' 


CHRONIC  GASTRITIS. 


353 


Kwald,  and  others,  and  we  now  recognize  tlio  fact  that  there  may  bo 
Hiich  dostruetlon  and  degeneration  of  the  ghindiilar  elements  by  a  pro- 
gressive development  of  interstitial  tissue  that  ultimately  scareely  a  traeo 
of  seereting  tissue  remains.  In  a  eharacteristio  oasc^  studied  by  Henry  and 
iiivsclf,*  the  greater  portion  of  the  lining  membrane  of  the  Ht<tmaeh  was 
converted  into  a  perfectly  smooth,  outicular  structure,  showing  no  trace 
wliiitever  of  glandular  elements,  with  enormous  hypertrophy  of  the  mus- 
cularis  mucosa?,  and  here  and  there  formation  of  cysts.  In  the  other  form, 
with  identical  atrophy  ami  cyst  formation,  there  is  enormous  increase  in 
the  connective  tissue,  and  the  stomach  may  bo  so  contracted  that  it  does 
not  hold  more  than  a  couple  of  ounces.  The  walls  may  measure  from 
two  to  three  centimetres ;  the  greatest  increase  in  thickness  is  in  the  sub- 
unicosa,  but  the  hypertrophy  also  extends  to  the  muscular  layers.  While 
(tno  is  not  justified  in  saying  that  all  cases  of  cirrhosis  of  the  stonuvch  rep- 
resent a  final  stage  in  the  history  of  a  clirnnic  catarrli,  it  is  true  that  in 
most  cases  the  process  is  associated  with  atrophy  of  the  gastric  mucosa, 
while  the  history  indicates  the  existence  of  chronic  dyspepsia. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as 
is  the  case  with  most  chronic  diseases,  changes  from  time  to  time.  The 
appetite  is  variable,  sometimes  greatly  impaired,  at  others  very  good. 
Among  early  symptoms  are  feelings  of  distress  or  oppression  after  eating, 
which  may  become  aggravated  and  amount  to  actual  pain.  "When  the 
stonuich  is  empty  there  may  also  be  a  jiainful  feeling.  The  pain  differs  in 
dilTorent  eases,  and  may  be  trifling  or  of  extreme  severity.  When  local- 
ized and  felt  beneath  the  sternum  or  in  the  praecordial  region  it  is  known 
as  heart-burn  or  sometimes  cardialgia.  There  is  pain  on  pressure  over 
the  stomach,  nsually  diffuse  and  not  severe.  The  tongne  is  coated,  and 
the  patient  complains  of  a  bad  taste  in  the  mouth.  The  tip  and  margin 
of  the  tongue  are  very  often  red.  Associated  with  this  catarrhal  stomati- 
tis there  may  be  an  increase  in  the  salivary  and  pharyngeal  secretions. 
Nausea  is  an  early  symptom,  and  is  particularly  apt  to  occur  in  the  morn- 
ing hours.,  It  is  not,  however,  nearly  so  constant  a  symptom  in  chronic 
gastritis  as  in  cancer  of  the  stomach,  and  in  mild  grades  of  the  affec- 
tion it  may  not  occur  at  all.  Eructation  of  gas,  which  may  continue  for 
some  hours  after  taking  food,  is  a  very  prominent  feature  in  cases  of  so- 
called  fiatnlent  dyspepsia,  and  there  may  be  marked  distension  of  the 
intestines.  With  the  gas,  bitter  fluids  may  be  brought  up.  In  other  in- 
stances a  clear  watery  fluid  is  ejected  (pyrosis  or  water-brash).  The  vom- 
iting docs  not  often  occur  when  the  stomach  is  empty,  but  either  imme- 
diately after  eating  or  an  hour  cr  two  later.  The  vomitus  consists  of  food 
in  various  stages  of  digestion  and  slimy  mucus,  and  the  chemical  examina- 
tion shows  the  presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in 
addition  to  lactic  acid,  while  the  hydrochloric  acid,  if  indeed  it  is  present, 

*  American  Journal  of  the  Medical  Sciences,  1886, 


I 


351 


DISKASES  OP  THE  DIGESTIVE  SYSTEM. 


' 


'},  ill  "■  ityt  f 


r     I, 


a 


is  much  rcduood  in  quimtity.  The  difjcstioii  miiy  ho  much  (hduyod,  and 
on  wuHhinj,'  out  tho  utoinuch  us  Into  as  seven  liours  after  eatin<,',  portinns 
of  food  are  still  j)resent.  TUv  i)rolon<,'ed  retention  favors  deeomjjosition, 
tlie  stomach  hecionies  disteiuk'd  with  gas,  and  this,  with  tlie  chronir, 
catarrh,  may  induce  graihuilly  an  atony  of  tlie  muscular  walls,  'i'lie  ah- 
Borption  is  slow,  and  iodide  of  potassium,  given  in  cajjsules,  whicli  should 
normally  reach  the  sulivu  within  lifteen  minutes,  nuiy  not  be  evident  for 
more  than  half  an  hour. 

Constipation  is  usually  i)rcsent,  hut  in  some  instances  there  is  diarrluna, 
and  undigested  food  i)asses  rapidly  through  the  bowels.  The  urine  is 
often  scanty,  high-colored,  and  deposits  u  heavy  sediment  of  urates. 

Of  other  symptoms  headache  is  conmion,  and  the  patient  feels  con- 
stantly out  of  sorts,  indisposed  for  exertion,  and  h>w-si)irited.  In  aggra- 
vated cases  melancholia  may  develop.  Trousseau  called  attention  to  the 
occurrence  of  vertigo,  a  nuirked  feature  in  certain  cases.  The  pulse  is 
small,  sometimes  slow,  and  there  may  be  palpitation  of  tlie  lieurt.  Fever 
docs  not  occur.  Cough  is  sometinu's  present,  but  the  so-called  stomach 
cougli  of  chronic  dy.'<i)eptics  is  in  all  probability  dependent  upon  pharyii- 
geul  irritation. 

The  symptoms  of  atrojdiy  of  the  mucous  membrane  of  the  stomadi, 
with  or  without  contraction  of  the  organ,  are  very  comjjlex,  and  cannot  lie 
said  to  present  a  uniform  i)icture.  The  nuijority  of  the  cases  present  the 
sym])toms  of  an  aggravated  chronic  dysj)epsia,  often  of  such  severity  that 
cancer  is  suspected.  In  one  of  the  cases  whidi  I  examined  the  persistent 
distress  after  eating,  the  vomiting,  and  tlu  gradual  loss  of  llesh  iiiid 
strengtli,  very  naturally  led  to  this  diagnosis,  but  the  duration  of  the 
disease  far  exceeded  that  of  ordinary  carcinoma.  lii  the  cirrhotic  form 
the  tumor  mass  may  sometinu;s  bo  felt.  In  atrojdiy  of  the  stomach, 
whether  associated  with  cirrhosis  or  not,  the  clinical  jiicture  nuiy  be  that 
of  pernicious  an.nemia.  As  early  as  1800,  Flint  called  attention  to  this 
connection  between  atrophy  of  the  gastric  tubules  and  ana'mia,  an  obser- 
vation which  Fenwick  and  others  have  amply  conlirmed. 

Diagnosis. — The  use  of  the  stomach-tube  and  the  chemical  examinu- 
tion  of  the  contents  of  the  stomach  obtained  in  this  way  have  given  us 
special  information  with  reference  to  tlio  various  forms  of  gastritis  .iiul 
the  modes  of  differentiating  them.  The  soft-rubber  stomach-tube,  pro- 
vided with  a  funnel-shaped  dilatation,  is  the  most  satisfactory  to  use,  ius 
it  is  very  readily  passed,  and  if  used  by  the  patient  is  not  likely  to  cause 
damage.  It  should  be  open  at  the  end  and  possess  one  or  two  latcnil 
openings. 

Ewald  distinguishes  three  forms  of  chronic  gastritis  :  (1)  Simi)le  gas- 
tritis ;  (2)  mucous  {schlcimiye)  gastritis ;  (3)  atrophy. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  shiny 
fluid,  while  after  the  test  breakfast  the  IICl  is  diminished  in  quantity  and 
lactic  acid  and  the  fat  acids  are  usually  present. 


m 


cnilOXIC  OASTIIITIS. 


3J5 


I 


III  (2)  llio  ju'iillty  is  alwiiy.s  Hli<,'lit  aiul  tho  coritHtioii  h  dLstin^'uirihod 
from  (1)  chiolly  by  tho  hirj^o  aiiioiiiit  of  iiniciis  present. 

Ill  {'.])  the  fuHtiiif;  sioinucli  is  jftiit'rally  cnipty,  whilo  after  tho  tost 
hicakl'ast  IICI,  pcpHiii,  ami  lliu  runlliiif,'  fi-niu'tjt  aro  wholly  wa/itiiij,'. 

Treatment. — Wliou  jjossHjIo  the  cuuso  in  each  case  hIiouUI  he  uscer- 
taiiu'd  and  an  attempt  made  to  determine  the  special  form  of  indi- 
pfstion.  Usually  there  is  no  dillieulty  in  dilTerentiatiii<,'  the  ordinary 
ciitarrhal  and  tho  nervous  varieties.  A  careful  study  of  the  jtheiioinena 
of  di<,'estion  in  the  way  already  laid  down,  thou<,'h  not  essential  in 
every  instance,  sliouhl  certaiidy  ho  carried  out  in  the  more  ohstimite  and 
obscure  forms.  Two  important  (piestions  should  be  asked  of  every  dys- 
pej)ti(; — first,  as  to  tho  time  taken  at  his  meals;  and,  second,  as  to  tho 
quantity  ho  eats.  I'ractically  a  lar;,'e  majority  of  all  cases  of  disturbed 
dijjestion  conio  from  hasty  and  imperfect  nuistication  of  the  food  and  from 
overeating.  Esiieeial  stress  should  be  laid  upon  tiie  former  j»oint.  In 
sonui  instances  it  will  alono  sullice  to  cure  dysix'jisia  if  the  ))alient  will 
count  u  certain  number  before  swallowing  each  mouthful.  Tiie  second 
point  is  of  oven  greater  importance.  People  habitually  eat  too  much,  and 
it  is  probably  true  that  a  greater  number  of  maladies  arise  from  excess  iu 
eiitiug  than  from  excess  in  drinking.  Particularly  is  this  the  case  in 
America,  where  tho  average  man  is  abstemious  in  the  nmtlcr  of  alcohol, 
but  iiupriuknt  to  a  degree  in  all  matters  relating  to  food,  ^loreover,  jjco- 
plo  luivo  not  had  time  to  learn  tho  art  of  cooking,  and  much  of  tho  indi- 
gestion, particularly  in  tho  country  districts,  may  be  charged  to  the  bar- 
barous methods  of  preparing  tho  food.  The  treatment  nuiy  be  consid- 
ered under  tho  headings  of  dietetic  and  medicinal. 

{i()  (I'eneral  and  Dietetic. — A  (!areful  and  systematically  arranged  di- 
etary is  tho  first,  sometimes  tho  only  essential  in  the  treatment  of  a  case  of 
c'jn'onic  dyspepsia.  It  is  imi)ossible  to  lay  down  rules  a|)plicable  to  all 
canes.  Individuals  diiTer  extraordinarily  in  their  cai)a])ility  of  digesting 
(lilleront  articles  of  food,  and  there  is  much  truth  in  the  ohl  adage,  "One 
man's  food  is  another  man's  poison."  Tho  individual  ])n'ferences  for  dif- 
ferent articles  of  food  should  bo  pormittod  in  the  mihler  forms.  Physi- 
ciiiiis  liavo  probably  been  too  arbitrary  in  this  direction,  and  have  not 
yieliknl  sufficiently  to  tho  intimations  given  by  tho  appetite  and  desires 
of  tho  patient, 

A  rigid  milk  diet  may  bo  tried  in  ohstinato  cases.  IMucli  depends 
U])on  whether  the  patient  is  able  to  take  and  digest  milk  properly.  In  tho 
forms  associated  with  Bright's  disease  and  chronic  portal  congestion,  as 
^^ell  as  in  many  instances  in  which  tho  dyspepsia  is  part  of  a  neurasthenic 
or  hysterical  trouble,  this  plan  iu  conjunction  with  rest  is  most  efficacious. 
If  milk  is  not  digested  well  it  may  bo  diluted  one  third  with  soda  water 
or  \'ichy,  or  five  to  ten  grains  of  carbonate  of  soda,  or  a  j)inch  of  salt 
niuy  be  added  to  each  tumblerful.  In  many  cases  tho  milk  from  which 
the  cream  has  been  taken  is  better  borne.     Buttermilk  is  particularly 


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DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


uuitable,  but  can  rarely  be  taken  for  as  long  a  time  alone,  as  patients 
tire  of  it  much  more  readily  than  they  do  of  ordinary  milk.  Nut  only 
can  the  general  nutrition  be  maintained  on  this  diet,  but  patients  some- 
times increase  in  weight,  and  the  unpleasant  gastric  symptoms  disappear 
entirely.  It  should  be  given  at  fixed  hours  and  in  definite  quantities.  A 
patient  may  take  six  or  eight  ounces  every  three  hours.  The  amoui-.t 
necessary  varies  a  good  deal,  but  at  least  three  to  five  pints  should  be 
given  in  the  twenty-four  hours.  This  form  of  diet  is  not,  as  a  rule,  well 
borne  when  there  is  a  tendency  to  dilatation  of  the  stomach.  The  milk 
may  be  previously  peptonized,  bi;t  it  is  imjiossible  to  feed  a  chronic  dys- 
peptic in  this  way.  The  stools  should  be  carefully  watched,  and  if  more 
milk  is  taken  than  can  be  digested  it  is  well  to  supplement  the  diet  witli 
eggs  and  dry  toast  or  biscuits. 

In  a  large  proportion  of  the  cases  of  chronic  indigestion  it  is  not 
necessary  to  annoy  the  patient  with  such  strict  dietaries.  It  may  be  quite 
sufficient  to  cut  off  certain  articles  of  food.  Thus,  if  there  are  acid  eruc- 
tations or  flatulency,  the  farinaceous  foods  should  be  restricted,  particularly 
potatoes  and  the  coarser  vegetables.  A  fruitful  source  of  indigestion  is 
the  hot  bread  Avhich,  in  different  formic,  is  regarded  as  an  essential  part 
of  an  American  breakfast.  Tliis,  as  well  as  the  various  forms  of  pan- 
cakes, pies  and  tarts,  with  heavy  pastry,  and  fried  articles  of  all  sorts, 
should  be  strictly  forbidden.  As  a  rule,  white  bread,  toasted,  is  more 
readily  digested  than  bread  made  from  the  whole  meal.  Persons,  how- 
ever, differ  very  much  in  this  respect,  and  the  Graham  or  brown  bread  is 
for  many  people  most  digestible.  Sugar  and  very  sweet  articles  of  food 
should  be  taken  in  great  moderation  or  avoided  altogether  by  persons 
with  chronic  dyspepsia.  Many  instances  of  aggravated  indigestion  have 
come  to  my  notice  due  to  the  prevalent  practice  of  eating  largely  of  ice- 
cream. One  of  the  most  powerful  enemies  of  the  American  stomach  in 
the  present  day  is  the  soda-water  fountain,  which  has  usurped  so  impor- 
tjint  a  place  in  the  apothecary  shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very 
fat  meats,  and  thick,  greasy  soups  should  be  avoided.  Ripe  fruit  in 
moderation  is  often  advantageous,  particularly  when  cooked.  Bananas 
are  not,  as  a  rule,  well  borne.  Strawberries  are  to  njfiny  persons  a  cause 
of  an  annual  attack  of  indigestion  and  sore  throat  in  tlie  spring  months. 

As  stated,  in  the  matter  of  special  articles  of  food  it  is  impossible  to 
lay  doAvn  rigid  rules,  and  it  is  the  common  cxp-jrience  that  one  patient 
with  indigestion  will  take  with  impunity  the  ycr\'  articles  which  cause 
the  greatest  distress  to  another. 

Another  detail  of  importance  which  miiy^  be  mentioned  in  this  con- 
nection is  the  general  h3'gienic  management  of  dyspeptics.  These  pa- 
tients are  often  introspective,  dwelling  in  a  morbid  manner  on  their 
symptoms,  and  much  inclined  to  take  a  despondent  view  of  their  con- 
dition.    Very  little  progress  can   be  made  unless  the  physician  gains 


CHRONIC  GASTRITIS. 


357 


thoir  confidence  from  the  outset.  Their  fears  and  whims  should  not  bo 
made  too  light  of  or  ridiculed.  Systematic  exercise,  carefully  regulated, 
particularly  when,  as  at  watering  places,  it  is  combined  with  a  restricted 
diet,  is  of  special  service.  Change  of  air  and  occupation,  a  prolonged 
sea  voyage,  or  a  summer  in  the  mountains  will  sometimes  cure  the  most 
obstinate  dyspepsia. 

(b)  Medicinal. — The  special  therapeutic  measures  may  be  divided  into 
those  whicli  attempt  to  replace  in  the  digestive  juices  important  elements 
wliich  are  lacking  and  those  which  stim^ulate  the  weakened  action  of  the 
organ.  In  the  first  group  come  the  hydrochloric  acid  and  ferments, 
which  arc  so  freely  employed  in  dyspepsia.  The  former  is  the  most  im- 
portant. It  is  the  ingredient  in  the  gastric  juice  most  commonly  deficient. 
It  is  not  only  necessary  for  its  own  important  actions,  but  its  prescace  is 
intimately  associated  Avith  that  of  the  pepsin,  as  it  is  only  in  the  presence 
of  a  sufficient  quantity  that  the  pepsinogen  is  converted  into  the  active 
digestive  ferment.  It  is  best  given  as  the  dilute  acid  taken  in  somewhat 
larger  quantities  than  are  usually  advised.  Ewald  recommends  large 
doses — of  from  90  to  100  drops — at  intervals  of  fifteen  minutes  after  the 
meals.  Leube  and  Riegel  advise  smaller  doses.  Probably  from  15  to  20 
drops  is  sufficient.  The  prolonged  use  of  it  does  not  appear  to  be  in 
any  way  hurtful.  The  use,  however,  should  be  restricted  to  cases  of 
neurosis  and  atrophy  of  the  mucous  membrane.  In  actual  gastritis  its 
value  is  doubtful. 

The  digestive  ferments :  These  are  extensively  employed  to  strengthen 
the  weakened  gastric  and  intestinal  secretions.  The  use  of  pepsin,  ac- 
cording to  Ewald,  may  be  limited  to  the  cases  of  advanced  mucous 
catarrh  and  the  instancef^.  of  atrophy  of  the  stomach,  in  which  it  should 
be  given,  in  doses  of  from  10  to  15  grains,  with  dilute  hydrochloric  acid 
a  quarter  of  an  hour  after  meals.  It  may  be  used  in  various  different 
forms,  either  as  a  powder  or  in  solution  or  given  with  the  acid.  The 
powder  is  much  more  certain.  Pepsin  wine  is  generally  inert,  as  there  is 
little  of  the  ferment  taken  up  by  alcohol.  It  is  important  to  use  a  reliable 
article.    Much  that  is  in  the  market  is  valueless. 

Pancreatin  is  of  equal  or  even  greater  value*  than  the  pepsin.  Pains 
sliould  be  taken  to  use  a  good  article,  such  as  that  prepared  by  Merck.  It 
should  be  given  in  doses  of  from  15  to  20  grains,  in  combination  with 
bicarbonate  of  soda.  It  is  conveniently  administered  in  ttiblets,  each 
of  Mhich  contains  5  grains  of  the  pancreatin  and  the  soda,  and  of  these 
two  or  three  may  be  taken  fifteen  or  twenty  minutes  after  each  meal. 
Ptyalin  and  diastase  jvre  particularly  indicated  when  the  acid  is  excessive. 
The  action  of  the  former  continues  in  the  stomach  during  normal  diges- 
tion.   The  malt  diastase  is  often  very  serviceable  given  with  alkalies. 

f^i  measures  which  stimulate  the  glandular  activity  in  chronic  dys- 
pepsia lavage  is  by  far  the  most  impuitant,  particularly  in  the  forms 
characterized  by  the  secretion  of  a  large  quantity  of  mucus.    Luke- warm 


';    . 


Ml  ■{'     ^ 


358 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


water  should  be  used,  or,  if  there  is  much  mucus,  a  one  per  cent  salt  solu- 
tion, or  a  three  to  five  per  cent  solution  of  bicarbonate  of  soda.  If  there 
is  much  fermentation  the  three  per  cent  solution  of  boric  acid  may  bo 
used,  or  a  dilute  solution  of  carbolic  acid.  It  is  best  employed  in  tlic 
morning  on  an  empty  stomach,  or  in  the  evening  some  hours  after  the 
last  meal.  It  is  perhaps  preferable  in  the  morning,  except  in  those  cases 
in  which  there  is  much  nocturnal  distress  and  flatulency.  Once  a  day  is, 
as  a  rule,  sufficient,  or,  in  the  case  of  delicate  persons,  every  second  day. 
The  irrigation  may  be  continued  until  the  water  which  comes  aAvay  is 
quite  clear.     It  is  not  necessary  to  remove  all  the  fluid  after  the  irrigation. 

While  perhaps  in  some  hands  this  measure  has  been  carried  to  ex- 
tremes, it  is  one  of  such  extraordinary  value  in  certain  cases  that  it  should 
be  more  widely  employed  by  practitioners.  When  there  is  an  insuperable 
objection  to  lavage  a  substitute  may  be  used  in  vhe  form  of  warm  alkaline 
drinks,  taken  slowly  in  the  early  morning  or  the  last  thing  at  night, 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important 
are  the  bitter  tonics,  such  as  quassia,  gentian,  columbo,  cundurango,  ipecacu- 
anha, strychnia,  and  cardamoms.  These  are  probably  of  more  value  in 
chronic  gastritis  than  the  hydrochloric  acid.  Of  these  strychnia  is  the  most 
powerful,  though  none  of  them  have  probably  any  very  great  stimulatitig 
action  on  the  secretion,  and  influence  rather  the  appetite  than  the  digestion. 
Of  stomachics  which  are  believed  to  favorably  influence  digestion  the  most 
important  are  alcohol  and  common  salt.  The  former  would  appear  to  act 
in  moderate  quantities  by  increasing  the  acid  in  the  gastric  juice,  and  with 
it  probably  the  jicpsin  formation.  Others  hold  that  it  is  not  so  much  the 
secretory  as  the  motor  function  of  the  stomach  which  the  alcohoF  stimu- 
lates. In  moderate  quantities  it  has  certainly  no  directly  injurious  influ- 
ence on  the  digestive  processes.  Special  care  should  be  taken,  however,  in 
ordering  alcohol  to  dyspeptics.  If  a  patient  has  been  in  the  habit  of  tak- 
ing beer  or  light  wines  or  stimulants  with  his  meals,  the  practice  may  be 
continued  if  moderate  quantities  are  taken.  Beer,  as  a  rule,  is  not  well 
borne.  A  dry  sherry  or  a  glass  of  claret  is  preferable.  In  the  case  of 
women  with  any  form  of  dyspepsia  stimulants  should  be  employed  witli 
the  greatest  caution,  and  the  practitioner  should  know  his  patient  well 
before  ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  upon  the  fact  that  its 
presence  is  essential  in  the  formation  of  the  hydrochloric  acid.  An  in- 
crease in  its  use  may  be  advised  in  all  cases  of  chronic  dyspepsia  in  Avhieli 
the  acid  is  defective. 

Treatment  of  Special  Conditions. — Fermentation  and  flatu- 
lency. When  the  digestion  is  slow  or  imperfect,  fermentation  goes  on  in 
the  contents,  with  the  formation  of  gas  and  the  production  of  lactic,  bu- 
tyric, and  acetic  acids.  For  the  treatment  of  this  condition  careful  diet- 
ing may  suffice,  particularly  forbidding  such  articles  as  tea,  pastrj',  and 
the  coarser  vegetables.     It  is  usually  combined  with  pyrosis,  in  which  tlio 


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NEUROSES  OF  THE  STOMACH. 


359 


acid  fluids  are  brought  into  the  mouth,  Bismutli  uud  carbonate  of  soda 
sometimes  suffice  to  relieve  tlie  condition.  Thymol,  creosote,  and  carbolic 
acid  may  be  employed.  For  acid  dyspepsia  Sir  William  Iloberts  recom- 
mends the  bismuth  lozenge  of  the  British  Pharmacopeia,  the  antacid 
properties  of  which  depend  on  chalk  and  bicai'bonate  of  soda.  It  should 
be  taken  an  hour  or  two  after  meals,  and  only  when  the  pain  and  un- 
easiness are  present.  Glycerine  in  from  twenty  to  sixty  minim  doses,  the 
essential  oils,  animal  charcoal  alone  or  in  combination  Avith  compound 
cinnamon  p"»wder,  may  be  tried.  If  there  is  much  pain,  chloroform  in 
tAveuty-minim  doses  or  a  teaspuonful  of  Hoffman's  anodyne  may  be  used. 
If  obstinate,  lavage  is  indicated  and  is  sometimes  striking  in  its  effects. 
Alkaline  solutions  may  bo  used. 

Vomiting  is  not  a  .  .aire  which  often  calls  for  treatment  in  chronic 
dyspepsia ;  sometimes  in  children  it  is  a  persistent  symptom.  Creosote 
and  carbolic  acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hy- 
drocyanic acid,  cocaine,  l)ismuth,  and  oxalate  of  cerium  may  bo  used.  If 
obstinate,  the  stomach  should  be  washed  out  daily. 

Constipation  is  a  frequent  and  troublesome  feature  of  most  forms  of 
indigestion.  Occasioaally  small  doses  of  mercury,  podophyllin,  the  laxa- 
tive mineral  waters,  sulphur,  and  cascara  may  be  emi^loyed.  Clycerino  sup- 
positories or  the  injection  of  from  half  a  teaspoonful  o  a  teaspoonful  of 
glycerine  is  very  efficacious. 

Many  cases  of  chronic  dyspepsia  are  greatly  benefited  by  the  use  of 
mineral  waters,  particularly  a  residence  at  the  springs  with  a  careful  super- 
vision of  the  diet  and  systematic  exercise.  The  strict  regime  of  certain 
German  Spas  is  particularly  advantageous  in  the  cases  in  which  the 
chronic  dyspepsia  has  resulted  from  excess  in  eating  and  in  drinking. 
Kissingen,  Carlsbad,  Ems,  and  Wiesbaden  are  to  be  specially  recom- 
mended. 


IV.  NEUROSES  OF  THE  STOMACH. 

(1)  Gastralgia;  Gastrodjniia. — Severe  pains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  {a)  as  a  manifestaiion  of  a  functional  neurosis, 
independent  of  organic  disease,  and  usually  associated  with  other  nervous 
symptoms  (it  is  this  form  which  will  here  be  described) ;  {b)  in  chronic 
disease  of  the  nervous  system,  forming  the  so-called  gastric  crises ;  and 
((')  in  organic  disease  of  the  stomach,  such  as  ulcer  or  cancer. 

The  functional  neur-^sis  occurs  chiefly  in  women,  very  commonly  in 
connection  with  disturbed  menstrual  function  or  with  pronounced  hys- 
terical symptoms.  The  affection  may  set  in  as  early  as  puberty,  but  it  is 
more  common  at  the  menopause.  Anaemic,  constipated  Avomen  who  have 
worries  and  anxieties  at  home  are  most  prone  to  the  affection.  It  is  more 
frequent  in  brunettes  than  in  blondes.  Attacks  of  it  sometimes  occur  in 
robust,  healthy  men.     More  often  it  is  only  one  feature  in  a  condition  of 


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360 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


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general  neurasthenia  or  a  manifestation  of  that  form  of  nervous  dyspepsia 
in  which  the  gastric  juice  or  liydrochlorio  acid  is  secreted  in  excess.  I  am 
very  skeptical  as  to  the  existence  of  a  gastralgia  of  purely  malarial  origin. 

The  symptoms  are  very  characteristic ;  the  patient  is  suddenly  seized 
with  agonizing  pains  in  the  epigastrium,  which  pass  toward  the  back  and 
around  the  lower  ribs.  The  attack  is  usually  independent  of  tlie  takiii<r 
of  food,  and  may  recur  at  definite  intervals,  a  periodicity  which  has  given 
rise  to  the  supposition  in  some  cases  that  the  affection  is  duo  to  malaria. 
The  most  marked  periodicity,  however,  may  be  in  the  gastralgic  attacks  of 
ulcer.  They  fi-equently  come  on  at  night.  Vomiting  is  rare ;  more  com- 
monly the  taking  of  food  relieves  the  pain.  To  this,  however.,  there  are 
striking  exceptions.  Pressure  upon  the  epigastrium  commonly  gives  re- 
lief, but  deep  pressure  may  be  painful.  It  seems  scarcely  necessary  to 
separate  the  forms,  as  some  have  done,  into  irritative  and  depressive,  as  the 
cases  insensibly  merge  into  each  other.  Stress  has  been  laid  upon  the 
occurrence  of  painful  points,  but  they  are  so  common  in  neurasthenia  that 
very  little  importance  can  be  attributed  to  them. 

The  diagnosis  offers  many  difficulties.  Organic  disease  either  of  the 
stomach  or  of  the  nervous  system  must  be  excluded.  In  the  case  of  ulcer 
or  cancer  this  is  not  always  easy.  I  well  remember  the  case  of  a  poor  fel- 
low who  was  discharged  from  the  ^Montreal  General  Hospital  as  a  malin- 
gerer. He  had  been  a  soldier,  was  well  nourished,  had  no  vomiting,  but 
had  severe  attacks  of  abdominal  pain.  The  examination  was  negative,  and 
it  was  thought  to  be  a  case  of  simulation.  A  week  subsequent  to  his  dis- 
charge he  was  readmitted  with  peritonitis  from  perforation.  The  fact 
that  the  pain  is  most  marked  when  the  stomach  is  empty  and  is  relieved 
by  the  taking  of  food  is  sometimes  regarded  as  pathognomonic  of  simple 
gastralgia,  but  to  this  there  are  many  exceptions,  and  in  cancer  the  pains 
may  be  relieved  on  eating.  The  prolonged  intervals  between  the  attacks 
and  their  independence  of  diet  are  important  features  in  simple  gastralgia; 
but  in  many  instances  it  is  less  the  local  than  the  general  symptoms  of  the 
case  which  enable  us  to  make  the  diagnosis. 

(2)  Nervous  Dyspepsia. — According  to  Leube,  who  first  separated  it 
from  the  ordinary  gastric  catarrh,  nervous  dyspepsia  is  characterized  by 
sensations  of  distress  and  uneasiness  during  digestion,  and  yet  the  act  is 
accomplished  within  the  physiological  time  limit.  The  studies  of  Ewald, 
Oser,  Rosenbach,  and  others  have  greatly  extended  our  knowledge  of  the 
condition.  The  cases  are  met  with  most  frequently  in  those  who  have 
either  inherited  a  neurotic  constitution  or  have  gradually,  through  indis- 
cretions, brought  about  a  condition  of  nervous  prostration.  All  grades  oc- 
cur, from  the  emaciated,  skeleton-like  subject  of  anorexia  nervosa  to  the 
well-nourished,  healthy-looking,  fresh-complexioned  patient  whose  con- 
stant complaint  is  distress  and  uneasiness  after  eating.  If  in  a  case  of 
dyspepsia  the  stomach  is  found  empty  seven  hours  after  the  test  dinner, 
the  supposition  is  that  the  trouble  is  nervous  (Leube).     The  separation  of 


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NEUROSES  OF  THE  STOMACH. 


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the  different  forms  can  only  be  made  accurately  by  the  chemical  examina- 
tion of  the  juices. 

Clinical  Forms. — Leube  recognizes  three  chief  types,  (a)  Nervous 
dyspepsia  with  normal  secretion.  There  is  no  dilatation  of  the  stomach, 
no  pain  on  pressure,  and  no  change  in  the  condition  of  the  acid.  The 
test  meal  is  digested  witliin  the  normal  time.  Yet,  despite  the  fact  that 
the  motor  and  chemical  functions  of  the  organ  are  perfectly  performed, 
there  are  distress  and  uneasiness  during  the  act  of  digestion.  The  patient 
complains  of  pressure  and  distention  of  the  stomach ;  eructations  occur. 

(A)  The  condition  of  subacid ity  or  inacidity.  Lack  of  the  normal 
amount  of  acid  is  found  in  chronic  catarrh,  and  particularly  in  cancer. 
According  to  Leube,  reduction  in  the  normal  amount  of  acid  may  exist 
with  the  most  pronounced  symptoms  of  nervous  dyspepsia,  and  yet  the 
stomach  will  be  free  from  food  within  the  regular  time.  A  condition  in 
which  the  gastric  juice  is  entirely  without  acid  may  occur  in  cancer,  in  ex- 
treme sclerosis  of  the  mucous  membrane,  and  as  a  nervous  manifestation 
of  hysteria,  and  occasionally  of  tabes.  The  most  aggravated  cases  are 
those  associated  with  hysteria  and  neurasthenia.  In  addition  to  the  gen- 
eral symptoms,  there  are  loss  of  appetite,  sleeplessness,  and  gastric  distress, 
and  wi  n  the  stomach  is  empty  there  are  uneasy  local  sensations  and  gen- 
eral feeli  nfs  of  malaise,  headache,  and  dizziness. 

(c)  Nervous  dyspepsia  with  hj'peracidity  of  the  gastric  juices.  This  is 
a  form  of  dyspepsia  which  has  long  been  recognized,  but  of  late  has  been 
specially  studied  by  Reichman  and  others.  The  percentage  of  acid  may 
be  doubled.  This  increase  in  the  acid  may  be  an  intermittent  condi- 
tion or  continuous.  The  periodic  form  is  really  a  neurosis  of  secretion — 
(jadroxynsis  of  Rosenbach — which  may  be  quite  independent  of  the  time 
of  digestion.  Such  cases  are  rare  and  are  associated  either  with  profound 
neurasthenia  or  with  locomotor  ataxia.  The  attack  may  last  for  several 
days.  It  usually  sets  in  with  a  gnawing,  unpleasant  sensation  of  the 
stomach,  severe  headache,  and  shortly  after  the  patient  vomits  a  clear, 
watery  secretion  of  such  acidity  that  the  throat  is  irritiited  and  made 
raw  and  sore.  As  mentioned,  the  attacks  may  be  quite  independent  of 
food,  The  chronic  condition  of  hyperacidity  is  more  common.  Digestion 
is  usually  retarded,  particularly  for  the  starches,  and  there  are  eructations 
of  acid  fluid  and  gastric  distress.  There  are  instances  also  in  which  when 
the  stomach  contains  no  food  there  is  a  secretion  of  a  highly  acid  juice. 
In  tliese  cases  burning  acid  eructations,  or  even  vomiting,  occurring  during 
the  night  or  early  in  the  morning,  are  quite  characteristic. 

Th(!  relation  of  hyperacidity  to  gastric  ulcer  will  be  considered  later. 
(^5)  Nervous  Vomiting ;  Peristaltic  Unrest ;  Rumination.— (rr)  Nerv- 
ous Vomiting' — a  condition  which  is  not  associated  with  anatomical 
changes  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due  to 
nervous  influences  acting  either  directly  or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.  The  patients  are,  as  a  rule,  women — 
24 


;       '  ,    ,     Hi.. 

It     r   '■'l  '  i'.i* 


r.  •, 


3G2 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


usually  brunettes — niul  the  subject  ol  more  or  less  marked  hysterical  mani- 
festations. A  special  feature  of  this  form  is  the  absence  of  the  preUmi- 
nary  nausea  and  of  the  straining  efforts  of  the  ordinary  act  of  vomitinp. 
It  is  rather  a  regurgitation,  and  without  visible  effort  and  without  gag- 
ging the  mouth  is  tilled  witli  tlie  contents  of  the  stomach,  whicli  nrc  then 
spat  out.  It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular 
intervals.  In  some  cases  the  nutrition  is  not  impaired,  a  feature  which 
may  give  a  clow  to  the  true  nature  of  the  disease,  as  there  may  bo  no  otlur 
hysterical  manifestation  present.  As  noted  by  Tuckwell,  it  may  occur  in 
children.  Xervous  vomiting  is  rarely  serious.  Death  nuiy,  howevei-,  fol- 
low, as  in  the  case  reported  by  (Jarland,*  in  which  a  young  wonuin,  aged 
twenty,  had  had  from  the  age  of  two  attacks  of  vomiting  which  lasted  for 
twenty-four  hoi;rs,  and  which  were  very  apt  to  occur  when  the  child  was 
extra  well  and  vivacious.  She  had  St.  Vitus's  dance  at  eleven.  At  ahor.t 
the  age  of  twenty,  she  had  excessive  muscular  twitchings,  clonic  in  char- 
acter and  uncontrollable,  and  amounting  to  violent  motion  of  the  nnisolos. 
When  twenty-two  she  had  severe  headache,  gradually  lost  flesh,  and  be- 
came low-spirited.  In  January,  1884,  she  had  headache,  twitching,;,  and 
constant  vomiting,  and  died  on  the  13th.  There  was  slight  atrophy  of 
the  mucous  membrane  of  the  stomach  and  slight  increase  in  the  firnuiess 
of  the  kidneys. 

A  type  of  vomiting  is  that  associated  with  certain  diseases  of  the  iicrv- 
0U8  system — particularly  locomotor  ataxia — forming  part  of  the  gastric 
crises.  Leyden  lias  reported  cases  of  primary  periodic  vomiting,  A^hicli  he 
regards  as  a  neurosis. 

(b)  Peristaltic  Unv^st. — This  condition,  as  described  by  Kussmanl,  is 
an  extremely  common  and  distressing  symptom  in  neurasthenia.  Shortly 
after  eating  the  peristaltic  movements  of  the  stomach  are  increased,  and 
borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  'J'he  sub- 
jective sensations  are  most  annoying,  and  it  would  appear  as  if  in  the 
hyperaesthetic  condition  of  the  nervous  system  the  patient  felt  normal 
peristalsis,  just  as  in  these  states  the  usual  beating  of  the  heart  may 
be  perceptible  to  him.  A  further  analogy  is  afforded  by  the  fact  that 
emotion  increases  this  peristalsis.  It  may  extend  to  the  nitestines,  par- 
ticularly to  the  duodenum,  and  on  palpation  over  this  region  the  gur- 
gling is  most  marked.  The  movement  may  be  anti-peristalsis,  in  which 
the  wave  passes  from  left  to  right,  a  condition  which  may  also  extend  to 
the  intestines.  There  are  cases  on  record  in  which  colored  enenuita  or 
even  scybala  have  been  discharged  from  the  mouth. 

(c)  Elimination ;  Merycismus. — In  this  remarkable  and  rare  condi- 
tion the  patients  regurgitate  and  chew  the  cud  like  ruminants.  It  occurs 
in  neurasthenic  or  hysterical  persons,  epileptics,  and  idiots.  In  some  in- 
stances it  is  lieredittiry.     There  is  an  instance  in  which  a  governess  taught 

*  Transactions  of  the  Association  of  American  Physicians,  vol.  iv. 


*:<:-\l. 


NEUROSES  OF  THE  STOMACH. 


303 


it  to  two  cliildren.     The  habit  may  persist  for  years,  and  docs  not  noces- 
Kiiiily  impair  tlie  health. 

Treatment  of  Neuroses  of  the  Stomach. — The  gastralfriu,  if 
vorv  severe,  requires  niorpliia,  wiiicii  is  best  administered  sidx'utaiieously 
in  eond)ination  with  atrojjia.  In  tlie  milder  attacks  the  combination  f)f 
iiiDrphia  (gr.  ^)  with  cocaine  and  belladonna  is  recommended  by  Ewald. 
The  greatest  caution  should,  liowever,  jc  exercised  in  these  cases  in  the 
use  of  the  hypodermic  syringe.  It  is  jjreferable,  if  opium  is  necessary,  to 
give  it  by  the  mouth,  and  not  to  let  the  ])atient  know  the  character  of  the 
drug.  Chloroform,  in  from  ten  to  twenty  drop  doses,  or  IIotTman's  ano- 
(Ivtie  will  sometimes  allay  the  severe  jjains.  The  general  condition  should 
receive  careful  attention,  and  in  many  cases  the  attacks  recur  until  the 
health  is  restored  by  change  of  air  witii  the  prolonged  use  of  arsenic.  If 
tliere  is  anaemia  iron  nuiy  be  given  freely.  Xitrate  of  silver  in  doses  of 
gr.  ^  to  ^  in  a  large  claret-glass  of  water  taken  on  an  empty  stomach  is 
u rueful  in  some  cases. 

Many  cases  of  nervous  dyspepsia  with  marked  neurasthenic  or  hysteri- 
cal symptoms  do  well  on  the  Weir-Mitchell  treatment,  and  in  obstinate 
forms  it  should  be  given  a  thorough  trial.  The  most  striking  results 
are  perhaps  seen  in  the  cases  of  anorexia  nervosa,  which  will  be  referred 
to  sul)sequently.  It  is  also  of  value  in  the  nervous  vomiting.  In  the  dis- 
tressing cases  of  hyperacidity,  in  addition  to  the  treatment  of  the  general 
neurotic  condition,  alkalies  must  be  employed,  either  in  the  form  of  mag- 
nesia or  bicarbonate  of  soda.  The  burning  acid  eructations  are  usually 
relieved  in  this  Avay. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure 
in  many  cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should 
be  taken  eilher  raw  or,  if  an  insuperable  objection  exists  to  this,  very 
slightly  cooked.  It  is  best  given  finely  minced  or  grated  on  stale  bread. 
An  ample  dietary  is  3^  ounces  (100  grammes)  of  meat,  two  medium 
slices  of  stale  bread,  and  an  ounce  (30  grammes)  of  butter.  This  may 
be  taken  three  times  a  day  with  a  glass  of  Apollinaris  water,  soda  water, 
or,  what  is  just  as  satisfactory,  spring  water.  The  fluid  should  not  be 
taken  too  cold.  Special  care  should  be  liad  in  the  examination  of  the 
meat  to  guard  against  tape-worm  infection,  but  suitable  instructions  on 
this  i)oint  can  be  given.  This  is  suflJicient  for  an  adult  man,  and  many 
obstinate  cases  yield  satisfactorily  to  a  month  or  six  weeks  of  this  treat- 
ment, after  which  time  the  less  readily  digested  articles  of  food  may  be 
gradually  added  to  the  dietary.  In  other  instances  the  use  of  the  stom- 
aeh-tubc  is  most  effectual. 

There  are  forms  of  nervous  dyspepsia  occurring  in  women  who  are 
often  w(>ll  nourished  and  with  a  good  color,  yet  who  suffer — particularly  at 
niglit — with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet, 
and  undisturbed  for  two  or  three  hours,  when  they  are  aroused  with  pain- 
ful sensations  in  the  abdomen  and  eructations.    The  appetite  and  diges- 


364 


DISEASES  OP  THE   DIGESTIVE  SYSTEM, 


ti()!i  may  appear  to  be  normal.  Constipation  is,  however,  usually  present. 
Iti  ma!iy  of  these  patients  tl>e  eondition  seems  rather  intestinal  dysjuipsiu, 
and  the  distress  is  due  to  the  accumulation  of  jjjases,  the  result  of  excess- 
ive putrefaction.  The  fats,  starches,  and  sugars  should  bo  restritited.  A 
diastase  ferment  is  sometimes  useful.  The  flatulency  nuiy  be  treated  by 
the  methods  above  mentioned.  Xaphthalin,  salicylate  of  bismuth,  uiu] 
salol  have  been  recommended.  Some  of  these  cases  obtain  relief  from 
thorough  irrigation  of  the  colon  at  bedtime. 


V.    DILATATION   OF  THE  STOMACH   [Gnslrectams). 


f,  V  i  ' ; 


«  ■' 


Etiology. — This  may  occur  either  as  an  acute  or  a  chronic  con- 
dition. 

Acute  dilatation  is  rarely  seen,  though  it  occurs  whenever  enormous 
quantities  of  food  and  drink  are  quickly  ingested.  Occasionally  this  loads 
to  extreme  paralytic  dilatation,  and  Fagge  has  described  two  cases  which 
came  on  in  this  way,  one  of  which  proved  fatal. 

Chronic  dilatation  results  from :  (rt)  Narrowing  of  the  pylorus  or 
of  the  duodenum  by  the  cicatrization  of  an  ulcer,  hypertrophic  stenosis  of 
the  pylorus  (whether  cancerous  or  simple),  congenital  stricture,  or  occa- 
sionally by  pressure  from  without  of  a  tumor  or  of  a  floating  kidney,  (h) 
Relative  or  absolute  insufficiency  of  the  muscular  power  of  the  stomiK^h, 
due,  on  lo  hand,  to  repeated  overfilling  of  the  organ  with  food  and 

drink  <  -•Mstreuffunr/  dcs  Mar/ens,  Striimpell),  and,  on  the  other,  to 

atony  of  tne  coats  induced  by  chronic  inflammation  or  degeneration  or 
impaired  nutrition,  the  result  of  constitutional  affections,  as  cancer,  tuber- 
culosis,  anaemia,  etc. 

The  most  extreme  forms  are  met  with  in  the  first  group,  and  most 
commonly  as  a  sequence  of  the  cicatricial  contraction  of  an  ulcer.  There 
may  be  considerable  stenosis  without  much  dilatation,  the  obstruction  being 
compensated  by  hypertrophy  of  the  muscular  coats.  Considerable  atten- 
tion has  been  directed  in  Germany  by  Litten,  Ewald,  and  others  to  the 
association  of  dilatation  with  dislocation  of  the  right  kidney.  Two  well- 
marked  instances  have  come  under  my  observation  among  a  very  large 
number  of  cases  of  movable  kidney,  but  in  neither  was  the  dilatation  ex- 
treme. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  must  dis- 
tinguish between  instances  in  which  the  stomach  is  simply  enlarged  and 
those  with  actual  dilatation,  the  conditions  which  Ewald  characterized  as 
megastrie  and  gastrectasis  respectively.  The  size  of  the  stomach  varies 
greatly  in  different  individuals,  and  the  maximum  capacity  of  a  normal 
organ  Ewald  places  at  about  1,G00  c.  c.  Measurements  above  this  point 
indicate  absolute  dilatation.  -  ^ 

■      Atonic  dilatation  of  the  stomach  may  result  from  weakness  of  the 


m-"nr^    [ 


DILATATION  OF  THE  STOMACH. 


3(16 


coalrf,  duo  to  repeated  overdistontioii  or  to  chroiiio  catarrh  of  tlio  mucous 
iiiciiihniiio,  or  to  the  general  niuscudar  debility  which  i.s  associated  with 
clironic  wasting  disorders  of  all  sorts.  The  cojuhinalioii  of  chronic  gastric 
catarrh  witii  overfeeding  and  excessive  drinking  is  one  of  the  most  fruit- 
ful sonnies  of  atonic  dilat;ition,  as  ])ointetl  out  by  Naunyn.  The  condition 
is  freciuently  seen  in  diabetics,  in  the  insane,  and  in  beer-drinkers.  In 
(ioriuany  this  form  is  very  common  in  men  employed  in  the  breweries, 
wliu  sometimes  drink  from  twenty  to  thirty  litres  of  beer  in  the  day.  Tiu^ 
extraordinary  size  to  which  the  organ  attains  in  some  of  these  cases  is 
well  shown  by  the  papicr-macJie  models  Avhich  have  been  j)repared  uiuler 
von  Ziemssen's  directions.  Possibly  muscular  weakness  of  the  coats  may 
rc'sidt  in  some  cases  from  disturbed  innervation.  Dilatation  of  (he 
Ptiiinach  is  nu)st  frequent  in  middle-aged  or  elderly  persons,  but  the 
couiliti(jn  is  not  uncommon  iu  children,  especially  in  association  with 
rickets. 

Symptoms. — These  are  very  variable  and  deperul  upon  the  cause 
and  tiie  d(;gree  of  dilatation.  Naturally  the  features  in  caiu-er  of  the  py- 
lorus would  be  very  different  from  those  met  with  in  an  excessive  drinker. 
Dyspepsia  is  present  in  neai'ly  all  cases,  and  there  are  feelings  of  distress 
and  uneasiness  in  the  region  of  the  stomach.  The  patient  may  comjjlain 
inncli  of  hunger  and  thirst  and  eat  and  drink  freely.  The  most  character- 
isti(!  symjitom  is  the  vomiting  at  intervals  of  enormous  quantities  of  licjuid 
and  of  food,  amounting  sometimes  to  four  or  more  litres.  The  material 
is  often  of  a  dark-grayish  color,  with  a  characteristic  sour  odor  due  to  the 
organic  acids  present,  and  contains  mucus  and  remnants  of  food.  On 
standing  it  separates  into  three  layers,  the  lowest  consisting  of  food,  the 
middle  of  a  turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth. 
The  microscopical  examiiuition  shows  a  large  variety  of  bacteria,  yeast 
fungi,  and  the  sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum 
stoiios,  and  grape  seeds. 

Chemically  the  hydrochloric  acid  may  be  absent,  diminished,  normal, 
or  in  ?;xcess,  depending  upon  the  cause  of  the  dilatation.  The  fermenta- 
tion produces  lactic,  butyric,  and,  possibly,  acetic  acids  and  various  gases. 
In  consequence  of  the  small  amount  of  fluid  which  passes  from  the 
stomach  or  is  absorbed  there  are  constipation,  scanty  nrine,  and  extreme 
dryness  of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly; 
tlusre  is  loss  of  flesh  and  strength,  and  in  some  cases  the  most  extreme 
emaciation.  A  very  remarkable  symptom  which  occurs  occasionally  is 
tetany,  first  desci  ibed  by  Kiissmaul.  The  spasm  affects  chiefly  the  muscles  of 
tlio  hands,  arms,  and  legs.  Loss  of  consciousness  may  occur.  The  spasms 
last  for  a  short  time  only.  Miiller  has  collected  eight  cases  of  the  kind, 
two  of  which  occurred  in  simple  dilat-  tion  of  the  stomach. 

Physical  Signs. — Inspection. — The  abdomen  nniy  be  large  and  promi- 
nent, the  greatest  projection  occurring  below  the  navel  in  the  standing 
posture.    In  some  instances  the  outline  of  the  distended  stomach  can  be 


'  .^ 


306 


DISKASKS  OF  TIIK   DIOKSTIVK  SYSTKM. 


j)liiiiily  seen,  tlui  siiiull  ciirvuiuro  a  coiipk'  of  iiichcH  holow  tlio  ('iiBifnrrn 
(furtilagc,  and  the  /^Mvutcr  ciirvatiire  jiussiiij;  (ibliciiicly  from  tin;  tip  of  lIh! 
tonth  rib  on  tlio  left  side,  toward  the  [)ul)t'S,  and  tiion  ciTvinj;  upward 
to  tlie  right  co.stal  niuryiii.  Tlu're  arc  inKtances  in  v  iiich  inHpi-ctiou 
alone  reveals,  at  a  ijiaiicc,  the  nat':re  of  the  ease.  Active  perislnlsis  may 
he  seen  in  the  dilated  orf,'an,  the  waves  passing  from  left  to  right.  Occa- 
sionally anti-peristalsis  may  he  seen.  Ii\  eases  of  stricture,  purtieidarly  of 
hypertrophie  stenosis,  as  the  peristaltic  wave  reaches  tho  pylorus,  tlm 
tumor-like  thickening  can  sometimes  bo  distinctly  seen  through  the  tliiu 
abdominal  wall.  To  stimulate  the  peristalsis  the  abdomen  may  he  llippul 
with  a  wet  towel. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  the 
tunu)r  is  evident  at  tho  pylorus.  The  resistance  of  a  dilated  stonuich  is 
j)eeuliar,  and  has  been  aptly  compared  to  that  of  an  air  cushion.  Hi- 
numual  palj)ation  elicits  a  splashing  sound,  which  is,  of  course,  not  dis- 
tinctive, as  it  can  be  obtained  whenever  there  is  much  licpiid  and  air  in 
tlie  organ,  but  it  cannot  be  obtained  in  a  healthy  person  two  or  thice 
hours  after  eating.  1'he  splashing  may  be  very  loud,  and  the  i)atient  may 
produce  it  himself  by  suddenly  depressing  the  diaphragm,  or  it  may  h(i 
readily  obtained  by  shaking  hi'.7i.  i^  tube  i)assed  into  the  stomach  nuiy  he 
felt  externally  through  the  skin,  a  procedure  no  longer  recommended  by 
Leube,  who  suggested  it. 

Percus.non. — Thj  note  is  tympanitic  over  the  greater  portion  of  ii 
dilated  stomach  ;  in  tlic  dependeiit  part  the  note  is  dull.  In  tho  uj)riglit 
])osition  the  percussion  should  be  made  from  above  downward,  in  the  left 
parasternal  line,  until  a  change  in  resonance  is  reached.  The  line  of  this 
should  be  marked,  and  the  patient  examined  in  tlie  recumbent  jjositiou, 
when  it  will  be  found  to  have  altered  its  level.  When  this  is  on  a  line 
with  the  navel  or  below  it,  dilatation  of  tho  stomach  may  generally  ho 
assumed  to  exist.  This  sign  may  be  deceptive  in  women  with  lax  abdo- 
men, as  the  whole  organ  may  be  depressed,  the  lesser  curvature  coming, 
perhaps,  as  low  as  the  navel.  The  fluid  may  be  withdrawn  from  the 
stomach  with  a  tube,  and  the  dulness  so  made  to  disappear,  or  it  may  he 
increased  by  pouring  in  more  fluid.  In  cases  of  doubt  the  organ  may  bo 
artificially  distended  with  carbonic-acid  gas.  A  teaspoonful  of  bicarl)()n- 
ate  of  soda  is  first  given  in  a  little  water,  and  then  the  same  quantity  of 
tartaric  acid.  The  most  accurate  method  of  determining  the  size  of  tlio 
stomach  is  by  inflation  through  a  stomach-tube  with  a  Davidson's  syringe. 
Pacanowski  has  shown  that  the  greatest  vertical  diameter  of  gastric  res- 
onance in  the  normal  stomach  varies  from  10  to  14  cm.  in  the  male  and  is 
about  10  cm.  in  the  female. 

AuscuUntion. — The  clapotement  or  sncciission  can  be  obtained  readily. 
Frequently  a  curious  sizzling  sound  is  present,  not  unlike  that  heard  whoa 
the  ear  is  placed  over  a  soda-water  bottle  when  first  oi)cned.  It  can  be 
heard  naturally,  and  is  usually  evident  when  the  artificial  gas  is  being 


v-i^M 


DILATATION  OF  THE  STOMACH. 


867 


m-r-  ^ 


» 


pMUTtitctl.     Tlio  liciirt.  soiiikIs  nmy  Koniotlmcs  ]tv  trininniitti'il  witli  ^rcat 
rlciirnt'ss  and  witi   ii  iiictalli*!  (|iiality. 

Mvnsiirntioii  iimy  l>o  iiHi'd  by  iMissiiig  >i  lianl  .snimd  into  tlui  Htoiniich 
until  tiio  ^ri'utdr  ciirvuturo  is  rcaclii'd.  Ndrniuliy  it  rarely  pJiHst'H  more 
tliau  <)0  fni.,  iiicasurcd  from  the  tci-tli,  hut  in  cases  of  dilatation  it  may 
pass  as  niueli  as  "0  em. 

Diagnosis. — 'I'iu*  diagnosis  can  usually  l)o  mado  without  much  ditH- 
culty  hy  attenti(m  to  tlioso  nicthods  of  oxaminution.  Curious  errors,  lu>w- 
cver,  uro  on  record,  one  of  tho  most  renuirkahle  of  which  was  tho  con- 
fuiiiiiliiij:  of  dilated  stomacli  with  an  ovarian  <'yst ;  even  after  lappinj^ 
and  the  renutval  of  portioJis  of  food  aiul  fruit  seeds,  abdoiniiud  section 
was  jK'rf(»rmed  and  tho  dilated  stonuich  o])eiu'd.  The  prni/iii>,sis  is  hiul 
in  cases  in  which  there  is  stenosis  of  the  pylorus,  either  simple  or  cun- 
oerons. 

Treatment. — With  care,  tho  dilatation  consequent  ui)on  simple  steiu>- 
sis  is  not  inconipatibhi  with  numy  years  of  life,  in  tlu^  cases  due  to  atony 
careful  rejjulation  of  the  diet  uiul  ])roper  treatment  oi"  ;  he  associated  euturrh 
will  sutlice  to  eU'ect  a  cure.  Strychnine,  er^'ot,  an  1  iion  are  recommended. 
Washing  out  the  stonuich  is  of  great  servic(>,  thouj;;!;  we  do  not  se(;  such 
striking  and  immediate  results  in  this  form.  In  ca.^es  of  mechanical  oh- 
stru(  tif.n  the  stojuaoh  should  he  emptied  and  thoroughly  washed,  either 
with  warm  water  or  with  an  antise{)tic  solutic^n.  As  Welch  states,  in  liis 
exhaustive  article  on  this  subject,  we  accomplish  in  this  way  three  impor- 
tant things :  We  remove  the  weight,  wliich  helps  to  disteiul  the  organ; 
Wf  rtiiMove  the  mucus  and  the  stagnating  and  fermenting  nuiterial  which 
irritates  and  inflames  the  stonuich  and  imi)edes  digestion ;  and  we  cleanse 
the  inner  surface  of  the  organ  by  the  application  of  water  and  medicinal 
siihstaiices.  The  introduction  of  this  method  by  Kiissmaul,  in  18^7,  has' 
|)ni(ti('ally  revolutionized  the  treatment  in  diseases  of  the  stomach.  The 
nii'thod  of  api»licatio:i  has  already  been  referred  to  The  patient  can 
usually  be  taught  to  wash  out  his  own  stomach,  and  in  a  case  of  dilatation 
from  simjjle  stricture  I  have  known  the  practice  to  be  followed  daily  for 
tlirec  years  with  great  benefit.  The  rapid  reduction  in  the  size  of  the 
stdiuach  is  often  remarkable,  the  vomiting  ceases,  the  food  is  taken  readily, 
and  in  many  cases  the  general  nutrition  improves  ra])idly.  As  a  rule, 
(jnce  a  day  is  sufficient,  and  it  may  be  ])ractised  either  the  first  thing  in 
the  morning  or  before  going  to  bed.  So  soon  as  the  fermentative  pro- 
cusses  have  been  checked,  lukewarm  water  alone  should  bo  used. 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals, 
and  should  consist  of  sciaped  beef,  Leube's  beef  solution,  and  tender 
meats  of  all  sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided. 
Liqnids  should  be  taken  sparingly. 

In  cicatricial  stenosis  of  the  pylorus  Loreta  has  practised  dilatation 
with  considerable  success.  The  statistics  of  Barton  show  that  of  2,5  pub- 
hshod  cases  15  recovered  and  10  died. 


^»! 


r 


\H  tHii 


'li; 


368 


DISExiSES  OP  THE  DIGESTIVE  SYSTEM. 


VI.  THE  PEPTIC  ULCER-GASTRIC  AND  DUODENAL. 

The  round,  perforating  or  simple  ulcer  is  usuully  single  and  ocenrd  in 
the  stoniacli  and  in  !  i:e  duodenum  as  far  as  the  papilla  biliuria.  It  proba- 
ably  follows  nutritional  disturbance  in  a  limited  region  of  the  mucosa, 
which  results  in  the  gradual  destruction  of  this  area  by  the  gastric  juice. 
The  condition  is  usually  associated  with  hyperacidity. 

Etiology.— Clinically  the  simple  ulcer  is  not  so  frequent  as  the  sta- 
tistics of  post-mortems  would  lead  us  to  expect ;  thus  in  the  extensive  rec- 
ords collected  by  Welch,  ulcer,  cicatrized  or  open,  Mas  present  in  about 
five  per  cent  of  persons  dying  from  all  causes.  The  scars  are  found  more 
frequently  than  the  open  ulcer. 

Females  are  more  frequently  affected  than  males.  Of  1,099  cases  col- 
lected from  hos2)ital  statistics  by  Welch,  and  examined  post  mortem,  40 
per  cent  were  in  nudes  and  GO  per  cent  were  in  females.  He  gives  the 
age  incidence  in  GOT  cases,  of  which  three  fourths  were  distributed  be- 
tween the  ages  of  twenty  and  sixty,  with  tolerable  uniformity  in  the  four 
decades.  In  females  the  largest  number  of  cases  occurs  between  twenty 
and  thirty ;  in  males,  between  thirty  and  forty.  Ulcer  occasionally  oc- 
curs in  children,  and  fJoodhart  has  reported  a  case  in  an  infant  thirtv 
hours  old.  Gastric  ulcer  is  stated  to  be  less  common  in  this  country  than 
in  Europe. 

In  Avomen  it  is  frequent  among  servant  girls,  and  in  men  who  follow 
ench  occupations  as  shoe-nuiking,  weaving,  and  tailoring,  possibly  connect- 
ed, as  Ilabershon  suggested,  with  pressure  on  the  stomach.  This  view 
has  been  develojied  by  Rasmussen,  who  holds  that  pressure  of  the  costal 
margin,  from  various  causes,  induces  ana?mia  and  atrophy  of  the  mucous 
membrane,  particularly  in  the  region  of  the  smaller  curvature.  Very 
rarely  the  disease  originates  from  traumatism  or  the  action  of  corrosive 
fluids.  Oastric  ulcer  is  associated  in  a  special  manner  with  certain  dis- 
eases, in  women  with  anaemia  and  chloi'osis  and  with  menstrual  disorders. 
It  is  not  infrequently  met  with  in  tuberculosis.  Such  cases  are  not,  how- 
ever, to  be  mistaken  for  the  true  tuberculous  ulcer,  which  may  be  found  in 
the  stomach. 

Many  cases  liave  occurred  in  connection  with  disease  of  the  heart  or 
of  the  blood-vessels,  a  relation  of  special  interest  in  connection  witli  tlu' 
embolic  theory  of  its  production. 

The  duodenal  xdcer  is  less  common  than  the  gastric  ulcer,  and  occurs 
most  frequently  in  nudes.  '^Fhe  combined  statistics  of  Krauss,  Chvostek, 
Lebert,  and  Trier  give  171  cases  in  males  and  39  in  females.  In  9  cases 
which  have  come  under  my  observation  7  were  in  males  and  3  in  females; 
one  of  these  was  in  a  lad  of  twelve.  It  has  been  found  in  association  with 
tuberculosis,  and  may  follow  large  superficial  burns. 

Morbid  Anatomy. — Though  usually  single,  the  ulcers  nmy  be  midti- 
ple.   In  none  of  my  cases  were  there  more  than  five,  but  there  is  an  instance 


THE  PEPTIC  ULCER-GASTRIC  AND  DUODENAL 


369 


on  record  of  thirty-four.  The  ulcer  is  pituated  most  commonly  on  the 
])().sterior  wall  of  the  pyloric  portion  at  or  near  the  lesser  curvature.  It  is 
not  nearly  so  frequent  on  the  anterior  wall.  Of  793  cases  collected  by 
Welch  from  hosi)ital  statistics,  288  were  on  the  lesser  curvature,  235  on 
the  posterior  wall,  95  at  the  pylorus,  69  on  the  anterior  wall,  50  at  the 
cardia,  29  at  the  fundus,  27  on  the  greater  curvature.  The  duodenal 
ulcer  is  usually  situated  just  outside  the  ring  in  the  first  portion  of 
the  gut. 

The  ulcer  varies  from  1  to  10  cm.  in  diameter.  It  may  be  small  and 
punched  out,  or  it  may  reach  an  enormous  size.  The  largest  of  which  I 
have  any  knowledge  is  one  reported  by  Peabody,  which  measured  19  by 
10  em.  and  involved  all  of  the  lesser  curvature  and  spread  over  a  large 
part  of  the  anterior  and  posterior  walls.  The  ulcer  is  usually  round  or 
oval  in  shape,  but  may  be  irregular  with  sinuous  borders.  It  is  often  dis- 
tinctly terraced.  In  acute  cases  the  mucous  membrane  is  siiarply  cut,  as 
if  punched  out  by  an  instrument.  In  old  cases  the  edge  is  indurated  and 
loses  the  sharp  margin.  The  floor  is  formed  either  by  the  submucosa,  by 
the  muscular  layers,  or,  not  infrerpiently,  by  the  neighboring  organs,  to 
which  the  stomach  has  become  attached.  In  the  healing  of  the  ulcer,  if 
the  mucosa  is  alone  involved,  the  granulation  tissue  develops  from  ihe  edges 
and  the  tloor  and  the  newly  formed  tiss^o  gradually  contrac  s  and  unites 
tlio  margins,  leaving  a  smooth  scar.  In  larger  ulcers  which  have  become 
deep  and  involved  the  muscular  coat  the  cicatricial  contraction  may  cause 
serious  clianges,  the  most  important  of  which  is  narrowing  of  the  ])ylorio 
orifice  and  consequent  dilatiition  of  the  stomach.  In  the  case  of  a  girdle 
ulcer,  hour-glass  contraction  of  the  stomach  may  be  produced.  It  is  prob- 
able that  large  ulcers  persist  for  years  Avithout  any  attcm})t  at  healing. 

Tlie  ulcer  may  deepen  and  penetrate  the  coats.  Fortunately,  in  a 
majority  of  the  cases,  adhesions  form  between  the  stomach  and  adjacent 
organs,  particularly  Avith  the  pancreas',  the  left  lobe  of  the  liver,  and  the 
omental  tissues  On  the  anterior  surface  of  the  stomach  adhesions  do  not 
so  readily  form,  hence  the  great  danger  of  the  ulcer  in  this  situation, 
which  more  readily  perforates  and  excites  a  diffuse  and  fatal  peritonitis. 
On  tlie  posterior  wall  the  ulcer  penetrates  directly  into  the  lesser  peri- 
toneal cavity,  in  which  case  it  may  jirodnce  an  .  a'-conlaining  abscess  with 
the  syuii)t()ins  of  the  condition  known  as  subphrenic  pyo-pneumothorax. 
In  rare  instances  adhesions  and  a  gastro-cutaneous  fistula  form,  usually 
in  tlie  umhdical  regioii.  Fistulous  communication  with  the  colon  may 
also  occur,  or  a  gastro-duodenal  fistula.  'Inhere  are  several  instances  on 
rucord  of  jierforation  into  the  pericardium,  and  at  least  two  of  rupture 
into  the  left  A'cntricle.  Perforation  into  the  i)leura  may  also  occur.  It  is 
to  bo  noted  that  general  emphysema  of  the  subcutjineous  tissues  occasion- 
ally follows  perforation  of  a  gastric  ulcer. 

One  of  the  most  serious  effects  of  gastric  ulcer  is  erosion  of  blood-ves- 
sels.   The  haemorrhage  may  occur  in  the  acutely  formed  ulcer  or  in  the 


370 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


ulceration  whicli  takes  place  at  the  base  of  the  chronic  form ;  it  is  in 
the  latter  condition  that  the  bleeding  is  most  common.  Ulcers  on  tlio 
posterior  wall  may  erode  the  splenic  artery,  but  perhaps  more  frequently 
the  bleeding  proceeds  from  the  artery  of  the  lesser  curve.  In  the  case  of 
duodenal  ulcer  the  pancreatico-duodenal  artery  may  be  eroded  or  (as  in 
one  of  my  cases)  fatal  hicmorihage  may  result  from  the  opening  of  the 
hepatic  artery,  or  more  rarely  tlie  portal  vein.  Interesting  changes  occur 
in  the  vessels.  Embolism  of  the  artery  supplying  the  ulcerated  region  has 
been  met  with  in  several  cases;  in  others  diffuse  endarteritis.  Small 
aneurisms  have  been  found  iv.  the  floor  of  the  ulcers  by  Douglas  Powell, 
Welch,  and  others. 

The  mode  of  the  origin  of  the  peptic  ulcer  has  been  much  discussed. 
Ulcers  have  been  produced  in  animals  in  many  ways,  both  by  artificial 
emboli  and  by  direct  chemical  and  mechanical  irritants  a})plied  to  the  uni- 
cosa.  The  ulcers  thus  produced  heal  with  great  rapidity  unless  the  ani- 
mals have  been  rendered  anaemic  by  repeated  abstraction  of  blood.  Yir- 
chow's  view  that  the  process  may  result  from  plugging  the  nutrient  artery 
of  the  part,  cither  by  an  embolus  or  by  a  thrombus,  and  the  infarct  so 
produced  is  destroyed  by  the  gastric  juice,  has  gained  general  acceptiuice. 
It  is  in  conformity  with  Pavy's  well-known  experiments  and  with  the  ana- 
tomical facts  already  mentioned,  particularly  with  the  funnel-like  shape 
of  the  ulcer,  and  the  actual  demonstration,  in  some  cases,  of  the  plugged 
vessels ;  but  this  view  scarcely  meets  all  the  cases,  in  many  of  which  the 
etiology  is  still  obs'"ire.  Mere  mechanical  injury  to  the  mucous  mem- 
brane is,  however,  in  most  cases,  insufficient  cause  for  an  ulcer,  for  nor- 
mally the  stomach  is  perfectly  able  to  withstand  such  insults.  Ewuld 
concludes  that  certain  predisposing  causes  play  an  important  role  in  its 
development.  He  points  to  its  frequency  in  conditions  of  amenorrhcjoa, 
chlorosis,  an«mia  after  confinements,  etc.,  where  one  may  assume  that  tlio 
condition  of  the  blood  is  not  wholly  normal,  and  also  to  the  fact  that  iu 
the  majority  of  cases  of  this  affection  there  is  a  hyperacidity  of  the  gas- 
tric juice.  One  or  both  of  these  predisposing  factors  seem  to  be  pres- 
ent in  most  cases,  and  it  has  been  recently  shown  that  in  the  various 
a.iEemine  there  is  an  appreciable  diminution  in  the  normal  alkalinity  of 
the  blood,  a  fact  which  tends  to  explain  one  of  the  predisposing  causes 
in  these  affections,  and  which  is  in  accord  with  the  "  alkalescence  theory  " 
of  Cohnheii.i  et  al.  The  duodenal  ulcer  has  an  identical  origin,  but  a  ft'w 
cases  of  acute  ulcer,  as  already  mentioned,  have  a  curious  relation  with 
superficial  burns.  In  one  of  my  cases  there  was  an  ulcer  in  the  posterior 
wall  of  the  duodenum,  1'5  cm.  in  diameter,  with  overlapping  edges,  and 
not  far  from  it  was  a  cyst-like  cavity  in  the  submucosa  associated  with 
Brunner's  glands,  and  it  is  possible  that  the  open  ulcer,  with  undermined 
edges,  resulted  from  the  rui)ture  of  one  of  these  cysts. 

Symptoms. — The  condition  may  be  met  with  accidentally,  post  mor- 
tem, in  cases  which  have  presented  no  indication  of  gastric  disturbaneo. 


THE  PEPTIC   ULCER— GASTRIC  AND  DUODENAL. 


371 


In  otlier  instances  the  first  symptoms  may  be  due  to  perforation.  In 
otlicrs  again  the  symptoms,  for  months  and  years,  may  be  those  of  ordi- 
nary dyspepsia,  and  the  ulcer  may  nut  have  been  suspected  until  the  oc- 
currence perhaps  of  a  sudden  haemorrhage. 

The  symptoms  snggestive  of  peptic  ulcer  are :  (a)  Dyspepsia,  which 
may  be  slight  and  trifling  or  of  a  most  aggravated  character.  In  a  con- 
siderable proportion  of  all  cases  nausea  and  vomiting  occur,  the  latter  not 
for  two  or  more  hours  after  eating.  The  vomitus  usually  contains  a  large 
aiiiount  of  HCl. 

[b)  Haemorrhage  is  present  in  at  least  one  half  of  all  cases.  It  may  be 
slight,  but  more  commonly  is  profuse,  and  may  be  in  such  quantities  and 
brought  up  so  quickly  that  it  is  fluid,  bright  red  in  color,  and  quite  unal- 
tered. When  the  blood  remains  for  some  time  in  the  stomach  and  is 
mixed  with  food  it  may  be  greatly  changed,  but  the  vomiting  of  a  large 
quantity  of  unaltered  blood  is  very  characteristic  of  ulcer.  Syncope 
may  follow  or  death  may  directly  result  from  the  haimorrhage.  A  most 
extreme  grade  of  anaemia  may  be  produced.  In  either  the  gastric  or 
duodenal  ulcer,  more  commonly  in  the  latter,  the  blood  may  be  passed  in 
tlie  stools  and  not  be  vomited.  This  may  occur  when  the  Inemorrhage  is 
sliglit,  but  also  when  it  is  profuse  enough  to  produce  collapse  and  extreme 
aiiivmia. 

(r)  Pain  is  perhaps  the  most  constant  and  distinctive  feature  of 
ulcor.  It  varies  greatly  in  character  ;  it  may  be  only  a  gnawing  or  burii- 
iug  sensation,  which  is  particularly  felt  when  the  stomach  is  empty,  and  is 
relieved  by  taking  food,  but  the  more  characteristic  form  comes  on  in 
paroxysms  of  the  most  intense  gastralgia,  in  which  the  pain  is  not  only 
felt  in  the  epigastrium,  but  radiates  to  the  back  and  to  the  sides.  These 
attacks  are  most  frequently  induced  by  taking  food,  and  they  may  recur 
at  a  variable  jieriod  after  eating,  sometimes  within  fifteen  or  twenty  min- 
utes, at  others  as  late  as  two  or  three  hours.  It  is  usually  stated  that 
wlieu  the  ulcer  is  near  the  cardia  the  pain  is  apt  to  set  in  earlier,  but  there 
is  no  certainty  on  this  point.  The  attacks  may  occur  at  intervals  with 
great  intensity  for  weeks  or  months  at  a  time,  so  that  the  patient  con- 
stantly requires  morphia,  then  again  they  may  disappear  entirely  for  a 
proloiigod  jjcriod.  In  the  attack  the  patient  is  usually  bent  forward,  and 
finds  relief  from  pressure  in  the  epigastric  region ;  one  patient  during  the 
attack  would  lean  over  the  back  of  a  chair;  another  would  lie  Hat  on  the 
fioor,  witli  a  hard  pillow  under  the  abdomen.  Pressure  is,  as  a  rule, 
grateful.  It  has  been  thought  that  the  posture  assumed  during  the  attack 
Wdulil  indicate  the  site  of  the  ulcer,  but  this  is  very  doubtful. 

('/)  Tenderness  on  pressure  is  a  common  symptom  in  uL^er,  and  pa- 
tients wear  the  waist-band  very  low.  There  may  be  a  painful  point  of 
very  limited  extent,  most  frequently  an  inch  or  two  below  the  cnsiform 
eartilago.  In  old  ulcers  with  thickened  bases  an  imlurated  nuiss  can  usu- 
ally be  felt  in  the  neighborhood  of  the  pylorus.    Pressure  should  be  made 


if 


i  '''I 


.Y  '  iK 


[ii'-ilf 


872 


DISEASES  OF  TDE  DIGESTIVE  SYSTEM. 


with  great  care,  as  rupture  of  an  ulcer  has  been  induced  by  careless 
manipulation. 

(e)  Of  general  symptoms,  loss  of  weight  results  from  the  prolonged 
dyspepsia,  but  it  rarely,  except  in  association  with  cicatricial  stenosis  of 
the  pylorus,  reaches  the  high  grade  met  with  in  cancer.  The  ana?niia  nuiv 
be  extreme,  and  in  one  case  of  duodenal  ulcer  which  I  examined  the  blddd 
count  was  as  low  as  700,000  per  c.  mm.  There  are  instances,  such  iis  the 
one  reported  by  Pepj)er  and  Griffith,  in  which  the  extreme  ana>mia  cannijt 
be  explained  by  the  occurrence  of  haemorrhage. 

According  to  Welch,  perforation  occurs  in  about  six  and  a  lialf  jxt 
cent  of  all  cases.  The  acute,  perforating  form  is  much  more  common  in 
women  than  in  men.  The  symptoms  are  those  of  j)erforative  peritonitis. 
In  some  instances  the  pain  associated  with  perforation  is  not  referred  to 
the  abdomen.  In  a  case  of  II.  C.  Wood's  the  chief  symptoms  were  pain  in 
the  left  shoulder  and  excessive  pain  in  the  back  on  movement.  iVr- 
foration  is  not  necessarily  fatal.  Several  cases  of  recovery  have  been  re- 
ported. 

The  course  of  the  disease  is,  in  the  majority  of  cases,  chronic.  Only  a 
few  instances  run  a  very  acute  course.  The  following  group  of  clinical 
forms,  described  by  AVelcli,  indicate  the  diversity  of  this  affection : 

"  1.  Latent  ulcers,  with  entire  absence  of  symptoms,  and  revealed  as 
open  ulcers  or  as  cicatrices  at  the  autopsy. 

"  ,2.  Acute  perforating  ulcers.  With  or  without  a  period  of  brief  gas- 
tric disturbance,  i)erf oration  occurs  and  causes  speedy  death. 

"  3.  Acute  hngniorrhagic  form  of  gastric  idcer.  After  a  latent  or  a 
brief  course  of  the  ulcer,  profuse  gastrorrhagia  occurs,  which  may  termi- 
nate fatally  or  may  be  followed  by  the  symptoms  of  chronic  ulcer. 

"4.  Gastralgic-dyspeptic  form.  In  this,  which  is  the  most  comnuin 
form  of  gastric  ulcer,  gastralgia,  dyspepsia,  and  vomiting  are  the  symptoms. 
Sometimes  one  of  the  symptoms  predominates  greatly  over  the  others,  so 
that  Lcbert  distinguishes  separately  a  gastralgic,  a  dyspeptic,  and  a  vomit- 
ive variety.     Gastralgia  is  the  most  frequent  symjjtom. 

"  5.  Chronic  ha^morrhagic  form.  Gastrorrhagia  is  a  marked  symptom, 
and  occurs  usually  in  combination  with  the  symptoms  just  mentioned. 

"  C.  Cachectic  form.  This  xisually  corresponds  only  to  the  linal  stairo 
of  Oiie  of  the  preceding  forms,  but  the  cachexia  may  develop  so  rapidly 
and  become  so  marked  that  the  course  of  the  disease  closely  resembles  that 
of  gastric  cancer. 

"  7.  Recurrent  form.  In  this  the  symptoms  of  gastric  ulcer  disappcai-, 
and  then  follow  intervals,  often  of  considerable  duration,  in  which  there 
is  apparent  cure,  but  the  symptoms  return,  especially  after  some  indiscre- 
tion in  iC  mode  of  living.  This  intermittent  course  may  continue  for 
many  years.  In  these  cases  it  is  probable  either  that  fresh  ulcers  form  or 
that  the  cicatrix  of  an  old  ulcer  becomes  ulcerated. 

"8.  Stenotic  form.      By  the  formation   of   cicatricial   tissue  in  and 


ti 
r 


THE  PEPTIC   ULCER— GASTRIC  AND  DUODENAL. 


373 


around  the  ulcer,  the  pyloric  orifice  becomes  obstructed  and  the  symptoms 
of  dilatation  o"  *;he  stomach  develop." 

The  course  may  be  very  protracted,  and  there  are  cases  in  which  the 
disease  has  persisted  for  over  twenty  years.  I  have  rejiorted  two  in- 
stances of  peptic  ulcer,  probably  duodenal,  in  which  well-marked  symp- 
toms were  present,  in  one  case  for  eighteen,  and  in  the  other  for  twelve 
years.     Both  were  of  the  chronic  hsemorrhagic  form. 

Diagnosis. — The  recognition  of  gastric  ulcer  is  in  many  cases  easy, 
as  the  combination  of  dyspepsia,  gastralgic  attacks,  and  liiwmatemesis  is 
very  characteristic.  Of  the  symptoms,  haemorrhage  with  the  gastralgic 
attack  is  the  most  characteristic.  The  distinctions  between  ulcer  and 
cancer  will  be  given.  The  greatest  difficulty  is  offered  by  certain  cases  of 
gastralgia,  which  may  resemble  ulcer  veiy  closely,  as,  with  the  exception 
of  tlie  hfemorrhage,  there  is  no  single  symptom  which  may  not  be  present. 
Even  with  hnemorrhage  the  case  may  not  be  clear,  and  no  less  an  author- 
ity than  the  late  Austin  Flint  made  a  diagnosis  of  recurring  gastralgia  in 
a  patient  who  had,  on  and  off  for  nine  years,  violent  pains  with  vomit- 
ing in  association  with  ulcer.  A  difficulty  also  results  from  the  fact  that 
in  many  instances  gastralgia  is  one  of  the  symtoms  of  nervoup  dyspepsia, 
ami  may  exist  with  marked  emaciation. 

The  following  points  are  of  value  in  discriminating  between  these  two 
conditions : 

(n)  In  ulcer  the  pain  is  more  definitely  connected  with  taking  food, 
though  this  is  not  always  the  case,  as  in  the  duodenal  form  the  gastralgic 
attacks  may  occur  at  night  when  the  stomach  is  empty.  Relief  of  pain 
after  eating  is  certainly  less  common  in  ulcer  than  in  gastralgia,  though  it 
is  a  very  uncertain  feature,  and  in  certain  cases  the  pain  in  ulcer  is  always 
relieved  by  taking  food. 

{h)  In  ulcer  dyspeptic  symptoms  are  almost  invariably  present  in  the 
intervals  between  the  attacks,  and  even  when  pain  is  absent  there  is  slight 
distress. 

(<;)  Local  sensitiveness  in  a  particular  spot  in  the  epigastrium  is  sug- 
gestive of  ulcer.  External  pressure  usually  aggravates  the  pain  in  ulcer, 
aiul  often  relieves  it  in  gastralgia.  This  is,  however,  a  very  uncertain 
feature,  us  patients  writhing  with  the  pains  of  ulcer  may  press  tlie  abdo- 
men over  the  back  of  a  chair  or  place  a  hard  pillow  under  it. 

('/)  The  general  condition  and  history  of  the  patient  often  give  the 
most  trustworthy  information.  The  nutrition  is  impaired  more  frequent- 
ly ill  ulcer  than  in  gastralgia.  In  the  former  we  find  more  commonly 
(in  women)  dysmenorrhoea  and.  chlorosis,  while  in  the  latter  there  are 
associated  nervous  phenomena — hysterical  manifestations  or  neuralgias  in 
other  regions. 

(e)  On  examination  of  the  abdomen,  not  only  is  pain  on  pressure  much 
more  common  in  ulcer,  but  there  may  also  be  thickening  about  the  pylo- 
rus and,  in  many  cases,  signs  of  dilatation  of  the  stomach. 


'^f 


374 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


(/)  II}7)eracidity  of  the  gastric  juice  exists  with  ulcer. 

The  (jadric  crises  which  occur  in  affections  of  the  spinal  cord,  particu- 
larly in  locomotor  ataxia,  may  simulate  very  closely  the  gastralgic  attacks 
of  ulcer,  and  as  they  so  often  exist  in  the  preataxic  stage  their  true 
nature  may  bo  overlooked  ;  but  the  occurrence  of  lightning  pains,  the  ocu- 
lar symptoms,  and  the  absence  of  the  knee  reflex  are  indications  usual]  v 
sufficient  to  render  the  diagnosis  clear. 

Can  the  gastric  and  duodenal  ulcer  be  distinguished  clinically  ?  As 
already  stated,  ^hey  originate  in  the  same  way  and  present  the  same  ana- 
tomical characters.  In  the  great  majority  of  cases  they  cannot  be  sopa- 
rated  during  life,  as  the  symptoms  produced  are  identical.  Bucquoy  lias 
suggested  that  the  duodenal  ulcer  can  be  distinguished  by  the  following 
definite  characters :  {a)  Sudden  intestinal  haemorrhage  in  an  apparently 
healthy  person,  which  tends  to  recur  and  produce  a  profound  anainiia. 
Haemorrhage  from  the  stomach  may  precede  or  accompany  the  meL-pna. 
{b)  Pain  in  the  right  hypochondriac  region,  coming  on  two  or  three  hours 
after  eating,  (p)  Gastric  crises  of  extreme  violence,  during  whicli  the 
haimorrhago  is  more  apt  to  occur.  Certainly  the  occurrence  of  sudden  in- 
testinal lunemorrhage  with  gastralgic  attacks  is  extremely  suggestive  of  duo- 
denal ulcer.  W.  W.  Johnston  has  reported  an  instance  in  which  he  made 
the  diagnosis  on  these  symptoms,  and  in  one  of  the  Montreal  cases  Palmer 
Howard  suggested  correctly  the  presence  of  a  duodenal  ulcer  on  siniilur 
grounds.  A  patient  under  my  care  who  had,  during  eighteen  years,  fre- 
quent attacks  of  hjematemesis  with  gastralgia  had  melaena  repeatedly  with- 
out vomiting  blood  ;*  but  as  a  rule  in  the  attacks  the  blood  was  vomited 
first,  and  did  not  appear  in  the  stools  until  later.  Occasionally  this  syni- 
ptom  will  be  found  an  important  aid  in  diagnosis.  The  situation  of  the 
pain  is  too  uncertain  a  factor  on  which  to  lay  much -stress,  and  the  char- 
acter of  the  crises  is  usually  identical. 

Gall-stone  colic  may  occasionally  simulate  the  pains  of  gastric  ulcer. 
The  sudden  onset  and  as  sudden  termination,  the  swelling  an<l  tenderness 
of  the  liver,  the  enlargement  of  the  gall-bladder,  if  present,  and  the  oc- 
currence of  jaundice  are  points  which  usually  make  the  diagnosis  clear. 

Treatment. — Post-mortem  observations  show  that  a  very  large  num- 
ber of  ulcers  heal  completely,  but  the  process  is  slow  and  tedious,  often 
requiring  months,  or,  in  severe  cases,  years.  The  following  are  the  im- 
portant points  in  treatment : 

{(i)  Absolute  rest  in  bed.  .  ;  i    ' 

[b)  A  carefully  and  systematically  regulated  diet.  While  theoretically 
it  is  better  to  give  the  stomach  complete  rest  by  rectal  feeding,  yet  in 
practice  this  strict  limitation  is  not  found  satisfactory.  The  food  should 
be  bland,  easily  digested,  and  given  at  stated  intervals.  The  following 
dietary  will  bo  found  useful :  At  8  A.  M.  give  200  c.  c.  of  Leubc's  beef  solu- 

*  On  tlie  Diagnosis  of  Duodenal  Ulcer,  Medical  Record,  November  34,  1888. 


THE   PEPTIC   ULCER-GASTRIC  AND  DUODENAL. 


375 


tion;  at  13  m.,  300  c.  c.  of  milk  gruel  or  peptonized  milk.  The  gruol 
should  ho  made  with  ordinary  flour  or  arrowroot,  and  is  mixed  with  an 
('(lual  quantity  of  milk.  If  necessary  it  may  bo  peptonized.  Buttermilk 
is  verv  well  borne  by  these  patients.  At  4  P.  M.  the  beef  solution  again, 
and  at  8  p.  m.  the  milk  gruel  or  the  buttermilk. 

'riie  stomach  in  some  cases  is  so  irritable  that  the  smallest  amount 
of  food  "u?  not  well  borne.  In  such  cases  lavage  may  be  practised,  if  neces- 
sary, every  morning  and  evening,  with  mildly  alkaline  water,  after  which 
the  beef  solution  is  given  and  the  feeding  supplemented  by  the  rectal  in- 
jections. Ill  etfects  rarely  follow  the  careful  use  of  the  stomach  tube  in 
gastric  ulcer.  There  are  some  cases  which  do  well  from  the  outset  on  a 
milk  diet,  given  at  regular  intervals,  three  or  four  ounces  every  two  hours. 
AVhon  milk  is  not  well  borne  egg  albumen  may  be  substituted,  or  the  whites 
of  eight  eggs  may  be  alternated  with  Leube's  beef  solution.  At  the  end 
of  a  month,  if  the  condition  has  improved,  the  patient  may  be  allowed 
scraped  beef  or  young  chicken,  perfectly  fresh  sweet-bread,  and  farina- 
ceous puddings  made  with  milk  and  eggs.  Local  applications,  such  as 
warm  fomentations,  over  the  abdomen  are  very  useful.  The  patient  should 
be  told  that  the  treatment  will  take  at  least  three  months,  and  for  the 
greater  portion  of  the  time  he  should  be  in  bed. 

{(.')  Medicinal  measures  are  of  very  little  value  in  gastric  ulcer,  and 
the  remedies  employed  do  not  probably  benefit  the  ulcer,  but  the  gastric 
catarrh.  The  Carlsbad  salts  are  warmly  recommended  by  von  Ziems- 
scn.  The  artificial  preparation  (sulphate  of  sodium,  50 ;  bicarbonate  of 
sodium,  (i ;  chloride  of  sodium,  3)  may  be  substituted,  of  which  a  tea- 
spoonful  is  taken  every  morning.  Bismuth,  in  doses  of  thirty  to 
sixty  grains  three  times  a  day,  and  nitrate  of  silver  may  be  given,  but 
they  influence  the  associated  conditions  rather  than  the  ulcer. 

The  pain  if  severe  requires  opium.  Unless  the  gastralgia  is  intense 
morpliia  should  not  be  given  hypodermically,  as  there  is  a  very  serious 
danger  in  these  cases  of  establishing  the  morphia  habit.  Doses  of  an 
eiglith  of  a  grain,  with  the  bicarbonate  of  soda  and  bismuth,  will  allay  the 
mild  attacks,  but  the  very  severe  ones  require  the  hypodermic  injection  of 
a  quarter  or  often  half  a  grain.  Antipyrin  and  antifebrin  may  be  tried, 
but,  as  a  rule,  are  quite  ineffectual.  In  the  milder  attacks  Hoffman's 
anodyne,  or  twenty  or  thirty  drops  of  chloroform,  or  the  spirits  of  camphor 
will  give  relief.  Counter-irritation  over  the  stomach  with  mustard  or 
cantliarides  is  often  useful. 

For  tlio  vomiting  there  is  no  measure  so  successful  as  lavage.  If  in- 
tnutable  the  patient  must  be  fed  per  rectum.  The  patient  will  sometimes 
retain  food  which  is  passed  into  the  stomach  through  the  tube,  and 
Leube's  beef  solution  or  milk  may  bo  given  in  this  way.  Cracked  ice, 
chloroform,  oxalate  of  cerium,  bismuth,  hydrocyanic  acid,  and  ingluvin 
may  be  tried.  AVhen  hasmorrhage  occurs  the  patient  should  be  put  under 
the  influence  of  opium  as  rapidly  as  possible.    No  attempt  should  be  made 


876 


DISEASES  OP  THE  DIGESTIVE  SVSTEM. 


to  check  tlie  hannorrhage  by  administering  medicines  tlirough  the  mouth  ; 
us  the  profuse  bleeding  is  always  from  an  eroded  artery,  frequently  froTu 
one  of  considerable  size,  it  is  doubtful  if  acetate  of  lead,  tannic  and 
gallic  acids,  and  tlie  usual  remedies  have  the  slightest  influence.  'I'lie 
essential  point  is  to  give  rest,  which  is  host  obtained  by  opium.  Er- 
gotin  may  be  administered  hypodermically  in  two-grain  doses.  Notliin-r 
should  be  given  by  the  mouth  except  small  quantities  of  ice.  In  prcjfusc! 
bleeding  a  ligature  may  be  applied  around  a  leg,  or  a  leg  and  arm.  Not 
infrequently  the  loss  of  blood  is  so  great  that  the  patient  faints.  A  fatal 
result  is  not,  however,  very  common  from  hajmorrhage.  Transfusion  may 
be  necessary,  or,  still  better,  the  subcutaneous  infusion  of  saline  solution. 
The  patients  usually  recover  rapidly  from  the  haemorrhage  and  require 
iron  in  full  doses,  which  may,  if  necessary,  be  given  hypodermically. 


VII.  CANCER  OF  THE  STOMACH. 


:'    k^K 


■    ( '    *  "f 


1 


li 


Etiolog'y. — The  stomach  comes  next  to  the  uterus  as  the  most  fre- 
quent seat  of  primary  cancer,  amounting,  as  shown  by  the  statistics  of 
W^lch,*  to  21-4  per  cent  in  a  total  of  over  30,000  cases.  The  ratio  of 
males  to  females  affected  is  about  five  to  four.  Age  has  an  important 
bearing.  Of  2,038  cases  tabulated  by  this  author  three  fourths  occurred 
between  the  fortieth  and  the  seventieth  year,  24*5  per  cent  between  tlie 
ages  of  forty  and  fifty,  and  30'4  between  the  ages  of  fifty  and  sixty.  In 
childhood  it  is  extremely  rare.  Cancer  of  the  stomach  is  a  very  common 
disease  in  this  country,  though  statistics  would  indicate  that  it  is  ratlier 
less  frequent  than  in  Europe.  With  reference  to  heredity,  Welch  analyzed 
1,744  cases  and  found  that  a  family  history  was  present  in  ^43.  Local 
conditions,  such  as  chronic  gastritis  and  traumatism,  have  been  thought 
by  some  to  be  important  factors.  Cancer  may  develop  in  a  simple 
ulcer  of  the  stomach,  but  this  sequence  is  extremely  rare.  It  is  not 
probable  that  depressing  emotions,  mode  of  life,  or  previous  disease  liave 
any  influence  whatever  in  the  causation  of  cancer. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer 
are  the  cylindrical-celled  epithelioma  and  the  encephaloid  ;  next  in  fre- 
quency is  scirrhous,  and  then  colloid  cancer.  With  reference  to  the  situa- 
tion of  the  tumor,  Welch  analyzed  1,300  cases,  in  which  the  distribution 
was  as  follows:  Pyloric  region,  791;  lesser  curvature,  148;  cardia,  104; 
posterior  wall,  G8 ;  the  whole  or  greater  part  of  the  stomach,  61 ;  multiple 
tumors,  45  ;  greater  curvature,  34;  anterior  wall,  30;  fundus,  10. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous 
projections  or  cauliflower-like  outgrowths.     It  is  soft,  grayish  white  in  color, 

*  System  of  Medicine,  vol.  ii,  Philadelphia,  1886. 


CANCER  OP  THE  STOMACH. 


377 


unci  contains  much  blood.  Microscopically  it  shows  a  scanty  stroma,  en- 
closing alveoli  which  contain  irregular  polyhedral  and  cylindrical  cells. 
The  cylindrical-celled  epithelioma  may  also  form  large  irregular  masses, 
but  the  consistence  is  usually  firmer,  particularly  at  the  edges  of  the  can- 
cerous ulcers.  Microscopically  the  section  shows  elongated  tubular  spaces 
tilk'(l  with  columnar  epithelium,  and  the  intervening  stroma  is  abundant. 
Cysts  arc  not  uncommon  in  this  form.  The  scirrhous  variety  is  character- 
ized by  great  hardness,  due  to  the  abundance  of  the  stroma  and  the  limited 
amount  of  alveolar  structures.  It  is  seen  most  frec:uently  at  the  pyloruc, 
where  it  is  a  common  cause  of  stenosis.  It  may  be  combined  with  the 
medullary  form.  The  colloid  cancer  is  peculiar  in  its  wide-spread  inva- 
sion of  all  the  coats.  It  also  spreads  with  greater  frequency  to  the  neigh- 
boring parts,  and  it  occasionally  causes  extensive  secondary  growths  of  the 
same  nature  in  other  organs.  The  appearance  on  section  is  very  distinct- 
ive, and  even  with  the  naked  eye  large  alveoli  can  be  seen  filled  with  the 
trauslucent  colloid  material.  The  term  alveolar  cancer  is  often  applied  to 
tliis  form.  Ulceration  is  not  constantly  present,  and  there  are  instances 
in  which,  with  most  extensive  disease,  digestion  has  been  very  slightly  dis- 
turbed. There  is  a  specimen  in  the  Warren  Museum,  at  the  Harvard 
Medical  School,  of  the  most  wide-spread  colloid  cancer,  in  which  the 
stomach  contained  after  death  large  portions  of  undigested  beef-steak. 

Secondary  cancer  may  also  occur  in  the  stomach.  Welch  has  collected 
37  cases,  17  of  which  were  secondary  to  cancer  of  the  breast.  The  cancer 
may  produce  important  changes  in  the  position  and  shape  of  the  organ, 
particularly  when  the  orifices  are  involved ;  thus,  a  cancer  at  the  cardia 
may  be  associated  with  wasting  of  the  organ  and  reduction  in  its  size. 
The  oesophagus  above  the  obstruction  may  be  greatly  distended.  On  the 
other  hand,  annular  cancer  at  the  pylorus  may  cause  stenosis  and  great 
dilatation  of  the  organ ;  not  necessarily,  however,  as  there  are  instances  on 
record  in  which  the  pylorus  has  been  extremely  narrowed  without  any  in- 
crease in  the  size  of  the  stomach.  In  scirrhous  cancer  the  organ  may  be 
very  greatly  thickened  and  contracted.  The  stomach  may  be  disjjlaced 
or  altered  in  shape  by  the  weight  of  the  tumor,  particularly  in  cancer 
of  the  pylorus,  which  has  been  found  in  every  region  of  the  abdomen, 
uiul  even  in  the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  ex- 
traordinary and  very  deceptive.  There  was  in  the  Philadelphia  Hospital 
an  old  man  with  a  tumor  at  the  pylorus  the  size  of  a  cricket  ball,  which 
was  usually  in  the  epigastric  region,  but  could  be  pushed  into  the  right 
hypochondria  or  into  the  splenic  region  entirely  beneath  the  ribs.  Adhe- 
sions very  frequently  occur,  particularly  to  the  colon,  the  liver,  and  the 
anterior  abdominal  wall. 

Secondary  cancerous  growths  are  very  frequent,  as  sho\vn  by  the  fol- 
lo\yng  analysis  by  Welch  of  1,574  cases :  Metastasis  occuiTed  in  the  lym- 
phatic glands  in  551 ;  in  the  liver  in  475  ;  in  the  peritonajum,  omentum, 
and  intestine  in  357 ;  in  the  pancreas  in  122  ;  in  the  pleura  and  lung  in 
26 


378 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


.HI 

'"•!  ''. 

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1 

!>•     *» 

Hi 


98  ;  in  tlio  spleen  in  2G  ;  in  tl\c  bruin  iind  meninp's  in  0  ;  in  otluT  ])!irls  in 
ya.  The  lymph  glands  iilTected  are  nsiuilly  tlioso  <»f  the  iibdonu-n,  Ijut  the 
cervical  and  ingninal  glands  arc  not  infrequently  attacked,  and  give  an 
important  dew  in  diagnosis.  Occasionally,  a  secondary  metastatic  growth 
occurs  suheutaneously,  either  at  the  navel  or  beneath  the  skin  in  the  vicin- 
ity. In  an  instance  recently  under  observation  in  a  patient  with  jaundice, 
which  deveh)ped  somewhat  suddeidy  mid  was  believed  to  be  catarrhal,  there 
were  no  signs  of  enlargement  of  the  liver  or  tumor  of  the  stonuich,  but  a 
nodular  body  developed  at  the  navel,  which  on  renu)val  jiroved  to  be  typi- 
cal scirrhus.  A  second  case  in  the  ward  at  the  same  time,  with  an  ob- 
scure doubtful  tumor  in  the  left  hypochondria,  develoj)(Hl  a  {juinful  nodu- 
lar subcutaneous  growth  midway  between  the  navel  and  the  left  nuirgin  of 
the  ribs. 

In  the  extensive  ulceration  which  occurs  perforation  of  the  stomach  is 
not  uncommon.  It  occurred  into  the  peritonaium  in  17  of  the  507  cases  of 
cancer  of  the  stomach  collected  by  Brinton.  "When  adhesions  form,  the 
most  extensive  destruction  of  the  walls  may  take  place  without  perfora- 
tion into  the  peritoneal  cavity.  In  one  instance  which  came  under  my 
observation  a  large  portion  of  the  left  lobe  of  the  liver  lay  within  the 
stomach.  Occasionally  a  gastro-cutaneous  llstula  is  established.  Perfora- 
tion may  occur  into  the  colon,  the  small  bowel,  the  pleura,  the  lung,  or 
into  the  pericardium. 

Symptoms. — Cancer  of  the  stomach  may  no*^^  produce  symptoms 
other  than  gradual  failure  of  health,  and  death  nuiy  take  place  from 
asthenia  without  any  susi)icion  of  the  existence  of  malignant  discas*e. 
These  cases  are  not  uncommon,  particularly  in  elderly  persons  in  institu- 
tions. In  a  great  majority  of  all  cases  there  are  very  definite  symptoms, 
but  the  disease  presents  a  very  diverse  clinical  picture.  Certain  general 
features  stand  out  Avith  special  prominence.  The  onset  is  insidious,  sonic- 
times  with  gastric  disturbance,  but  more  commonly  with  impairment  of 
health  and  strength.  A  dyspepsia  Avhich  may  have  been  troublesome  for 
years  becomes  aggravated.  Ewald,  however,  states  that  dyspeptic  symp- 
toms are  rare  prior  tc  the  onset  of  gastric  cancer.  There  are  attacks  of 
nausea  and  vomiting,  and  there  is  pain  in  the  region  of  the  stomach, 
which  is  aggravated  by  taking  food.  The  patient  emaciates,  the  anemia 
becomes  pronounced,  and  the  prostration  may  be  extreme.  With  slight 
intermissions  the  course  is  progressively  downward,  and  from  month  to 
month  the  loss  is  striking.  The  face  has  a  sallow  cachectic  appearance, 
the  antemia  becomes  more  intense,  and  there  may  be  codema  of  the 
ankles.  Blood  may  be  present  in  the  vomited  matter.  If  M'ith  these 
general  features  a  tumor  can  be  felt  in  the  region  of  the  stomach  the 
diagnosis  is  rendered  certain.  The  course,  in  rapid  cases,  may  be  from 
three  to  six  months,  but  as  a  rule  the  disease  extends  from  eighteen  mouths 
to  two  years. 

Dyspepsia  is  common  at  the  outset,  but  in  so  many  cases  the  patients 


CANCER  OP  THE  STOMACH. 


379 


litivc  had  indigestion  for  ycara  that  the  trouble  is  BUi)poscd  at  first  to  bo 
only  an  aggravation  of  the  chronic  con»i)laint.  Losa  of  the  desire  for 
food  is  a  very  frequent  symptom.  There  are  excei)tioTuil  instances,  how- 
ever, in  which  the  appetite  is  retained  throughout,  and  the  functions  of 
the  stomach  very  slightly  disturbed.  Mausea  is  a  striking  feature  in  many 
cases,  and  is  much  more  common  than  in  lUcer.  There  may  even  bo  a 
sudden  repulsion  at  the  sight  of  food. 

V())ni/i)i(/,  which  is  one  of  the  most  constant  symptoms  of  cancer  of 
the  stonuich,  may  (!ome  on  early,  or  only  after  the  dyspejjsia  has  persisted 
for  some  time.  At  first  it  is  at  long  intervals,  but  subsequently  it  is  moro 
fri'(iuent,  and  may  recur  several  times  in  the  day.  There  are  cases  in 
which  it  comes  on  in  paroxysms  and  then  subsides;  in  other  cases,  it  seta 
in  early,  persists  with  great  violence,  and  may  cause  a  fatal  termination 
within  a  few  weeks.  Vomiting  is  more  frequent  when  the  cancer  involves 
the  orifices,  particularly  the  pylorus,  in  which  case  it  is  usually  delayed 
for  an  hour  or  more  after  taking  the  food.  AVhcn  the  cardiac  orifice  is 
involved  it  may  follow  at  a  shorter  interval.  Extensive  disease  of  the 
fundus  or  of  the  anterior  or  posterior  wall  may  be  present  without  the 
occurrence  of  vomiting.  The  vomited  matters  consist  of  food  and  mucus 
in  a  grayish  or  dark  sour-smelling  fiuid.  'IMie  food  is  sometimes  very 
little  changed,  even  after  it  has  remained  in  the  stomach  for  twenty-four 
hours. 

Ihcmorrhaye  is  a  frequent  symptom,  but  the  bleeding  is  rarely  profuse ; 
more  eonmionly  there  is  slight  oozing,  and  the  blood  is  mixed  with,  or 
altered  by  the  secretions,  and  when  vomited  the  material  is  dark  brown 
or  black,  the  so-called  "  coifee-ground  "  vomit.  This  is  present  in  a  con- 
sitlenible  proportion  of  all  cases  of  cancer,  and  is  an  important  indication. 
Tlio  blood  can  be  recognized  by  the  microscojie  as  shells  of  the  red  blood- 
corpuscles  and  irregular  masses  of  altered  blood  pigment.  In  cases  of 
doiilit  the  spectroscope  may  be  employed  or  htemin  crystals  obtained. 

Fragments  of  the  tumor  are  rarely  found  in  the  vomit,  and  of  the 
nunu'ious  specimens  which  I  have  had  occasion  to  examine  I  have  never 
been  able  to  satisfy  myself  of  the  existence  of  cancerous  tissue.  As 
Rosenbach  states,  in  the  material  washed  out  with  the  stomach-tube  un- 
doubted fragments  may  be  found.  The  yeast  fungus,  various  bacteria, 
and  the  sarcina  ventriculi  may  be  present,  the  latter  not  so  often  in  cancer 
as  in  dilatation. 

Great  stress  has  been  laid  of  late  years  upon  the  absence  of  free 
hydrocliloric  acid  in  the  secretions.  As  an  outcome  of  the  enormous 
nunil)or  of  observations  which  have  recently  been  made  it  may  be  said 
that  free  hydrochloric  acid  is  absent  in  a  majority  of  cases  of  cancer  of 
the  tttoniach.  This  defect  is  associated  with  impairment  of  the  secreting 
function  of  the  organ.  The  examination  should  be  made  repeatedly,  by 
the  methods  already  referred  to,  and  with  our  present  knowledge  the  per- 
sistent absence  of  free  HCl  in  the  stomach  contents,  taken  in  conjunc- 


»B0 


DISK  ASKS  OF  THE   DIOKSTIVK  SYSTEM. 


n  I 


>     <, 


1  *>l^ 


1(, 


h. 


lit  til.     . 


tion  with  otlior  Hymptonis,  may  ho  roganlet!  im  liij^lily  flii{?«?('stiv»)  of  ciuipcr. 
llnfortunutt'ly,  tho  froo  uv'\d  niiiy  l)o  ubseiit  in  certiiiii  othtir  cDinlitions, 
Huoh  ua  utrophy,  uud  oociisioiuilly  in  chronit;  gastritiH,  ho  that  it  is  of 
greater  vahio  from  the  negative  8tan(l|)oint.  As  Kinnicutt  expro.sscs  it, 
"tho  preHon(!0  of  free  IK-l  in  tho  Htoniaoh  oontentrt  in  repeated  exaniiiin- 
tions  in  (h)ubtfnl  eases  is  of  the  greatest  diagnostie  value,  and  points 
very  eertainly  to  absence  of  eaneer."  Uoseidieini  1ms  recently  shown  that 
in  cases  in  which  cancer  develops  in  the  base  of  an  old  ulcer  IICI  may 
be  })resent  throughout  tho  course. 

Pain  is  an  early  and  important  syini)tom.  It  is  very  variul)lo  in  situa- 
tion, and  while  most  common  in  the  epigastrium,  it  nuiy  be  referred  to 
tho  shoulders,  the  back,  or  the  loins.  The  i)ain  is  described  as  dragging, 
burning,  or  gnawing  in  character,  and  very  rarely  occurs  in  severe 
paroxysms  of  gastralgia,  us  iji  gastric,  ulcer.  As  a  rule,  the  pain  U 
aggravated  by  taking  food.  There  is  usually  nuirked  teiulerness  on 
pressure  in  the  epigastric  region.  It  is,  however,  renuirkablo  how  miiiiy 
cases  run  a  painless  course. 

Tho  physical  cu^a77ii)iafioH  ot  the  abdomen  reveals  in  many  instances 
the  presence  of  a  tunu)r.  Inspet^tion  may  show  a  nodular  mass  in  the 
epigastrium,  or  tho  outlines  of  a  dilated  stomach,  with  peristaltic  action. 
In  tho  palpaticjn  of  the  stomach  it  is  important  to  bear  in  mind  cer- 
tain anatomical  points.  At  least  two  thirds  of  the  organ  lie  in  the  left 
hypochondrium  beneath  the  ribs,  and  so  are  practically  out  of  reach. 
The  jiylorio  orifice  lies  to  the  right  of  tho  median  line,  particularly 
when  tho  stomach  is  full,  in  which  ease  it  may  be  reached.  It  is  about 
on  a  level  with  the  inner  extremity  of  the  eighth  right  costal  cartilage. 
The  pylorus  is  movable  and  changes  considerably  in  position  with  tho 
distention  of  the  stomach.  Practically,  in  liealth  there  is  available  for 
palpation  only  a  part  of  the  anterior  surface  of  the  stomach  and  the 
pylorus,  which  is  sometimes,  but  not  always,  overlapped  by  the  liver. 
Tumors  limited  to  the  cardia,  even  when  extensive,  cannot  be  felt  at  all. 
Tumors  involving  tho  fundus,  the  posterior  wall,  and  the  greater  part  of 
the  lesser  curvature  cannot  be  detected  unless  very  large.  Tumors  of  tho 
pylorus,  of  the  anterior  wall,  and  of  a  large  part  of  tlie  greater  curvature 
are  in  accessible  situations.  In  the  examination  the  knees  siiould  be 
drawn  up,  and  tho  patient  asked  to  relax  tl  e  abdominal  walls  as  much  as 
possible.  Sometimes,  when  nothing  can  be  felt  on  quiet  breathing,  a 
deep  inspiration  will  force  down  the  stomach  and  bring  a  tumor  mass 
within  reach.  Examination  should  also  be  made  in  the  knee-elbow  posi- 
tion. Cancerous  tumors  of  the  stomach  are  usually  felt  in  the  epigastric 
region,  but  a  mass  at  the  pylorus  m  vy  be  felt  in  the  umbilical  region, 
or,  in  cases  of  extreme  mobility,  in  a  hypochondriac  region,  or,  very  ex- 
ceptionally, low  down  in  the  iliac  region.  The  tumor  is  usually  linn, 
hard,  nodular,  and  paipful  on  pressure.  At  the  pylorus  the  mass  may 
be  rounded,  ball-like,  and  readily  grasi)cd.     Gas  may  sometimes  be  felt 


CANCER  OF  TIIK  STOMACH. 


881 


hiiliblltig  through  it.  ('oniinunicutcil  j)iilsiiti(»ii  fnim  the  nnrtii  is  not  at 
all  imcoinmon.  Inflation  of  the  Htoiniujli  with  guy  is  often  a  vuhmble  aid 
ill  diagnosis.  A  tcaspoonful  of  hicurhoniite  of  sochi  is  first  given  in  water, 
followed  by  the  same  amount  of  tartaric  aeid.  'I'lie  distention  of  the 
stoniueh  which  follows  may  sutlice  to  bring  tumor  masses  into  reach. 

Careful  examination  ahould  be  mad(i  to  determine  tho  presence  of  sec- 
ondary cancer  of  tho  liver  or  involvement  of  tho  lynifih  glan<ls  in  the  groins 
or  in  tho  supraclavicular  spaces.  As  already  mentioned,  the  development 
of  iiudules  about  the  navel  may  give  an  important  hint,  or  there  amy  ))© 
signs  of  secondary  involvement  of  the  iieritonteum. 

Intestinal  Hymj)toms  are  not  very  common.  Constipation  is  more  fre- 
quently present  than  diurrhu'a,  which  may,  however,  set  in  and  jirovo  ob- 
stinate toward  the  end.  When  there  is  much  bleeding  the  stools  may  be 
(lurk  in  color. 

A  progressive  nnwmia  is  one  of  the  most  striking  features  of  gastric 
cancer.  As  a  rule  the  blood-count  does  not  fall  below  fifty  per  cent.  A 
K'UCdcytosis  is  almost  constantly  present,  and  Welch  has  noted  an  instiince 
ill  which  the  ratio  of  white  to  red  corpuscles  was  one;  to  twenty.  There 
are  instances  in  which  tho  clinical  picture  is  rather  that  of  a  pernicious 
aiuviiiia,  with  reduction  of  the  red  blood-eorpnscles  to  twenty-five  per  cent 
and  marked  poikilocytosis.  When  any  degree  of  aiuBmia  is  present  nucle- 
ated red  (!orpuscles  may  be  found  in  dried  and  stained  specimens,  and  this 
method  of  examination  may  be  of  much  service  when  an  actual  blood- 
count  is  impossible.  The  condition  is,  however,  an  ansvmia  with  wasting, 
and  the  layer  of  pannicnlus  is  not  retained  as  in  tho  ordinary  forms  of  p(!r- 
nicioiis  anaemia.  Ultimately  the  patient  develops  an  aspect  to  which  the 
term  cachectic  is  applied,  and  which  is  perhaps  more  marked  in  gastric 
cuiucr  than  in  any  other  disease.  There  may  be  a  slight  yellowish  tint  to 
the  skin,  and  it  is  not  uncommon  to  see  brownisli  stains,  the  cachectic 
chloasma. 

Associated  with  the  anaemia  and  directly  dei»ondent  upon  it  are  the 
dropsical  symptoms  so  common  in  this  afTection.  (Edema  of  the  ankles 
and  of  the  legs  is  present  and  may  progress  to  a  general  anasarca ;  the 
cases  may  be  mistaken  for  heart-disease  or  dropsy.  There  are  no  special 
cardiac  symptoms;  the  pnlse  becomes  rapid  and  feeble  toward  the  end. 
The  aiiieniia  may,  however,  produce  such  pali)itation  aiid  dyspnoea  that 
tiie  case  may  be  regarded  as  cardiac.  Thrombosis  of  a  femoral  vein  may 
occur. 

The  urine  may  contain  a  trace  of  albumen  and,  toward  the  close, 
tube-casts.  Indican  is  often  present  in  increased  quantity,  and  occasion- 
ally acetone  and  diacetic  acid. 

Tile  temperature  is  usnally  normal,  and  toward  the  end,  when  cachexia 
IS  well  marked,  subnormal.  There  are,  however,  interesting  paroxysmal 
elevations  of  temperature,  definite  chills  with  fever,  in  which  the  ther- 
mometer registers  103°  or  104°,  followed  by  profuse  sweating.     The  rigors 


'^M&' 


tlviiiiifS 


Uti\' 


1     i 


382 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


may  recur  at  intervals  for  Aveeks,  and,  if  no  tumor  is  felt,  may  complicate 
the  diagnosis.  In  a  case  at  the  Philadelpliia  Hospital  the  paroxysms  re- 
curred for  more  than  six  weeks.  The  autopsy  showed  a  cancer  of  the 
stomach  with  adhesions  to  the  colon  and  extensive  suppuration  at  the  base 
of  the  cancer  and  in  a  pocket  between  the  stomach  and  omentum. 

The  mind  usually  remains  clear  to  the  close.  Naturally  the  patient 
has  attacks  of  despondency.  Toward  the  close  d(  .irium  is  common.  A 
form  of  coma  resembling  that  which  occurs  in  diabetes  is  occasionally 
met  with  in  gastric  cancer.  The  patient  becomes  restless  or  excited,  and 
gradually  unconsciousness  supervenes,  with  or  without  dyspnoea.  It  is 
due  to  the  presence  of  some  toxic  agent  in  the  blood,  possibly  the  diace- 
tic  acid. 

Ariiong  symptoms  referable  to  the  development  of  secondary  growths 
those  pertaining  to  the  liver  are  most  important.  Jaundice  is  not  uncom- 
mon, and  there  may  be  signs  of  great  enlargement  of  the  liver.  Maiiv 
instances  which  are  clinically  recorded  as  primary  cancer  of  this  organ  are 
in  reality  secondary  to  latent  cancer  of  the  stomach.  The  importance 
of  enlargement  of  the  supra-clavicular  and  inguinal  glands  in  gastric  can- 
cer has  already  been  emphasized.  The  new  growths  may  extend  to  the 
peritonaeum  and,  if  there  is  much  effusion,  produce  ascites.  Reference 
has  been  made  to  the  perforations  liable  to  occur  in  gastric  cancer.  The 
course  of  the  disease  is  progressively  downward.  In  the  majority  of  all 
cases  death  occurs  within  two  years,  and  the  average  duration  is  not  more 
than  eighteen  months.     In  cases  of  scirrhus  the  progress  is  slower. 

Diagnosis. — When  a  tumor  is  present  there  is  not  much  difficulty 
in  determining  the  nature  of  the  trouble ;  even  in  its  absence  the  pro- 
gressive emaciation,  the  loss  of  energy  and  strength,  the  anaemia  and 
cachexia,  when  associated  with  marked  gastric  symptoms,  are  almost  path- 
ognomonic. There  are  many  instances,  however,  in  which  a  positive  diag- 
nosis is  impossible.  The  diseases  with  which  cancer  is  most  liable  to  be 
confounded  are  ulcer  and  chronic  gastric  catarrh,  and  the  differential 
features  are  so  well  drawn  in  the  elaborate  article  by  my  colleague  Welch 
that  I  here  append  them  :  * 

CHRONIC   CATAUKHAL 
GASTRITIS. 


GASTRIC   CANCER. 


GASTRIC    ULCER. 


1.  Tumor  is  present  1.  Tumor  rare. 


1.  No  tumor. 


in  three  fourths  of  the 
cases. 

2.  Rare  under  forty 
years  of  age. 


2.  May  occur  at  any 
age  after  chi'.dhood. 
Over  one  half  of  the 
cases  under  forty  years 
of  age. 


2.  May  occur  at  any 


age. 


*  Op.  cit.,  vol.  ii,  p.  670. 


CANCER  OF  THE  STOMACO. 


383 


iC   CATAUUHAL 
L.STRITIS. 


OASTRIC   CANCER. 

3.  Average  duration 
about  one  year,  rarely 
over  two  years. 

4.  Gastric  lia^mor- 
rhage  frequent,  but 
rarely  profuse ;  most 
common  in  the  cachec- 
tic stage. 


5.  Vomiting  often 
has  tlie  peculiarities  of 
that  of  dilatation  of  the 
stomacji. 

6.  Free  hydrochloric 
acid  usually  absent  from 
the  gastric  contents  in 
cancerous  dilatation  of 
the  stomach. 

7.  Cancerous  frcg- 
nients  may  be  found  in 
the  washings  from  the 
stomach  or  in  the  vomit 
(rare). 

8.  Secondary  can- 
cers may  be  recognized 
in  the  liver,  tho  perito- 
neum, the  lympliatic 
glands,  and  i-arely  in 
other  parts  of  the  body. 

9.  Loss  of  flesh  and 
strength  and  develop- 
ment of  cachexia  usu- 
ally more  marketl  and 
more  riipid  than  in  ul- 
cer or  in  gastritis,  and 
less  explicable  by  the 
gastric  symptoms. 

10.  Epigastric  pain 
is  often  more  continu- 
ous, less  dependent  up- 
on taking  food,  less  re 


GASTRIC   ULCER. 

3.  Duration  indefi- 
nite;  may  be  for  sev- 
eral years. 

4.  Gastric  ha3mor- 
rhage  less  frequent  than 
in  cancer,  but  oftener 
profuse ;  not  uncom- 
mon when  the  general 
health  is  but  little  im- 
paired. 

5.  Vomiting  rarely 
referable  to  dilatation 
of  the  stomach,  and 
then  only  in  a  late 
stage  of  the  disease. 

G.  Free  hydrochloric 
acid  usually  present  in 
the  gastric  contents. 


7.  Absent. 


CIIROXIC    CATARRHAL 
QASTKITIS. 


8.  Absent. 


9.  Cachectic  appear- 
ance usually  less  marked 
and  of  later  occurrence 
than  in  cancer,and  mpre 
manifestly  dependent 
upon  the  gastric  disor- 
ders. 

10.  Pain  is  often 
more  paroxysmal,  more 
influenced  by  taking 
food,   oftener    relieved 


3.   Duration  indefi- 


nite. 


4.    Gastric   ha3mor- 
rhage  rare. 


5.  Vomiting  may  or 
may  not  be  present. 


C.  Free  hydrochloric 
acid  may  be  present  or 
absent. 


7.  Absent. 


8.  Absent. 


9.  When  uncompli- 
cated, usually  no  ap- 
pearance of  cachexia. 


10.  The  pain  or  dis- 
tress induced  by  taking 
food  is  usually  less  se- 
vere than  in  cancer  or 


teiif 


384 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


GASTKIC    CAXCKU. 

lieved  by  vomiting,  and 
less  localized  than  in 
ulcer. 

11.    Causation    not 
known. 


GASTRIC    ULCER, 

by  vomiting,  and  more 
sharply  localized  than 
in  cancer. 

11.    Causation    not 
known. 


12.  No  improve- 
ment, or  only  tempo- 
rary improvement,  in 
the  course  of  the  dis- 
ease. 


12.  Sometimes  a  his- 
tory of  one  or  more  pre- 
vious similar  attacks. 
The  course  ma\  be  ir- 
regular and  intermit- 
tent. Usually  marked 
improvement  by  regula- 
tion of  diet. 


CHRONIC   CATARRHAL 
GASTRITIS. 

ulcer.  Fixed  point  of 
tenderness  usually  ab- 
sent. 

11.  Often  referable 
to  some  known  cause, 
such  as  abuse  of  alco- 
hol, gormandizing,  and 
certain  diseases,  as 
phthisis,  Bright's  dis- 
ease, cirrhosis  of  tlie 
liver,  etc. 

12.  May  be  a  history 
of  previous  similar  at- 
tacks. More  amenable 
to  regulation  of  diet 
than  is  cancer. 


Treatment. — The  disease  is  incurable  and  palliative  measures  are 
alone  indicated.  1'he  diet  should  consist  of  readily  digested  substances  of 
all  sorts.  Many  patients  do  best  on  milk  alone.  Washing  out  of  the 
stomach,  which  may  be  done  with  a  soft  tube  without  any  risk,  is  particu- 
larly advantageous  when  there  is  obstruction  at  the  pylorus,  and  is  by  far 
the  most  satisfactory  means  of  combatting  the  vomiting.  The  excessive 
fermentation  is  also  best  treated  by  lavage.  When  the  pain  becomes  se- 
vere, particularly  if  it  disturbs  the  rest  at  night,  morphia  must  be  given. 
One  eighth  of  a  grain,  combined  with  carbonate  of  soda  (gr.  v),  bismuth 
(gr,  v-x),  usually  gives  prompt  relief,  and  the  dose  does  not  always  re- 
quire to  be  increased,  Creo'?ote  (itl  J-ij)  and  carbolic  acid  are  very  useful. 
The  bleeding  in  gastric  cancer  is  rarely  amenable  to  treatment.  Opera- 
tive measures  have  been  advised  and  practised,  and  in  exceptional  in- 
stances there  are  cases  in  which  the  limited  cancer  could  be  resected  with 
reasonable  hope  of  recovery. 

Kon- cancerous  tumora  of  the  stomac'/  rarely  cause  inconvenience. 
Polypi  are  common  and  they  may  be  numerous  ;  as  many  as  one  hundred 
and  fifty  have  been  reported  in  one  case.  Sarcomata  are  very  rare,  Fi- 
hromata  and  lipomata  have  been  described. 

Foreign  bodies  occasionally  produce  remarkable  tumors  of  the  stom- 
ach. The  most  extraordinary  is  the  hair  tumor,  of  which  a  number  of 
instances  have  been  reported  in  hysterical  women  who  have  been  in  the 
habit  of  eating  their  own  hair,    A  specimen  in  the  medical  museum  of 


'^. 


HEMORRHAGE  FROM  THE  STOMACH. 


385 


McGill  University  is  in  two  sections,  which  form  an  exact  mould  of  the 
stomach.  The  tumors  wliich  they  form  are  large  and  very  puzzling  and 
have  been  mistaken  for  cancer.  In  one  instance  the  ball  of  hair  was  re- 
moved by  a  surgical  operation.  The  tumor  was  thought  to  be  a  movable 
kidney. 


Vm.    HiCMORRHAGE  FROM  THE  STOMACH  {Ilmmatemenu^). 

Etiology. — Gastrorrhagia,  as  this  symptom  is  called,  may  result  from 
many  condi'Jons,  some  of  which  are  local,  others  general. 

1.  In  local  disease  in  the  stomach  itself:  (a)  Cancer;  {b)  ulcer;  (c) 
disease  of  the  blood-vessels,  sucli  as  miliary  aneurisms  of  the  smaller  arte- 
ries, and  occasionally  varicose  veins ;  (d)  acute  congestion,  as  in  gastritis, 
and  possibly  in  vicarious  ha;morrhage,  but  both  of  these  are  extremely 
rare  causes. 

2.  Passive  congestion  due  to  obstruction  in  the  portal  system.  This 
may  be  either  (a)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the 
portal  vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in 
cases  of  chronic  disease  of  the  heart  and  lungs ;'  (b)  splenic.  Gastrorrhagia 
is  by  no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  ex- 
pluincd  by  the  intimate  relations  which  exist  between  the  vasa  brevia  and 
the  splenic  circulation. 

3.  Toxic :  (a)  The  poisons  of  the  specific  fevers,  small-pox,  measles, 
yellow  fever ;  (b)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy 
and  in  purpura ;  (c)  phosphorus. 

4.  Traumatism :  (a)  Mechanical  injuries,  such  as  blows  and  wounds, 
and  occasionally  by  the  stomach-tube ;  (b)  the  result  of  severe  corrosive 
poisons. 

5.  Certain  constitutional  diseases :  (a)  Hicmophilia ;  {b)  profound 
anaemias,  whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria ; 
(c)  chola^mia. 

G.  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  progressive  paralysis  of  the  insane  and  epilepsy. 

7.  The  blood  may  not  come  from  the  stomach,  but  flow  into  it.  Thus 
it  may  pass  from  the  nose  or  the  pharynx.  In  hfemoptysis  some  of  the 
blood  may  find  its  way  into  the  stomach.  The  bleeding  may  take  place 
from  the  a3sophagus  and  trickle  into  the  stomach,  from  which  it  is  eject- 
ed. This  occurs  in  the  case  of  rupture  of  aneurism  and  of  the  oesopha- 
geal varices.  A  child  may  draw  blood  with  the  milk  from  the  mother's 
breast  even  in  considerable  quantities  and  then  vomit  it. 

8.  Miscellaneous  causes:  Aneurism  of  the  .-lorta  or  of  its  branches 
may  rupture  into  the  stomach.  There  are  instances  in  which  a  patient 
has  a  single  attack  of  haemorrhage  without  even  having  a  recurrence  or 
witliout  symptoms  pointing  to  disease  of  the  stomach. 


9m 


DISEASES  OF  TOE  DIGESTIVE  SYSTEM. 


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In  new-born  infants  haemorrhage  may  occur  within  the  first  two  weeks 
and  prove  rapidly  fatal ;  the  precise  etiology  of  this  is  not  known.  This 
melwna  nconitturum^  according  to  Ilecker,  occurs  in  one  of  every  five 
hundred  infants.  In  a  few  instances  it  seems  to  he  associated  with  an 
acquired  or  hereditary  haimophilia.  Occasionally  it  is  met  with  in  sound, 
healthy  infants ;  in  others  the  hirth  has  been  premature,  and  in  such 
cases  the  bleeding  may  be  associated  with  premature  interruption  of  the 
fu3tal  circulation.  In  very  exceptional  cases  ulcer  of  the  stomach  has 
been  found. 

In  medical  jiractice,  haemorrhage  from  the  stomach  occurs  most  fre- 
quently in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 
It  is  more  frequent  in  women  than  in  men,  owing  to  the  greater  preva- 
lence of  round  ulcer  in  the  former. 

Morbid  Anatomy. — "When  death  lias  occurred  from  the  hfemato- 
mesis  there  are  signs  of  intense  anaemia.  The  condition  of  the  stomach 
varied  extremely.  The  lesion  is  evident  in  cancer  and  in  ulcer  of  the 
stomach.  It  is  to  be  borne  in  mind  that  fatal  haemorrhage  may  come 
from  a  small  miliary  aneurism  communicating  with  the  surface  by  a  pin- 
hole pei'foration,  or  the  bleeding  may  be  due  to  the  rupture  of  a  sub- 
mucous vein  and  the  erosion  in  the  mucosa  may  be  small  and  readily 
overlooked.  It  nuiy  require  a  careful  and  prolonged  search  to  avoid  over- 
looking such  lesions.  In  the  large  group  associated  with  portal  obstruc- 
tion, whether  dne  to  hepatic  or  sjilenic  disease,  the  mucosa  is  i;sually  pale, 
smooth,  and  shows  no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  haMnor- 
rhage,  one  may  sometimes  search  in  vain  for  any  focal  lesion  to  account 
for  the  gastrorrhagia,  and  we  must  conclude  that  it  is  possible  for  even 
the  most  profuse  bleeding  to  occur  by  diapedcsis.  The  stomach  may  be 
distended  with  blood  and  the  source  of  the  haemorrhage  not  apparent 
either  in  the  stomach  or  in  the  the  portal  system.  In  such  cases  tlie 
oesophagus  should  be  examined,  as  the  bleeding  may  come  from  tluit 
source.  In  toxic  cases  there  are  invariably  haemorrhages  in  the  mucous 
membrane  itself. 

Symptoms. — In  rare  instar  jes  fatal  syncope  may  occur  without  any 
vomiting.  In  a  case  of  the  kind,  in  which  the  woman  had  fallen  over  and 
died  in  a  few  minutes,  the  stomach  contained  between  three  and  four 
pounds  of  blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound 
anaemia.  "When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  for 
several  days.  Fatal  haemorrhage  from  the  stomach  is  met  with  in  ulcer, 
cirrhosis,  enlargement  of  the  spleen,  and  in  instances  in  which  an  aneur- 
ism ruptures  into  the  stomach  or  oesophagus.  Gastrorrhagia  may  occur 
in  splenic  aiuemia  or  in  leukaemia  before  the  condition  has  aroused  the 
attention  of  friends  or  physician. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day 
the  patient  may  bring  up  three  or  four  pounds,  or  even  more.  In  a 
case  under  the  care  of  George  Ross,  in  the  Montreal  General  Hospital,  tlio 


HEMORRHAGE  FROM  THE  STOMACH. 


387 


patient  lost  during  seven  days  ten  pounds,  by  measurement,  of  blood. 
Tiio  usual  symptoms  of  anaemia  develop  rapidly,  and  there  may  be  slight 
fever,  and  subsequently  odema  may  occur.  An  interesting  circumstance 
connected  with  gastro-intestinal  haemorrhage  is  the  development  of  amau- 
rosis, the  mode  of  production  of  which  is  still  under  discussion. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to 
the  origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the 
case  has  not  been  seen  during  the  attack.  Examination  of  the  vomit 
readily  determines  whether  blood  is  present  or  not.  The  materials  vom- 
ited may  be  stained  by  wine,  the  juice  of  strawberries,  raspberries,  or  cran- 
berries, which  give  a  color  very  closely  resembling  fresh  blood,  while  iron 
and  bismuth  .and  bile  may  produce  a  blackish  color  like  altered  blood. 
In  such  cases  the  microscope  will  show  clearly  the  presence  of  the  shadowy 
outlines  of  the  red  blood-corpuscles,  and,  if  necessary,  spectroscopic  and 
chemical  tests  may  be  applied. 

Deception  is  sometimes  practised  by  hysterical  patients,  who  swallow 
and  then  vomit  blood  or  colored  liquids.  "With  a  little  care  such  cases  can 
nsually  be  detected.  The  cases  must  be  excluded  in  which  the  blood 
passes  from  the  nose  or  pharynx,  or  in  which  infants  swallow  it  with  the 
milk. 

There  is  not  often  difficulty  in  distinguishing  between  hfemoi)tysis  and 
haematemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.    The  following  are  points  to  be  borne  in  mind  in  the  diagnosis : 


II.'EMATEMESIS. 

1.  Previous  history  points  to  gas- 
tric, hepatic,  or  splenic  disease. 

2.  The  blood  is  brought  up  by 
vomiting,  prior  to  which  the'patient 
may  experience  a  feeling  of  giddi- 
ness or  faintness. 

3.  The  blood  is  usually  clotted, 
mixed  with  particles  of  food,  and 
has  an  acid  reaction.  It  may  be 
dark,  grumous,  and  fluid. 

4.  Sul)scquent  to  the  attack  tho 
patient  passes  tarry  stools,  and  signs 
of  disease  of  the  abdominal  viscera 
nay  be  detected. 


IliEMOPTYSIS. 

1.  Cough  or  signs  of  some  pul- 
monary or  cardiac  disease  precedes, 
in  many  cases,  the  hosmorrhage. 

2.  The  blood  is  coughed  up, 
and  is  usually  preceded  by  a  sensa- 
tion of  tickling  in  the  throat.  If 
vomiting  occurs,  it  follows  the 
coughing. 

3.  The  blood  is  frothy,  bright 
red  in  color,  alkaline  in  reaction. 
If  clotted,  rarely  in  such  large  co- 
agula,  and  muco  pus  may  be  mixed 
with  it. 

4.  The  cough  persists,  physical 
signs  of  local  disease  in  the  chest 
may  usually  be  detected,  and  the 
sputa  may  be  blood-stained  for  many 
days. 

Prognosis. — Except  in  the  case  of  rupture  of  aneurism  or  of  large 
vems,  hffimatemesis  rarely  proves  fatal.    In  my  experience  death  has  fol- 


V 


388 


DISEASES  OF  THE  DIGESTIVE  SYSTEM, 


lowed  more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than 
in  ulcer  or  cancer.  In  ulcer  it  is  to  be  remembered  that  in  the  chronic 
haemorrhagic  form  the  bleeding  may  recur  for  years.  The  treatment  of 
lifematemesis  is  considered  under  gastric  ulcer. 


VII.    DISEASES  OF  THE  INTESTINES. 

I.  DISEASES    OF    THE    INTESTINES    ASSOCIATED  WITH 

DIARRHCEA. 


,( , 


CATARRHAL  ENTERITIS;  DIARRHCEA. 

In  the  classification  of  catarrhal  enteritis  the  anatomical  divisions  of 
the  bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejunitis,  ilei- 
tis, typhlitis,  colitis,  and  proctitis  have  been  recognized ;  whereas  in  a 
majority  of  cases  the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is 
involved,  sometimes  the  small  most  intensely,  sometimes  the  large  bowel, 
but  during  life  it  may  be  quite  impossible  to  say  which  portion  is  specially 
affected. 

Etiology. — The  causes  may  be  either  jon'ww?'?/  or  secondary.  Among 
the  causes  of  primary  catarrhal  enteritis  are  :  (a)  Improper  food,  one  of 
the  most  frequent,  especially  in  children,  in  whom  it  follows  overeating, 
or  the  ingestion  of  unripe  fruit.  In  some  individuals  special  articles  of 
diet  will  always  produce  a  slight  diarrhoea,  which  may  not  be  due  to  a 
catarrh  of  the  mucosa,  but  to  increased  peristalsis  induced  by  the  offend- 
ing material,  (b)  Various  toxic  substances.  Many  of  the  organic  poi- 
sons, such  as  those  produced  in  the  decomposition  of  milk  and  articles  of 
food,  excite  the  most  intense  intestinal  catarrh.  Certain  inorganic  sub- 
stances, as  arsenic  and  mercury,  act  in  the  same  way.  (c)  Changes  in  the 
weather.  A  fall  in  the  temperature  of  from  twenty  to  thirty  degrees,  par- 
ticularly in  the  spring  or  autumn,  may  induce— how,  it  is  difficult  to  say 
— an  acute  diarrhoea.  We  speak  of  this  as  a  catarrhal  process,  the  result 
of  cold  or  of  chill.  On  the  other  hand,  the  diarrhceal  diseases  of  chililren 
are  associated  in  a  very  special  Avay  with  the  excessive  heat  of  summer 
months,  {d)  Changes  in  the  constitution  of  the  intestinal  secretions. 
We  know  too  little  about  the  succns  enfericus  to  be  able  to  speak  of  influ- 
ences induced  by  change  in  its  quantity  or  quality.  It  has  long  been  held 
that  an  increase  in  the  amount  of  bile  poured  into  the  bowel  might  excite  ii 
diarrhoea ;  hence  the  term  bilious  diarrhoea,  so  frequently  used  by  the  older 
writers.  Possibly  there  are  conditions  in  which  an  excessive  amount  of  bilo 
is  poured  into  the  intestine,  increasing  the  peristalsis,  and  hurrying  on  the 
contents ;  but  the  opposite  state,  a  scanty  secretion,  by  favoring  the  natural 
fermentative  processes,  much  more  commonly  causes  an  intestinal  catarrh. 
Absence  of  the  pancreatic  secretion  from  the  intestine  has  been  associated 


DISEASES  OP  THE   INTB:STINES  ASSOCIATED   WITH   DIARIUKKA.  389 


Eireus  in  a 


ill  certain  cases  with  a  fatty  (iiarrlia?a.  (e)  Nervous  influences.  It  is  by 
no  means  clear  liow  mental  states  act  upon  the  bowels,  and  yet  it  is  an  old 
and  trustworthy  observation  which  every-day  experience  confirms  that  the 
mental  state  may  profoundly  affect  the  intestinal  canal.  These  influences 
aliould  not  properly  bo  considered  under  catarrhal  processes,  as  they  result 
simply  from  increased  peristalsis  or  increased  secretion,  and  are  usually  de- 
Bcribcd  under  the  heading  nervous  diarrhcea.  In  children  it  frequently 
follows  fright.  It  is  common,  too,  in  adults  as  a  result  of  emotional  dis- 
turbances. Canstatt  mentions  a  surgeon  who  always  before  an  important 
operation  had  watery  diarrhcea.  In  hysterical  women  it  is  seen  as  an  occa- 
sional occurrence,  duo  to  transient  excitement,  or  as  a  chronic,  protracted 
diarrhcea,  which  may  last  for  months  or  even  years. 

Among  the  secondary  causes  of  intestinal  catarrh  may  bo  mentioned : 
{a)  Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyaemia, 
septicaemia,  tuberculosis,  and  pneumonia  are  occasionally  associated  with 
intestinal  catarrh.  In  dysentery  and  typhoid  fever  the  ulceration  is  in 
part  responsible  for  the  catarrhal  condition,  but  in  cholera  it  is  probably  a 
direct  influence  of  the  bacilli  or  of  the  toxic  materials  produced  by  them. 
[b)  The  extension  of  inflammatory  processes  from  adjacent  parts.  Thus, 
in  peritonitis,  catarrhal  swelling  and  increased  secretion  are  always  present 
in  the  mucosa.  In  cases  of  invagination,  hernia,  tuberculous  or  cancerous 
ulceration,  catarrhal  processes  are  common,  {c)  Circulatory  disturbances 
cause  a  catarrhal  enteritis,  usually  of  a  very  chronic  character.  Tliis  is 
common  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in  chronic  affections 
of  the  heart  and  lungs — all  conditions,  in  fact,  which  produce  engorge- 
ment of  the  terminal  branches  of  the  portal  vessels,  {d)  In  the  cachectic 
conditions  met  with  in  cancer,  profound  anaemia,  Addison's  disease,  and 
Bright's  disease  intestinal  catarrh  may  develop,  and  may  terminate  life. 

Morbid  Anatomy. — Changes  in  the  mucous  membrane  are  not 
always  visible,  and  in  cases  in  which,  during  life,  the  symptoms  of  intes- 
tinal catarrh  have  been  marked,  neither  redness,  swelling,  nor  increased 
secretion — the  three  signs  usually  laid  down  as  characteristic  of  catarrhal 
inflammation — may  be  present  post  mortem.  It  is  rare  to  see  the  mucous 
membrane  injected ;  more  commonly  it  is  pale  and  covered  with  mucus. 
In  the  upper  part  of  the  small  intestine  the  tips  of  the  valvulae  conniventes 
may  be  deeply  injected.  Even  in  extreme  grades  of  portal  obstruction 
intense  hyperaemia  is  not  often  seen.  The  entire  mucosa  may  be  softened 
and  infiltrated,  the  lining  epithelium  swollen,  or  even  shed,  and  appearing 
as  large  flakes  among  the  intestinal  contents.  This  is,  no  doubt,  a  post- 
mortem change.  The  lymph  follicles  are  almost  always  swollen,  particu- 
larly in  children.  The  Peyer's  patches  may  be  prominent  and  the  solitary 
follicles  in  the  large  and  small  bowel  may  stand  out  with  distinctness  and 
present  in  the  centres  little  erosions,  the  so-called  follicular  ulcers.  This 
may  be  a  striking  feature  in  the  intestine  in  all  forms  of  catarrhal  enteri- 
tis in  children,  quite  irrespective  of  the  intensity  of  the  diarrhoea. 


nvmf^'i  ^''^ 


^vtfi 


1 .1!.^^ 


300 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


When  the  jiroccss  is  more  chronic  the  mucosii  is  firmer,  in  some  in- 
stanres  thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles 
present  a  slaty  pigmentation. 

Symptoms. — Acute  and  chronic  forms  may  be  recogniried.  The  im- 
portant symptom  of  both  is  diarrhuni,  which,  in  the  majority  of  instances, 
is  the  sole  indication  of  this  condition.  It  is  not  to  bo  supposed  that  diar- 
rhoea is  invariably  caused  by,  or  associated  with,  catarrhal  enteritis,  as  it 
may  be  produced  by  nervous  and  other  influences.  It  is  probable  that 
catarrh  of  the  jejunum  may  exist  without  any  diarrhoea ;  indeed,  it  is  a 
very  common  circumstance  to  find  post  mortem  a  catarrhal  state  of  the 
small  bowel  in  persons  who  have  not  had  diarrhea  during  life.  Tlie 
stools  vary  extremely  in  character.  The  color  depends  upon  the  amount 
of  bile  with  which  they  are  mixed,  and  they  may  he  of  a  dark  or  blackish 
brown,  or  of  a  light-yellow,  or  even  of  a  grayish-white  tint.  The  consist- 
ence is  usually  very  thin  and  watery,  but  in  some  instances  the  stools  are 
pultaceous  like  thin  gruel.  Portions  of  undigested  food  can  often  be  soon 
(lienteric  diarrhoea),  and  flakes  of  yellowish-brown  mucus.  Microscoiiic- 
ally  there  are  innumerable  micro-organisms,  epithelium  and  mucous  colls, 
crystals  of  phosphate  of  lime,  oxalate  of  lime,  and  occasionally  cholesterin 
and  Charcot's  crystals. 

Pain  in  the  abdomen  is  usually  present  in  the  acute  catarrhal  enteritis, 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  the 
colon  is  involved  tlicre  may  be  tenesmus.  !More  or  less  tymjianites  exists, 
and  there  are  gurgling  noises  or  borborygmi,  due  to  the  rapid  passage  of 
fluid  and  gas  from  one  part  to  another.  In  the  very  acute  attacks  there 
may  be  vomiting.  Fever  is  not,  as  a  rule,  present,  but  there  may  be  a 
slight  elevation  of  one  or  two  degrees.  The  appetite  is  lost,  there  is  in- 
tense thirst,  and  the  tongue  is  dry  and  coated.  In  very  acute  cases,  when 
the  quantity  of  fluid  lost  is  great  and  the  pain  excessive,  there  may  be 
collapse  symptoms.  The  number  of  evacuations  varies  from  four  or  five 
to  twenty  or  more  in  the  course  of  the  day.  The  attack  lasts  for  two  or 
three  days,  or  may  be  prolonged  for  a  Aveek  or  ten  days. 

Clironie  catarrh  of  the  bowels  may  follow  the  acute  form,  or  may  de- 
velop gradually  as  an  independent  affection  or  as  a  sequence  of  obstruc- 
tion in  the  portal  circulation.  It  is  characterized  by  diarrhoea,  with  or 
without  colic.  The  dejections  vary ;  when  the  small  bowel  is  chiefly  in- 
volved the  diarrhoea  is  of  a  lienteric  character,  and  when  the  colon  is 
affected  the  stools  are  thin  and  mixed  with  much  mucus.  A  spooial 
form  of  mucous  diarrhoea  will  be  subsequently  described.  The  genonil 
nutrition  of  the  patient  in  these  chronic  cases  is  greatly  disturbed ;  there 
may  be  much  loss  of  flesh  and  great  pallor.  The  patients  are  inclined  to 
suffer  from  low  spirits,  or  hypochondriasis  may  develop. 

Diagnosis. — It  is  important,  in  the  first  place,  to  determine,  if  pos- 
sible, Avhether  the  large  or  small  bowel  is  chiefly  affected.  In  catarrh  of 
the  small  bowel  the  diarrhoea  is  less  marked,  the  pains  are  of  a  colicky 


inSEA^^ES  OP  THE  INTESTINES   ASSOCIATED  WITH   DIAIIUIKEA.  391 

cliarac'tpr,  borbor3-gnii  aro  luit  s.)  frequent,  tlie  iivc.oH  usually  contaiu  })or- 
tions  of  food,  mid  arc  more  yellowish-greeu  or  gruyi.sh-yoUow  and  floc- 
culcnt  and  do  not  contain  much  mucus.  When  the  larjjo  intcstliio  is  at 
fault  tlicro  may  bo  no  pain  whatever,  as  in  the  catarrh  of  the  hirfjfo  intes- 
tine associated  with  tuberculosis  iind  liri^fht's  disease.  A\'hen  present,  the 
]iains  aro  most  intense  and,  if  the  lower  portion  of  the  bowel  is  involved, 
tlioro  may  bo  marked  tenesmus.  The  stools  have  a  uniform  soupy  con- 
sistence, grayish  in  color  and  granular  throughout,  with  hero  and  there 
flakes  of  mucus,  or  they  may  contain  very  large  quantities  of  mucus. 

There  aro  no  positive  symptoms  l)y  Avhieh  the  diagnosis  of  duodenitis 
can  be  made.  It  is  usually  associated  with  acute  gastritis  and,  if  the  j^ro- 
CCS3  extends  into  the  bilo-duot,  with  jaundice.  Neither  jejunitis  nor 
ileitis  can  bo  separated  from  general  intestiiud  catarrh. 


ENTERITIS  IX  CHILDREN. 

Wo  may  recognize  three  forms :  (1)  The  acute  dyspeptic  diarrhoea ;  (2) 
cholera  infantum  ;  and  (3)  acute  entoro-colitis. 

General  Etiology  of  the  Diarrhoeas  of  Children. — The  dis- 
ease is  most  frequent  in  artificially  fed  children,  and  the  greatest  number 
of  cases  occur  between  the  ages  of  six  and  eighteen  months.  A  popular 
and  well-founded  belief  ascribes  special  danger  to  the  second  summer  of 
the  infant.  Infantile  diarrhoea  is  very  prevalent  among  the  poorer  classes 
in  the  largo  cities.  It  attacks,  however,  children  with  the  most  favorable 
surroundings.  Two  factors  influence  the  disease,  diet  and  temperature. 
An  immense  majority  of  all  fatal  cases  aro  artificially  fed.  Of  1,943  fatal 
cases  in  Holt's  statistics,  only  three  per  cent  wore  exclusively  breast  fed. 
Among  tho  poor  the  bowel  complaint  in  children  begins  with  the  artificial 
feeding.  Tho  relation  of  temperature  to  tho  prevalence  of  diarrheal  dis- 
eases in  children  has  long  boon  recognized.  Tho  mortality  curve  begins 
to  rise  in  May,  increases  in  June,  reaches  the  maximum  in  July,  and  grad- 
ually sinks  tlu'ough  August  and  Sei)tembcr.  The  maximi;m  corresponds 
closely  with  the  highest  mean  temperature  ;  yet  we  cannot  regard  the  heat 
itself  as  the  direct  agent,  but  only  one  of  sevei'al  factors.  Thus  tho  mean 
teiuporature  of  June  is  only  four  or  five  degrees  lower  than  that  of  July, 
and  yet  the  mortality  is  not  more  than  one  third.  Scibert,  who  has  care- 
fully analyzed  the  mortality  and  tho  temperature,  month  by  month,  in 
New  York,  for  ten  years,  fails  to  find  a  constant  relation  between  tho 
degree  of  heat  and  the  number  of  cases  of  diarrhoea.  Neither  barometric 
pressure  nor  humidity  appears  to  have  any  influence. 

Relation  of  Bacteria. — The  healthy  fasces  of  sucklings  contain  a 
number  of  bacteria  and  micrococci,  tho  most  important  of  Avhich  are  the 
hadcrium  lactis  acrogcnes  and  the  hactermvi  coli  cnmimtnc.  The  former 
i?  only  present  in  the  intestine  after  a  milk  diet,  the  milk  sugar  appear- 
ing to  furnish  the  materials  necessary  for  its  growth.     It  occurs  more 


:| 


fflli-i'  ■' 


'i^';-' 


11 


if 


392 


DISEASKS  OF  THE   DIGESTIVE  SYSTEM. 


in  tho  upper  portion  of  tlio  bowel,  and  in  tliis  region  excitoa  tlio  for- 
mentativo  processes  in  the  milk.  The  lartcrimn  coli  commune  is  found 
more  abundantly  in  tlic  lower  portion  of  tlio  small  intestine  and  in  tho 
oolon,  and  excites  fermentative  changes  which  are  probably  associated  with 
certain  phases  of  digestion.  The  ob.servations  of  Escherich  show  the  re- 
markable simplicity  of  this  bacterial  vegetation  in  tho  healthy  fa*cog  of 
milk-fed  children,  as  those  two  alone  d(>velop  and  are  constant.  In  infan- 
tile diarrlura  the  number  ^)i  bacteria  which  may  be  isolated  from  tho  stools 
is  rcnuirkablo.  Booker  has  discriminated  forty  varieties,  tho  greatest  num- 
ber of  whicih  were  found  in  the  cases  of  cholera  infantum.  Tho  two  con- 
stant forms  noted  above  do  not  disappear  in  tho  diarrhcoal  stools.  Ko 
forms  have  been  found  to  bear  a  constant  or  specific  relation  to  tho  diar- 
rhcoal faeces,  such  as  the  two  al)ovc  mentioned  do  to  the  healthy  milk 
faeces.  Tho  bacteria  of  the  jyrotcnn  group  are  most  frequent,  and  possess 
pathogenic  properties.  All  the  varieties  develop  and  produce  important 
changes  in  the  milk,  which  have  been  dealt  with  very  fully  by  Booker  in 
his  studies.  This  author  concludes  tluu  in  the  diarrhoea  of  infants  "not 
ono  specific  kind,  but  many  dilTorent  kiiul.s  of  bacteria  are  concerned, 
and  that  their  action  is  manifested  more  in  the  alteration  of  tho  food  and 
intestinal  contents  and  in  the  production  of  injurious  products  than  in  a 
direct  irritation  upon  the  intestinal  wall."  AVith  these  agree  tho  conclu- 
sions of  Jeffries  and  Baginsky  regardiiig  cholera  infantum. 

Morbid  Anatomy. — Wo  find  most  fi-equently  a  catarrhal  swelling 
of  the  mucosa  of  both  small  and  largo  bowel  with  enlargement  of  the 
lymph  follicles.  In  more  chronic  cases  the  latter  show  small  erosions  or 
follicular  ulcers ;  more  rarely  there  is  croupous  enteritis  affecting  tho 
lower  part  of  the  ileum  and  the  colon.  The  changes  in  the  other  organs 
are  neither  numerous  nor  characteristic.  Broncho-pneumonia  occurs  in 
many  cases.  The  spleen  may  bo  swollen.  Brain  lesions  arc  rare;  the 
membranes  and  substance  are  often  antemic,  but  meningitis  or  thrombosis 
is  very  uncommon. 

Clinical  Forms.— Acute  Dyspeptic  Diarrhoea. — The  child  may  ap- 
pear in  its  usual  health,  but  has  an  increase  in  the  number  of  stools,  with- 
out fever  or  special  disturbance  except  slight  restlessness  at  night.  After 
persisting  for  a  day  or  two  the  stools  become  more  frequent  and  contain 
undigested  food  and  curds,  and  are  very  offensive.  In  other  cases  the  dis- 
ease sets  in  abruptly  Avith  vomiting,  griping  pains,  and  fever,  which  may  rise 
rapidly  and  reach  104°  or  105°.  There  may  bo  convulsions  at  the  outset. 
The  abdomen  is  sensitive,  and  the  child  lies  with  the  legs  drawn  up.  The 
stools  consist  of  grayish  or  greenish-yellow  faeces  mixed  Avith  gas,  curds, 
and  portions  of  food.  In  children  over  two  years  of  ago  such  attacks  not 
infrequently  follow  eating  freely  of  unripe  fruit  or  tho  drinking  of  milk 
which  has  been  tainted.  "With  judicious  treatment  the  children  improve 
in  a  few  days ;  but  relapses  are  not  uncommon,  and  in  the  hot  weather 
the  attack  may  be  tho  starting  point  of  a  severe  entero-colitis.    In  a  de- 


DISEASES  OF  THE   INTESTINES  ASSOCIATED  WITH   DIARRIICEA.  393 


liilitatcd  child  a  mild  attack  may  prove  fatal.  This  dyspeptic  diarrhea  is 
distinguished  sliarply  from  cliolcra  infantum  by  the  character  of  the 
stools,  which  never  have  a  watery,  serous  character.  In  many  instauces 
tliis  form  precedes  the  onset  of  the  8])ecific  fevers,  jmrticularly  during  the 
hot  weiithor. 

Cholfira  Infantum. — This  is  the  counterpart  iu  the  infant  of  the  so- 
called  choleraic  diarrhoea  in  the  adult,  and  iu  their  clinical  asi)ects  those 
two  forms  arc  identical.  It  is  by  no  means  so  common  as  the  ordinary 
dysjieptic  diarrhoea  of  children,  and,  according  to  Ilolt,  occurs  only  in 
two  or  three  per  cent  of  the  cases  of  summer  diarrhea.  It  prevails  iu 
tlie  hot  weather  and  in  children  artificially  fed  or  who  have  had  i)rc- 
viously  some  slight  dyspeptic  derangement.  It  is  characterized  by  vomit- 
ing, uncontrollable  diarrhoea,  and  collapse.  The  disease  sets  in  with 
vomiting,  which  is  incessant  and  is  excited  by  any  attempt  to  take  food  or 
drink.  The  stools  arc  profuse  and  frequent ;  at  first  faecal  in  character, 
brown  or  yellow  in  color,  and  finally  thin,  serous,  and  watery.  The  stools 
first  passed  are  very  offensive ;  subsequently  they  are  odorless.  I'he  thin, 
serous  stools  are  alkaline.  There  is  fever,  but  the  axillary  temperature 
may  register  three  or  more  degrees  below  that  of  the  rectum.  From  the 
outset  there  is  marked  prostration;  the  eyes  are  sunken,  the  features 
pinc'lied,  the  fontanelle  depressed,  and  the  skin  has  a  peculiar  ashy  pallor. 
At  first  restless  and  excited,  the  child  subsequently  becomes  heavy,  dull, 
iiiul  listless.  The  tongue  is  coated  at  the  onset,  but  subsequently  becomes 
rod  and  dry.  As  in  all  choleraic  conditions,  the  thirst  is  insatiable ;  the 
pulse  is  rapid  and  feeble,  and  toward  the  end  becomes  irregular  and  im- 
perceptible. Death  may  occur  within  twenty-four  hours,  with  symptoms 
of  collapse  and  great  elevation  of  the  internal  temperature.  Before  the 
end  the  diarrhoea  and  vomiting  may  cease.  In  other  instances  the  intense 
symptoms  subside,  but  the  child  remains  torpid  and  semi-comatose  with 
fingers  clutched,  and  there  may  be  convulsions.  The  head  may  be  retract- 
ed and  the  respirations  interrupted,  irregular,  and  of  the  Cheyne-Stokes 
type.  The  child  may  remain  in  this  condition  for  aome  days  without  any 
signs  of  improvement.  It  was  to  this  group  of  symptoms  in  infantile 
diarrlioja  that  Marshall-Hall  gave  the  term  "  hydrcncephaloid "  or  spuri- 
ous hydrocephalus.  As  a  rule,  no  changes  in  tlie  brain  or  other  organs 
are  found,  and  the  condition  is  no  doubt  caused  by  the  toxic  agents 
absorbed  from  the  intestine.  A  remarkable  condition  of  sclerema  is  de- 
scribed as  a  sequel  of  cholera  infantum.  The  skin  and  subcutaneous  tis- 
sues become  hard  and  firm  and  the  appearance  has  been  compared  to  that 
of  a  half -frozen  cadaver. 

No  constant  organism  has  been  found  in  these  cases.  Baginsky  con- 
siders the  disease  the  result  of  the  action  on  the  system  of  the  poisonous 
products  of  decomposition  encouraged  by  the  various  bacteria  present — a 
fdiiJniss  disease.  The  clinical  picture  is  that  produced  by  an  acute  bac- 
terial infection,  as  in  Asiatic  cholera. 
2« 


2394 


DISKASKS  OF  TIIM   DiaKSTIVH  SVSTKM. 


,u 


It   1 

i 


The  diagnosis  h  roiulily  mudo.  1'liorc  is  no  othor  iiitostiniil  (iiructioa 
in  I'liiltlron  for  wliidi  it  can  l)u  ini>stakc'ti.  Tlio  couHtaiit  voiiutiii<^,  tlio 
fr(V|uent  wutiT}'  (lisclmr^^cs,  (lio  colliipwc  symptoms,  uikI  tlio  cIcviUimI  ((>ni- 
porutiiru  make  an  unmistakahlo  clitiiail  ])ictiiri'.  Tliu  outlook  in  the  nm- 
jority  of  cases  is  bad,  particularly  in  oliildrcn  artirjcially  fnl.  Ifypcrpj- 
rcxia,  extreme  collapse,  and  incessant  vomiting  uro  the  most  serious  syni  )- 
toms. 

Acute  Entero-colitis. — In  this  form  tlio  ileum  and  colon  are  most 
affected,  cliielly  in  the  lymph  follicles,  hence  the  term  follicular  enteritis 
or  follicular  dysentery.  It  occurs  most  frecjuently  in  warm  weather,  in 
artificially  fed  children ;  but  it  may  set  in  at  any  reason  of  the  year,  and 
is  the  form  of  enteritis  most  common  as  a  secondary  complieation  in  the 
specific  fevers  of  childhood. 

The  attack  may  follow  the  ordinary  dyspeptic  diarrha'ti.  The  tem- 
perature increases,  the  stools  change  in  character  and  contain  traces  of 
blood  and  mucus,  the  former  usually  only  in  streaks.  The  fu'ces  are 
passed  without  any  pain.  The  abdomen  is  distended  and  tender  along 
the  lino  of  the  colon.  Vomiting  may  bo  ])resent  at  the  outset,  but  is  not  a 
characteristic  feature,  as  in  cholera  infantum.  I'lio  diarrha-a  may  be 
gradually  checked  and  convalescence  is  established  in  two  or  three  weeks ; 
in  other  instances  the  disease  becomes  subacute,  the  fever  subsides,  but  the 
diarrha?a  persists  and  the  general  health  of  the  child  rapidly  deteriorates. 
The  case  may  drag  on  for  five  or  six  weeks,  who.,  improvement  gradually 
occurs  or  the  child  is  carried  off  by  a  severe  intercurrent  attack.  In  a 
third  form  of  acute  entero-colitis,  in  which  anatomically  tiie  legions  arc 
those  already  mentioned — namely,  an  intense  follicular  inffammation — the 
symptoms  are  of  a  more  severe  character,  and  the  ailection  is  sometimes 
spoken  of  as  acute  dysentery.  It  attacks  children  up  to  the  tiiird  or 
fourth  year  or  even  older.  The  onset  is  sudden,  with  high  fever,  vomit- 
ing, frequent  stools,  which  at  first  contain  remnants  of  food  and  fa'ces 
and  subsequently  much  mucus  and  some  blood.  There  is  incessant  pain, 
which  may  be  more  severe  than  in  any  iiitestiiuil  affection  of  childhood. 
The  prostration  is  very  great  and  the  fatal  termination  may  occur  Avithin 
forty-eight  hours.  More  commonly  the  case  lasts  for  a  week  or  longer. 
In  two  cases  of  this  sort,  in  one  ol  wliich  death  occurred  in  forty-eiglit 
and  in  the  other  in  sixty-four  hours,  the  anatomical  characters  were  those 
of  the  most  acute  follicular  enteritis,  characterized  by  great  swelling  of 
the  lymph  follicles,  some  of  which  already  presented  necrotic  foci. 

The  Goeliao  Affection. — Under  this  heading  Gee  has  described  an  intes- 
tinal disorder,  most  commonly  met  with  in  children  between  the  ages  of 
one  and  five,  characterized  by  the  occurrence  of  pale,  loose  stools,  not 
unlike  gruel  or  oatmeal  porridge.  They  are  bulky,  not  watery,  yeasty, 
frothy,  and  extremely  offensive.  The  affection  has  received  various  names, 
such  as  diarrhoea  alba  or  diarrhoea  chylosa.  It  is  not  associated  with 
tuberculosis  or  other  hereditary  disease.     It  begins  insidiously  and  there 


DlSKAtiES  OP  TIIK   INTESTINES  ASSOCIATED  WITH   DIAKUIKEA.    396 


nrc  profTivssivo  wnstinj,',  wcakiioss,  ami  piillor.  Tlio  bolly  liocomoH  doupjliy 
and  iiu'liistic.  Tliere  is  ofti-ri  lliitiilciicy.  Fuvi-r  is  usiuilly  ul»sciit.  Tiio 
(iisciiso  i.s  liiij,'cring  mid  a  fiitul  tci'iiiiimtioii  is  cotniiioii.  So  far  nothing,'  ia 
known  of  the  patholojyy  of  the  disoasu.  L'UHiration  of  tlio  intestines  ium 
lici'ii  met  with,  but  it  is  not  constant.  This  alTection  resenil)les  soniewliat 
the  disease  in  adults  known  as  the  hill  t/iarr/nfu,  ov  the  white  llux  of 
India;  but  certain  of  these  tropical  diarrlueas  are,  as  will  be  inuntiuuud, 
a.'Sociated  with  the  presence  of  the  itnchijloxtuma, 

DIPHTHERITIC  OR  CROUPOUS  ?:nteritis. 

'I'hore  are  many  conditions  in  which  an  intense  croui)ou8  or  diph- 
tlierilio  inflammation  of  the  mucosa  of  the  small  and  large  intestines 
occurs.  It  is  met  with  most  frequently,  {a)  as  a  secondary  process  in  the 
infectious  diseases — pneumonia,  pyaemia  in  its  various  forms,  and  typhoid 
fever;  (/>)  as  a  terminal  i)roeess  in  nuiny  chronic  all'ecti(ms,  such  as 
Bijifht's  disease,  cirrhosis  of  the  liver,  or  (iancer;  and  {c)  us  an  effect  of 
certain  poisons — mercury,  lead,  and  arsenic. 

Tliv!  diseiuso  i)resents  three  different  anatomical  pictures.  In  one  group 
of  cases  the  mucosa  presents  on  the  to})  of  the  folils  a  thin  grayish-yellow 
dii)htlieritic  exudate  situated  upon  a  deeply  congested  base.  In  some 
cases  all  grades  may  bo  seen  between  the  thinnest  film  of  8U])erficial 
necrosis  and  involvement  of  the  entire  thickness  of  the  mucosa.  In  the 
colon  similar  transversely  arranged  areas  of  necrosis  are  seen  situated 
upon  hypa'ramic  patches,  and  it  may  be  here  nuudi  more  extensive  and 
involve  a  large  portion  of  the  membrane.  There  may  be  most  extensive 
inflammation  without  any  involvement  of  the  solitary  follicles  of  the  large 
or  small  bowel. 

In  a  second  group  of  cases  the  membrane  has  rather  a  croupous 
cliaracter.  It  is  grayish  white  in  color,  more  flake-like  and  extensive, 
limited,  perhaps,  to  the  caecum  or  to  a  portion  of  the  colon;  thus,  in 
several  cases  of  pneumonia  I  found  this  flaky  adherent  false  membrane, 
in  one  instance  forming  patches  1  to  2  cm.  in  diameter,  which  were  not 
unlik(!  in  form  to  rupia  crusts. 

In  a  third  group  the  affection  is  really  a  follicular  enteritis,  involving 
the  solitary  glands,  which  are  swollen  and  capped  with  an  area  of  diph- 
theritic necrosis  or  are  in  a  state  of  suppuration.  Follicular  ulcers  are 
common  in  this  form.  The  disease  may  run  its  course  without  any 
symptoms,  and  the  condition  is  unexpectedly  met  with  post  mortem.  In 
other  instances  there  are  diarrhoea,  pain,  but  not  often  tenesmus  or  the 
passage  of  blood-stained  mucus.  In  the  toxic  cases  the  intestinal  symp- 
toms may  be  very  marked,  but  in  the  terminal  colitis  of  the  fevers  and  of 
constitutional  affections  the  symptoms  are  often  trifling. 


■i^l-f,- 


il  i . 


iT  W 


V 


t'     i 


!'/'        f 


i 


'J' 


896 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


rnLEGMONOUS  ENTEIIITIS. 


As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterpart  in  the  stomach.  It  is  seen  occasionall}'  in  connection 
with  intussusception,  stranguhvted  liernia,  and  cln-onic  ol)struction.  Apart 
from  these  conditions  it  occurs  most  frequently  in  the  duodoiuiin,  and 
leads  to  suppuration  in  the  subniucosa  and  abscess  formation,  Excei)t 
when  associated  with  hernia  or  intussusception  tho  affection  cannot  bo 
The  symptoms  usually  resemble  those  of  peritonitis. 


diagnosed 


MUCOUS  COLITIS. 

This  affection  is  known  by  various  names,  such  as  meinhranomi  en- 
teritis, tubular  diarrlia'a,  and  mucous  colic.     It  is  a  renuirkable  disease 
to  which  much  attention  has  been  paid  for  several  centuries.    An  exhaust- 
ive description  of  it  is  given  by  Woodward,  in  Vol.  II  of  the  Medical 
and  Surgical  Reports  of  the  Civil  War.     It  is  an  affection  of  tho  largo 
bowel,  characterized  by  the  production  of  a  very  toiuicious  adherent  mucus, 
which  may  be  passed  in  long  strings  or  as  a  continuous,  tubular  nioin- 
brane.     I  have  twice  had  opi)ortuaities  of  seeing  this  membrane  in  situ, 
closely  adherent  to  the  mucosa  of  the  colon,  but  capable  of  separation 
without  any  lesion  of  the  surface.     Judging  from  the  statement  of  Eng- 
lish authors  as  to  its  rarity,  it  would  appear  to  be  a  more  frequent  disease 
in  this  country.     According  to  AV.  A.  Edwards,  80  per  cent  of  the  re- 
corded adult  cases  have  been  in  women.     It  occurs  occasionally  in  children. 
Of  111  cases  six  were  under  the  age  of  ten.     The  cases  are  almost  invari- 
ably seen  in  nervous  or  hysterical  women  or  in  men  with  neurasthenia. 
All  grades  of  the  affection  occur,  from  the  passage  of  a  slimy  mucus,  like 
frog-spawn,  to  large  tubular  casts  a  foot  or  more  in  length.    Microscopi- 
cally the  casts  are,  as  shown  by  Sir  Andrew  Clark,  not  fibrinous,  but 
mucoid,  and  even  the  firmest  consist  of  dense,  opaque,  transformed  mucus. 
It  is  due  to  a  derangement  of  the  mucous  glands  of  the  colon,  the  nature 
of  which  is  quite  unknown. 

Symptoms. — The  disease  persists  for  years,  varying  extremely  from 
time  to  time,  and  is  characterized  by  paroxysms  of  pain  in  the  abdomen, 
tenderness,  occasionally  tenesmus,  and  the  passage  of  flakes  or  long  strii'gs 
of  mucus,  sometimes  of  definite  casts  of  tho  bowel.  The  attacks  last  for 
a  day  or,  in  some  instances,  for  ten  days  or  two  weeks.  INIental  emotions 
and  worry  of  any  sort  seem  particularly  apt  to  bring  on  an  attack.  Occa- 
sionally errors  in  diet  or  dyspepsia  precede  an  outbreak.  Membranes  arc 
not  passed  with  every  paroxysm,  even  when  the  pains  and  cramps  are  severe. 
There  are  instances  in  which  the  morphia  habit  has  been  contracted  on 
account  of  tho  severity  of  the  pain.  There  may  be  marked  nervous 
symptoms,  and  authors  mention  hysterical  outbreaks,  hypochondria.sif, 
and  melancholia. 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH  DIARRRffiA.    397 

The  diagnosis  is  rarely  doubtful,  but  it  is  important  not  to  mistake 
tlie  membranes  for  other  substances;  thus,  the  external  cuticle  of  aspara- 
gus and  undigested  portions  of  meat  or  saus<age-skina  sometimes  asauitie 
tonus  not  unlike  mucous  casts,  but  the  microscopical  examination  will 
(juickly  differentiate  them. 


ULCERATIVE   ENTERITIS. 

In  addition  to  the  specific  ulcers  of  tuberculosis,  syphilis,  and  typhoid 
fever,  the  following  forms  of  ulceration  occur  in  the  bowels : 

(a)  Follicular  Ulceration. — As  previously  mentioned,  this  is  met  with 
very  commonly  in  the  diarrheal  diseases  of  children,  and  also  in  the  sec- 
ondary or  terminal  inflammations  in  many  fevers  and  constitutional  disor- 
ders. The  ulcers  are  small,  punched  out,  with  sharply  cut  edges,  and 
they  are  usually  limited  to  the  follicles.  With  this  form  may  be  placed 
the  catarrhal  ulcers  of  some  writers. 

(It)  Stercoral  Ulcers,  which  occur  in  long-standing  cases  of  constipa- 
tion. Very  remarkable  indeed  are  the  cases  in  which  the  sacculi  of  the 
colon  become  filled  with  roundea  small  scybala,  some  of  which  i)roduce 
distinct  ulcers  in  the  mucous  membrane.  The  fa'cal  masses  may  have 
lime  salts  deposited  in  them,  and  thus  form  little  enteroliths. 

((■)  Simple  Ulcerative  Colitis. — This  affection,  which  clinically  is  char- 
acterized by  diarrhoea,  is  often  regarded  wrongly  as  a  form  of  dysentery. 
It  is  not  a  very  uncommon  affection,  and  is  most  frequently  met  with  in 
men  above  the  middle  period  of  life.  The  ulceration  may  be  very  exten- 
sive, so  that  a  large  proportion  of  the  mucosa  is  removed.  The  lumen  of 
the  colon  is  sometimes  greatly  increased,  and  the  muscular  walls  hyper- 
trophied.  There  are  instances  in  which  the  bowel  is  contracted.  Fre- 
quently the  remnants  of  the  mucosa  are  very  dark,  even  black,  and  there 
may  be  polypoid  outgrowths  between  the  ulcers. 

These  cases  rarely  come  under  observation  at  the  outset,  and  it  is  diffi- 
cult to  speak  of  the  mode  of  origin.  They  are  characterized  by  diarrha'a 
of  a  lienteric  rather  tlum  of  a  dysenteric  cduiracter.  1'here  is  never  blood 
or  pus  in  the  stools.  Constipation  may  alternate  with  the  diarrluea. 
'riiore  is  usually  great  impairment  of  nutrition,  ami  the  patients  get  weak 
and  sallow.    Perforation  occasionally  occurs. 

Tlio  disease  may  prove  fatal,  or  it  may  pass  on  and  become  chronic. 
The  affection  was  not  very  infrequent  at  tlie  Philadelphia  Hospital,  and 
though  tlie  disease  bears  some  resemblance  to  dysentery,  it  is  to  be  sepa- 
rated from  it.  Some  of  the  cases  which  we  have  learned  to  recognize  as 
ama>bic  dysentery  resemble  this  form  very  closely.  An  excellent  descrip- 
tion of  it  is  given  by  Halo  White.* 

{(I)  Ulceration  from  E,vternal  Perforation. — This  may  result  from  the 

*  Guy's  Ilospital  Reports,  1»88.  ,:      i..  ;  ...  • 


it    3 


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398 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


erosion  of  new  growths  or,  mor  a  commonly,  from  localized  peritonitis  with 
abscess  formation  and  perforation  of  the  bowel.  This  is  met  with  most  fre- 
quently in  tuberculous  peritonitis,  but  it  may  occur  in  the  abscess  which 
follows  perforation  of  the  appendix  or  suppurative  or  gangrenous  p.ui- 
creatitis.     Fatal  haemorrhage  may  result  from  the  perforation. 

(e)  Cancerous  Ulcers. — In  very  rare  instances  of  multiple  cancer  or 
sarcoma  the  submucous  nodules  break  down  and  ulcerate.  In  one  case 
the  ileum  contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  ex- 
tensive sarcoma  in  the  neighborhood  of  the  shoulder-joint. 

(/)  Occasionally  a  solitary  ulcer  is  met  with  in  the  caecum  or  colon, 
which  may  lead  to  perforation.  Two  instances  of  ulcer  of  the  caecum, 
both  with  perforation,  have  come  under  my  observation,  and  in  one 
instance  a  simple  ulcer  of  the  colon  perforated  and  led  to  fatal  perito- 
nitis. 

Diagnosis  of  Intestinal  Ulcers. — As  a  rule,  diarrhcea  is  present 
in  all  cases,  but  exceptionally  there  nuiy  be  extensive  ulceration,  jjartieu- 
larly  in  the  small  bowel,  without  diarrhwa.  Very  limited  idccration  in 
the  colon  may  be  associated  with  frequent  stools.  The  character  of  th " 
dejections  u  of  great  imj)ortance.  Pus,  shreds  of  tissue,  and  blood  are 
the  most  valuable  indications.  Pus  occurs  most  frequently  in  connection 
with  ulcers  in  the  large  intestine,  but  when  the  bowel  alone  is  involved 
the  amount  is  rarely  great,  and  the  passage  of  any  quantity  of  pure  })us  is 
an  indication  that  it  has  come  from  without,  most  commonly  from  the 
rupture  of  a  periea^cal  abscess,  or  in  women  an  abscess  of  the  broad  liga- 
ment. Pus  may  also  bo  present  in  cancer  of  the  bowel,  or  it  may  bo  due 
to  local  disease  in  the  rectum.  A  purulent  mucus  may  be  present  in  the 
stools  in  cases  of  ulcer,  but  it  has  not  the  same  diagnostic  value.  The 
swollen,  sago-like  masses  of  mucus  which  are  believed  by  some  to  indicate 
follicular  ulceration  are  met  with  also  in  mucous  colitis*.  IlaMnorrhage  is 
an  important  and  valuable  symptom  of  ulcer  of  the  bowel,  particularly  if 
profuse.  It  occurs  under  so  many  conriitions  that  taken  alone  it  may 
n  /t  be  specially  signilicant,  but  with  other  coexisting  circumstances  it 
may  be  the  most  important  indication  of  all. 

Fragments  of  tissue  are  ocinisionally  found  in  the  stools  in  ulcer,  par- 
ticularly in  the  extensive  and  ra])id  sloughing  in  dysenteric  i)roc'\<ses. 
Deilnite  portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of 
*he  muscular  coat  may  be  found.  Pain  occurs  in  many  cases,  either  of  a 
diffuse,  colicky  character,  or  sometimes,  in  the  ulcer  of  the  colon,  very 
limited  and  M'ell  defined. 

Perforation  is  an  accident  liable  to  happen  when  the  ulcer  extends 
deeply.  In  the  small  bowel  it  leads  to  a  localized  or  general  poritoiutis. 
In  the  large  intestine,  too,  a  fatal  peritonitis  may  result,  or  if  perforation 
takes  place  in  the  posterior  wall  of  the  ascending  or  descending  color., 
the  production  of  a  large  abscess  cavity  in  the  retro-peritonajuni.  In  a 
case  at  the  University  Hospital,  Philadelphia,  there  was  a  perforaHon  at 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH   DIARRHOEA.    399 


the  splenic  flexure  of  the  colon  with  an. abscess  contiiiniug  air  and  pus 
■ — a  condition  of  subphrenic  pyo-pneumothorax. 
Treatment  of  the  Previous  Conditions. 

(a)  Acute  Dyspeptic  Diarrhoea.— All  solid  food  should  be  withheld. 
If  vomiting  is  present  ice  may  be  given,  and  small  quantities  of  milk  and 
soda  Avater  may  be  taken.  If  the  attack  has  followed  the  eating  of  large 
quantities  of  undigestible  material,  castor  oil  or  calomel  is  advisable,  but 
is  not  necessary  if  the  patient  has  been  freely  purged.  If  the  ])ain  is  se- 
vere, twenty  drops  of  laudanum  and  a  di'achm  of  spirits  of  chloroform 
may  be  given,  or,  if  the  colic  is  very  intense,  a  hypodermic  of  a  quarter  of 
ii  grain  of  morphia.  It  is  not  well  to  check  the  diarrhani  unless  it  is  pro- 
fuse, as  it  usually  stops  spontaneously  within  forty-eight  hours.  If  per- 
sistent, the  aromatic  chalk  powder  or  large  doses  of  bisnuuh  (thirty  to 
forty  giains)  may  be  given.  A  small  enema  of  starch  (two  ounces)  with 
twenty  drops  of  laudanum,  every  six  hours,  is  a  most  valuable  remedy. 

{(')  Chronic  Diarrhcea,  including  chronic  catarrh  and  ulcerative  enter- 
itis. It  is  important,  in  the  first  place,  to  ascertain,  if  possible,  the  cause 
and  whether  idccration  is  pivsent  or  not.  So  mucli  in  treatment  depends 
upon  the  careful  examination  of  the  stools — as  to  tlie  anu)unt  of  mucus, 
the  presence  of  pus,  the  occurrence  of  parasites,  and,  above  all,  the  state  of 
digestion  of  the  food — that  the  practitioiu'r  should  pay  special  attention 
to  them.  ]\rany  cases  simply  require  rest  in  bed  and  a  restricted  diet. 
CIn'onic  diarrlui>a  of  many  months'  or  even  of  several  years'  duration  may 
bo  sometimes  cured  by  strict  coniinenu^nt  to  l)cd  ami  a  diet  of  ])oiled  milk 
and  albumen  water. 

In  that  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  is  usually  foui'.d  that  some  one  article  of  diet  is  at 
fault.  Tlie  patient  should  rest  for  na  hour  or  more  after  meals.  Some- 
times this  alone  is  suflieient  to  prevent  tlu^  occurrence  of  the  diarrhoea. 
In  tliose  forms  which  dei)end  upon  abnormal  conditions  in  tlie  small  in- 
'ostine,  either  too  rapid  peristalsis  or  faulty  fermentative  processes,  bis- 
iMlh  is  indicated.  It  must  be  given  in  large  doses— from  half  a  drachm 
^'  a  draelun  three  tinu\'i  a  day.  The  smaller  doses  are  of  little  use. 
-•  'I'lithalin  preparations  here  do  much  good,  given  in  doses  of  from  ten 
"^1  •  ftoen  grains  (in  capsule)  four  or  five  times  a  day.  Larger  doses  may 
be  needed.     Salol  and  tlie  salicylate  of  bismuth  may  be  tried. 

An  extremely  obstinate  and  intractable  form  is  the  diarrlura  of  hyster- 
ical woi;  .11.  A  systematic  rest  cure  will  be  found  most  advantageous,  and 
if  a  milk  diet  is  not  well  borne  the  ])atieiit  may  be  fed  exclusively  on  egg 
albumen.  The  condition  seems  to  be  associated  in  some  cases  with  in- 
creased peristalsis,  and  in  such  the  bromides  may  do  good,  or  preparations 
ot  opium  may  be  necessary.  There  are  inshinces  which  prove  most  obsti- 
iiiite  and  resist  all  forms  of  treatment,  and  the  i)atioTit  may  be  greatly 
K'iuced.    A  change  of  air  and  surroundings  may  do  more  than  medicines. 

1)1  a  large  group  of  the  chronic  diarrhu^as  the  ijiiischitjf  is  seated  in  the 


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400 


DISEASES  OF  THL  DIGESTIVE  SYSTEM, 


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colon  and  is  due  to  iilccration.  Medicines  by  the  mouth  are  here  of  little 
value.  The  stools  should  be  carefully  watched  and  a  diet  arranged  which 
shall  leave  the  smallest  possible  residue.  Boiled  or  peptonized  milk  may 
be  given,  but  the  stools  should  be  examined  to  see  whether  there  is  an 
excess  of  food  or  of  curds.  Meat  is,  as  a  rule,  badly  borne  in  these  cases. 
The  diarrha^a  is  best  treated  by  enemata.  The  starch  and  laudanum 
should  be  tried,  but  when  ulceration  is  present  it  is  better  to  use  astringent 
injections.  From  two  to  four  pints  of  warm  water  containing  from  half  a 
drachm  to  a  drachm  of  nitrate  of  silver  may  be  used.  In  the  chronic 
diarrha^a  which  follows  dysentery  this  is  particularly  advantageous.  In 
giving  large  injections  the  patient  should  be  in  the  dorsal  position,  with 
the  hips  elevated,  and  it  is  best  to  allow  the  injection  to  flow  in  gradually 
from  a  siphon  bag.  In  this  way  the  entire  colon  can  be  irrigated  and  the 
patient  can  retain  the  injection  for  some  time.  The  silver  injections  may 
be  very  painful,  but  they  are  invaluable  in  all  forms  of  ulcerative  colitis. 
Acetate  of  lead,  r.'^i".  acid,  sulphate  of  copper,  sulphate  of  zinc,  and 
salicylic  acid  may  be  in  one  per  cent  solutions. 

In  mucous  colitis  ii  eneiit  can  be  expected  from  remedies  adminis- 
tered by  the  mouth.  The  topical  applications  should  be  made  to  the 
mucous  membrane  of  the  colon  by  the  enemata  just  mentioned,  and  the 
general  nervous  condition  should  receive  appropriate  treatment. 

In  the  intense  forms  of  choleraic  diarrhoea  in  adults  associated  witli 
constant  vomiting  and  frequent  watery  discharges  the  patient  should  be 
given  at  once  a  hypodermic  of  a  quarter  of  a  grain  of  morphia,  which 
should  be  repeated  in  an  hour  if  the  pains  return  or  the  purging  persists. 
This  gives  prompt  relief,  and  is  often  the  only  medicine  needed  in  the 
attack.  The  patient  should  be  given  stimulants,  and,  when  the  vomiting 
is  allayed  by  suitable  remedies,  small  quantities  of  milk  and  lime  Mater. 

(c)  TheDiarrhoBa  of  Children.— /%/(>»/c  management  is  of  the  first 
importance.  The  effect  of  a  change  from  the  hot,  stifling  atmosphere  of 
a  town  to  the  mountains  or  the  sea  is  often  seen  at  once  in  a  reduction 
in  the  number  of  stools  and  a  rapid  improvement  in  the  physical  condi- 
tion. Even  in  cities  much  may  be  done  by  sending  the  child  into  the 
parks  or  for  daily  excursions  on  the  water.  However  extreme  the  condi- 
tion, fresh  air  is  indicated.  The  child  should  not  be  too  thickly  clad. 
Many  mothers,  even  in  the  warm  weather,  clothe  their  children  too  heavily. 
Bathing  is  of  value  in  infantile  diarrhoea,  and  when  the  fever  rises  above 
103-5°  the  child  should  be  placed  in  a  warm  bath,  the  temperature  of 
which  may  be  gradually  reduced,  or  the  child  is  kept  in  the  bath  for 
twenty  minutes,  by  which  time  the  water  is  sufficiently  cooled.  Much 
relief  is  obtained  by  the  application  of  ice-cold  cloths  or  of  the  ice-cap  to 
the  head.  Irrigation  of  the  colon  with  ice-cold  water  is  sometimes  favor- 
able, but  it  luis  not  the  advantage  of  the  general  bath,  the  beneficial  olToct 
of  wliich  is  seen,  not  only  in  the  reduction  of  the  temperature,  but  m  a 
general  stimulation  of  the  nervous  system  of  the  child. 


DISEASES  OP  THE  INTESTINES  ASSOCIATED  WITH   DIARRHCEA.    401 


Dietetic  Treatment. — In  the  case  of  a  hand-fed  child  it  is  important, 
if  possible,  to  get  a  wet-nurse.  While  fever  is  present,  digestion  is  sure 
to  be  much  disturbed,  and  the  amount  of  food  should  be  restricted.  If 
water  or  barley  water  be  given  the  child  will  not  feel  the  deprivation  of 
food  so  much.  When  the  vomiting  is  incessant  it  is  much  better  not  to 
attempt  to  give  milk  or  other  articles  of  food,  but  let  the  child  take  the 
water  whenever  it  will. 

In  the  dyspeptic  diarrhoeas  of  infants,  practically  the  whole  treatment 
is  a  miitter  of  artificial  feeding,  and  there  is  no  subject  in  medicine  on 
wliioh  it  i*?  more  dif!icult  to  lay  down  satisfactory  rules.     No  doubt  within 
a  few  years  the  study  of  the  bacterial  processes  going  on  in  the  intestines 
of  the  child  will  give  us  most  important  suggestions.    From  his  observa- 
tions Escherich   lays  down  the  following  rules,  recognizing  two  well- 
dellned  forms  of  intestinal  fermentation — the  acid  and  the  alkaline :  If 
tiunv  is  much  decomposition,  with  foul,  offensive  stools,  the  albuminous 
articles  should  bo  withheld  from  the  diet  and  the  carbohydrates  given, 
such  as  dextrin  foods,  sugar,  and  milk,  which,  on  account  of  its  sugar, 
ranks  with  the  carbohydrates.     If  there  is  acid  fermentation,  with  sour 
but  not  fetid  stools,  an  albuminous  diet  is  given,  such  as  broths  and  egg 
albumen.    It  is,  however,  by  no  means  certain  whether  the  reaction  of  the 
stools,  upon  which  this  author  relies,  is  a  sufficient  test  of  the  nature  of 
the  intestinal  fermentation.     In  the  dyspe{)tic  diarrho:'as  of  artificially  fed 
infants  it  is  best,  as  a  rule,  to  withhold  .milk  and  to  feed  the  child,  for  the 
time  at  least,  on  egg  albumen,  broths,  and  beef  juices.     To  prepare  the 
egg  albumen,  the  whites  of  two  or  three  eggs  may  bo  stirred  in  a  pint  of 
water  and  a  teaspoonful  of  brajidy  and  a  little  salt  mixed  with  it.     The 
child  will  usually  take  this  freely,  and  it  is  both  stimulating  and  nourish- 
ing.   It  is  sometimes  remarkable  with  what  rapidity  a  child  which  has 
been  fed  on  artificial  food  and  milk  will  pick  up  and  improve  on  this  diet 
alone.     Beef-juice  is  obtained  by  pressing  with  a  lemon-squeezer  fresh 
steak,  previously  minced  and  either  uncooked  or  slightly  broiled.     This 
may  be  given  alternately  with  tlu^  egg  albumen  or  it  may  be  given  alone. 
Mutton  or  chicken  broth  will  ])e  found  equally  serviceable,  but  it  is  pre- 
pared with  greater  difficulty  and  contains  more  fat.     In  the  preparation,  a 
pound  of  mutton,  chicken,  or  beef,  carefully  freed  from  fat,  is  minced  and 
placed  in  a  pint  of  cold  water  and  allowed  to  stand  in  a  glass  jar  on  ice 
for  three  or  four  hours.     It  should  then  be  cooked  over  a  slow  fire  for  at 
loaj^t  three  hours,  then  strained,  allowed  to  cool,  the  fat  skimmed  olT,  suf- 
ficient salt  added,  and  it  may  then  be  given  either  warm  or  cold.     These 
naturally  prepared  albumen  foods  are  very  much  to  be  preferred  to  the 
various  artificial  substances.     There  is  no  form  of  nourishment  so  readily 
assimilated  and  apt  to  cause  so  little  disturbance  as  egg  albumen  or  the 
simple  beef  juices.     The  child  should  be  fed  every  two  hours,  and  in  the 
intervals  water  may  be  freely  given.     It  cannot  be  expected  that,  with 
the  digestion  seriously  impaired,  as  much  food  can  be  taken  as  in  health. 


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402 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


and  in  many  instances  we  see  the  (liarrhcpa  aggravated  by  persistent  over- 
feeding. AVhen  tlic  child's  stomach  is  quieted  and  the  diarrhoea  checked 
there  may  be  a  gradual  return  to  the  milk  diet.  The  milk  should  be  ster- 
ilized, and  in  institutions  and  in  cities  this  simple  prophylactic  measure  is 
of  the  very  first  importance  and  is  readily  carried  out  by  means  of  the  Ar- 
nold steam  sterilizer.  The  milk  should  be  at  first  freely  diluted — four 
parts  of  water  to  one  of  milk,  which  is  perhaps  the  preferable  way — or  it 
may  be  peptonized.  The  stools  should  be  examined  daily,  as  important 
indications  may  be  obtained  from  them.  Milk-whey  and  forms  of  fer- 
mented milk  are  sometimes  useful  and  may  be  employed  when  the  stom- 
ach is  very  irritable.  These  general  directions  as  to  food  also  hold  good 
in  cholera  infantum. 

Medicinal  Treatment. — The  first  indication  in  the  dyspeptic  diarrhcea 
of  children  is  to  get  rid  of  the  decomposing  matter  in  the  stomach  and 
intestines.  The  diarrhoea  and  vomiting  partially  effect  this,  but  it  may 
be  more  thoroughly  accomplished,  so  far  as  the  stomach  is  concerned,  by 
irrigation.  It  may  seem  a  harsh  procedure  in  the  case  of  young  infants, 
but  in  reality,  with  a  large-sized  soft-rubber  catheter,  it  is  practised  with- 
out any  ditticulty.  By  means  of  a  funnel,  lukewarm  water  is  allowed 
to  pass  in  and  out  until  it  comes  away  quite  clear.  I  can  speak  in  the 
very  warmest  manner  of  the  good  results  obtained  by  tliis  simple  pro- 
cedure in  cases  of  the  most  obstinate  gastro-intestinal  catarrh  in  children. 
In  most  cases  the  warm  water  is  sufficient.  In  some  hands  this  metliod 
has  probably  been  carried  to  excess,  but  that  does  not  detract  from  its 
great  value  in  suitable  cases.  To  remove  the  fermenting  substances  from 
the  intestines,  doses  of  calomel  or  gray  powder  may  be  administered.  The 
castor  oil  is  equally  efficacious,  but  is  more  apt  to  be  vomited.  Irri- 
gation of  the  large  boAvel  is  useful,  and  not  only  thoroughly  removes 
fermenting  substances,  but  cleanses  the  mucosa.  The  child  should  be 
placed  on  the  back  Avith  the  hips  elevated.  A  flexible  catheter  is  jiassed 
for  from  six  to  eight  inches  and  from  a  pint  to  two  pints  of  water  allowed 
to  flow  in  from  a  fountain  syringe.  A  pint  will  thoroughly  irrigate  the 
colon  of  a  child  of  six  months  and  a  quart  that  of  a  child  of  two  years. 
The  water  may  be  lukewarm,  but  when  there  is  high  fever  ice-cold  water 
may  be  used.  In  cases  of  entero-colitis  there  may  be  injections  with 
borax,  a  drachm  to  the  pint,  or  dilute  nitrate  of  silver,  which  may  be 
either  given  in  large  injections,  as  in  the  adult,  or  in  injections  of  three  or 
four  ounces  with  three  grains  of  nitrate  of  silver  to  the  ounce.  These 
often  cause  very  great  pain,  and  it  is  well  in  such  cases  to  follow  the  silver 
injection  with  irrigations  of  salt  solution,  a  drachm  to  a  pint. 

We  are  still  without  a  reliable  intestinal  antiseptic.  Neither  naphtha- 
lin,  salol,  resorcin,  the  salicylates,  nor  mercury  meets  the  indications.  As 
in  the  diarrhoea  of  adults,  bismuth  in  large  doses  is  often  very  effective, 
but  practitioners  are  in  the  habit  of  giving  it  in  doses  which  are  quite  in- 
sufficient.    To  be  of  any  service  it  must  be  used  in  large  doses,  so  that  an 


MISCELLANEOUS  AFFECTIONS  OP  THE   BOWELS. 


403 


infant  a  year  old  will  take  as  much  as  two  drachms  in  the  day.  The  gray 
powder  has  long  been  a  favorite  in  this  condition  and  may  bo  given  in 
l)alf-""rain  doses  every  hour.  It  is  perhaps  preferable  to  calomel,  which 
may  bo  used  in  small  doses  of  from  one  tenth  to  one  fourth  of  a  grain 
cvorv  hour  at  the  onset  of  the  trouble.  Tlio  sodium  salicylato  (in  doses 
of  two  or  three  grains  every  two  hours  to  a  child  a  year  old)  has  been 
recommended. 

In  cholera    infantum    serious    symptoms    may  develop    with    great 
rapidity,   and   here   tho   incessant   vomiting   and   the   frequent  purging 
rcnilcr   tho   administration   of   reincdics  extremely  difticult.      Irrigation 
of  the  stomach  and  large  bowel  is  of  great  service,  and  when  the  fever 
is  high  ice-water  injections  may  bo  used  or  a  graduated  bath.     As  in 
the  acute  choleraic  diarrhoea  of  adults,  morphia  hypodcrmically  is  the 
rc'inody  which  gives  greatest   relief,  and   in   the  conditions  of   extreme 
vomiting  and  purging,   with   restlessness   and  collapse   symptoms,   this 
drug  alone  commands  the  situation.     A  child  of  one  year  may  be  given 
from  ^^  to  -gV  of  a  grain,  to  be  repeated  in  an  hour,  and  again  if  not 
bettor.     ^Vhcn  the  vomiting  is  allayed,  attcmjits  may  be  made  to  give 
gray  powder  in  half-grain  doses  with  ^  of  Dover's  powder.     Starch  (  3  ij) 
and  laudanum  (niij-iij)  injections,  if  retained,  are  soothing  and  benefi- 
cial.   The  combination  of  bismuth  with  Dover's  powder  will  also  be  found 
beneficial.    No  attempt  should  be  made  to  give  food.    Water  may  be 
allowed  freely,  even  when  ejected  at  once  by  vomiting.     Small  doses  of 
brandy  or  champagne,  frequently  repeated  and  given  cold,  are  sometimes 
retained.    When  the  collapse  is  extreme,  hypodermic  injections  of  one  per 
cent  saline  solution  may  be  used  as  recommended  in  Asiatic  cholera,  and 
hypodermic  injections  of  ether  and  brandy  may  be  tried.     The  convales- 
cence requires  very  careful  management,  as  many  cases  pass  on  into  the 
condition  of  entei'o-colitis.     AVhen  Ihe  intense  symptoms  have  subsided, 
the  food  should  be  gradually  given,  beginning  with  teaspoonful  doses  of 
egif  albumen  or  beef-juice.     It  is  best  to  withhold  milk  for  several  days, 
and  when  used  it  should  be  at  first  completely  peptonized  or  diluted  with 
gruel.    A  teaspoonf  al  of  raw,  scraped  meat  three  or  four  times  a  day  is 
often  well  borne. 


II.  MISCELLANEOUS  AFFECTIONS  OF  THE  BOWELS. 


Dilatation  of  the  Colon. — This  may  be  general  or  localized  t^t  tho  sig- 
moid ilexure.  , 

It  occurs  not  infrequently  as  a  transient  condition,  ard  in  many  cases 
it  has  an  important  influence,  inasmuch  as  the  distention  may  be  ex- 
treme, pushing  up  tho  diaphragm  and  seriously  impairing  the  action  of 
the  heart  and  lungs.  11.  FenAvick  ha3  called  attention  to  this  as  occasion- 
ally a  cause  of  sudden  heart-failure. 


404 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Dilatation  of  tlie  sigmoid  flexure  occurs  particularly  when  this  portion 
of  the  bowel  is  congcnitally  very  long.  In  such  cases  the  bowel  may  bo 
BO  diritended  that  it  occupies  the  greater  part  of  the  abdomen,  pushing  up 
the  liver  and  tlu;  diaphragm.  An  acute  condition  is  sometimes  caused  l)y 
a  twist  in  the  mesocolon. 

There  is  a  chronic  form  in  which  the  gut  reaches  an  enormous  size. 
The  coats  may  be  hypertrophied  without  evidence  of  any  special  organic 
change  in  the  mucosa.  In  a  specimen  which  I  saw  with  W.  E.  Hughes, 
in  Philadelphia,  tlie  colon  was  enormously  dilated  aiul  held  fourteen  pints 
of  water,  and  the  sigmoid  flexure  was  four  inches  in  diameter.  It  was 
removed  from  a  boy,  aged  three,  who  had  had  obstinate  constii)ation  and 
at  the  age  of  two  an  attack  of  entero-colitis.  At  one  time  he  was  nineti'eii 
days  without  a  passage ;  on  another  occasion  twenty-four.  The  abdo- 
men was  enormously  distended,  everywhere  tympanitic.  The  hyper- 
trophy of  the  bowel-wall  was  much  greater  toward  the  sigmoid  flexure 
than  near  the  c;ccum.  In  the  section  on  Constipation  in  Infants  a 
case  is  referred  to  in  which  the  colon  and  sigmoid  flexure  appeared  to  be 
dilated. 

Infarction  of  the  Bowel. — The  mesenteric  vessels  are  terminal  arteries, 
and  when  blocked  by  emboli  or  thrombi  the  condition  of  infarction  fol- 
lows in  the  territory  supplied.  Probably  the  occlusion  of  small  vessels 
does  not  produce  any  symptoms  and  tlie  circulation  may  be  re-establisliod. 
If  the  superior  mesenteric  artery  is  blocked  a  serious  and  fatal  conditi(Mi 
follows.  Three  instances  have  come  under  my  observation.  In  one,  a 
woman  aged  fifty-five  was  seized  with  nausea  and  vomiting,  which  per- 
sisted for  more  than  a  week.  There  was  pain  in  the  abdomen,  tympanites, 
and  toward  the  close  the  vomiting  was  incessant  and  f{\;cal.  The  aut(){)sy 
showed  great  congestion,  with  swelling  and  infil'tration  of  the  jojiinuin 
and  ileum.  The  superior  mesenteric  artery  was  blocked  at  its  orifice  by  a 
firm  thrombus.  In  the  second  case,  a  woman  aged  seventy-five  was  seized 
with  severe  abdominal  pain  and  frequent  vomiting.  At  first  there  was 
diarrhoea ;  subsequently  the  symptoms  pointed  to  obstruction,  Avith  great 
distention  of  the  abdomen.  The  post-mortem  .showed  the  small  bowel, 
with  the  exception  of  the  first  foot  of  the  jejunum  and  the  last  six  inclies 
of  the  ileum,  greatly  distended  and  deeply  infiltrated  with  blood.  The 
mesentery  was  also  congested  and  infiltrated.  The  superior  mesenteric 
artery  contained  a  firm  brownish-yellow  clot.  There  were  many  recent 
warty  vegetations  on  the  mitral  valve.  In  the  third  ease,  a  man  aged  forty 
was  suddenly  seized  with  intense  pain  in  the  abdomen,  became  faint,  fell 
to  the  ground,  and  vomited.  For  a  week  he  had  persistent  vomiting, 
severe  diarrhoea,  tympanites,  and  great  pain  in  the  abdomen.  The  stools 
were  thin  and  at  times  blood-tinged.  The  autopsy  showed  an  aneurism 
involving  the  aorta  at  the  diaphragm.  The  superior  mesenteric  artery, 
half  an  inch  from  its  origin  on  the  sac,  was  blocked  by  a  portion  of  the 
fibrinous  clot  of  the  aneurism.    In  the  horse,  infarction  of  the  intestine  is 


M^ 


APPENDICITIS. 


405 


oxtromely  common  in  connection  with  tlio  verminous  aneurisms  of  the 
mesenteric  arteries  and  is  the  usual  cause  of  colic  in  this  animal. 


III.  APPENDICITIS. 

{Typhlilis  a7id  Ferilyphlitia). 

This  is  one  of  the  most  important  of  intestinal  affections.  Unfortu- 
nately, much  confusion  still  exists  about  the  forms  of  inflammation  in 
tlie  coecal  region.  Thus  there  are  recognized  typhlitis,  inflammation  of  the 
eajcum  itself;  perityphlitis,  inflammation  of  the  peritona3um  covering  the 
ciecum ;  paratyphlitis,  inflammation  of  the  connective  tissue  behind  the 
('leoum,  or,  more  correctly,  as  the  caicum  is  usually  covered  by  a  serous 
meiubnine,  of  the  connective  tissue  in  the  neighborhood  of  this  part  of 
tlu!  bowel.  The  use  of  the  last  two  terms  should  be  altogether  discarded, 
as  the  cases  are,  with  rare  exceptions,  due  to  disease  of  the  appendix  ver- 
niiforniis,  and  not  to  afTeotions  of  the  caecum. 

We  have  in  the  coecal  region  the  following  affections : 
Typhlitis,  inflammation  of  the  caecum  proper — a  doubtful  and  un- 
certain nudady,  the  pathology  of  which  is  unknown,  but  which  clinically 
is  still  recognized  by  authorities.     A  majority  of  the  cases  are  unquestion- 
ably due  to  appendix  disease. 

Appendicitis:  (1)  Catarrhal;  (2)  ulcerative;  (3)  perforative,  with 
the  production  of  abscesses,  which  may  be  perica?cal,  pelvic,  intra-perito- 
ueal,  perincphritic,  or  lumbar,  depending  on  the  situation  of  the  vermi- 
form process. 

TYPHLITIS. 

At  present  inflammation  of  any  sort,  accompanied  by  pain  in  the  right 
iliac  fossa,  is  generally  thought  to  be  due  to  disease  of  the  appendix ;  and, 
so  far  as  post-mortem  statistics  indicate,  an  immense  majority  of  all  these 
casos  are  due  to  this  cause.  Clinically,  however,  authors  still  recognize 
typlilitis  (inflammation  of  the  ctecum),  associated  with  lodgment  of  faeces 
[lyphlitis  stercoralis)  The  cases  are  met  with  in  young  persons,  in  boys 
more  commonly  than  in  girls ;  the  subjects  have  usually  been  constipated, 
or  there  have  been  errors  in  diet.  The  patient  complains  of  pain  in  the 
right  iliac  fossa;  there  are  constipation,  nausea,  sometimes  vomiting; 
fever,  if  present,  is  usually  slight,  rarely  rising  above  101°.  There  is  ful- 
ness in  the  right  iliac  fossa,  the  decubitus  is  dorsal,  and  the  right  thigh 
may  he  flexed.  On  pressure  there  is  tenderness,  and  in  many  instances  a 
doughy,  sausage-shaped  tumor  in  the  right  flank.  The  attack  lasts  for 
from  three  days  to  a  week,  the  pain  gradually  subsides,  the  tumor  mass 
disappears,  and  recovery  is  complete. 

The  anatomical  condition  is  unknown,  and  it  is  by  no  means  certain 
that  these  cases  are  in  reality  caecal.    Many  are  probably  due  to  dis- 


^(■■i. 


1 1 


1 

f     id    ll'     ^ 

ill' 

406 


DISEASES  OF  THE  DIOESTIVE  SYSTEM. 


case  of  the  appendix,  and  even  wlicn  tho  sausage-shaped,  dougliy  tumor, 
regarded  as  diagnostic  of  typhlitis  stercoralis,  is  jireseut,  tho  ca^eitis  and 
fipcal  retention  may  bo  secondary.  Tho  cases  do  well ;  a  great  majority 
of  them  terminate  favorably,  a  [toint  which,  as  l'ej)per  remarks,  is  opposed 
to  tlie  belief  that  they  are  all  d('[)endent  upon  ap})endix  disease. 

In  tlie  trcafmcnt  of  this  condition  an  ice-bag  should  be  jjlaced  over  tlie 
ca>o.'d  region,  large  cnemata  given  onco  or  twice  a  day  to  empty  tho  colon, 
and  opium  given  to  allay  tho  pain. 

More  serious  disease  of  the  cfficum  does  occasionally  occur,  and  there 
arc  a  few  instances  in  which  an  ulcer  perforates.  The  rarity  of  this,  how- 
ever, is  shown  by  tho  fact  that  Fitz  was  only  able  to  collect  three  cases. 
Two  instances  have  como  under  my  observation  in  which  perforation  of 
an  ulcer  iu  tho  cajcum  led  to  extensive  periciecal  abscess. 

APPENDICITIS. 

The  appendix  vermiformis  is  extremely  variable  in  position.  It  com- 
monly lies  behind  the  ileum  with  the  tip  pointing  toward  the  spleen.  It 
is  frequently  turned  up  behiiul  the  caecum  or  it  lies  upon  the  psoas  muscle 
with  its  tip  at  tlie  margin  of  the  pelvis.  It  has,  however,  been  found  in 
almost  every  region  of  the  abdomen.  Thus  in  my  post-mortem  notes  it  is 
stated  to  have  bjcn  found  in  close  ••ontact  with  the  bladder;  adherent  to 
the  ovary  or  broul  ligamer.t;  in  the  central  portion  of  the  abdomen,  close 
to  the  navel ;  in  contact  with  the  gail-bladder ;  passing  out  at  right  angles 
and  adherent  to  the  sigmoid  flexure  to  the  left  of  the  middle  line  of  the 
abdoh  m ;  and  in  one  case  it  passed  with  the  caecum  into  tho  inguinal 
canal,  curved  upon  itself,  re-entered  the  abdomen,  and  Avas  adherent  to  tlie 
wall  of  an  abscess  cavity  just  to  the  right  of  the  promontory  of  the  sacrum. 
Foreign  bodies  rarely  lodge  in  it.  Only  two  instances  have  come  under 
my  notice ;  in  one  there  were  eight  snipe  shot  and  in  the  other  five  apple 
pips.  On  the  other  hand,  oval  bodies  resembling  date  stones  are  very 
common.  They  consist  of  inspissated  mucus  and  faeces,  in  which  in  time 
lime  salts  are  deposited,  forming  enteroliths. 

Post-mortem  examinations  show  that  the  appendix  is  very  frequently 
the  seat  of  extensive  disease,  past  or  present,  without  the  history  of  any 
,  definite  symptoms  pointing  to  trouble  in  the  cffical  region.  Among  the 
commonest  of  these  conditions  is  obliteration,  either  total  or  partial. 
When  at  the  cascal  end,  the  appendix  may  be  enormously  dilated,  forming 
a  tumor  the  size  of  the  thumb  or  as  large  as  a  sausage.  In  the  cases  of 
obliteration  the  appendix  may  be  free,  more  commonly  it  is  adherent,  and 
there  may  be  about  it  signs  of  old  inflammation  or  even  a  small  encapsu- 
lated abscess,  which  has  given  no  trouble. 

!Etiolog*y. — Appendicitis  is  a  disease  of  young  persons.  According 
to  Fitz's  statistics,  more  than  fifty  per  cent  of  the  cases  occur  before  the 
twentieth  year ;  sixty  per  cent  between  the  sixteenth  and  thirtieth  years 


APPENDICITIS. 


407 


(Einlioni).  It  lias  been  met  with  as  early  us  the  Hcventii  week,  but  it  is 
niri'ly  rtoou  prior  to  the  tliird  year.  It  is  very  much  nuirc  common  iu 
iiialcd  than  in  females — eighty  i)er  cent,  uccortliiig  to  the  tables  of  Fitz, 
but  in  his  personal  exi)orienco  in  TZ  cases  males  were  oivly  twice  as  fre- 
quently ailccted  as  IVnuiles.  Contrary  to  the  g-Micral  experience,  the 
Miiiiich  figures  (Einhorn)  indicate  a  relatively  greater  number  of  women 
attiicki'd.  'L'ho  fa'cal  concretions  and  foreign  bodies  already  referred  to 
probalily  i)lay  the  most  im2)0rtant  role  iu  the  etiology  of  the  disease.  In  a 
series  of  Ib'Z  cases  the  fivcal  masses  were  present  in  forty-seven  per  cent 
anil  foreign  bodies  in  twelve  per  cent.  Matterstock,  in  109  cases  of  per- 
forative appendicitis,  found  tlio  percentage  to  be  fifty-three  and  twelve, 
respectively.  Typhoid  fever  and  tuberculosis  frequently  induce  ulceration 
of  the  appendix,  but  not  often  perforation.  Fitz  suggests  that  some  of 
the  cases  of  peritonitis  which  recover  in  typhoid  fever  are  due  to  perfora- 
tion of  the  appendix.  Traumatism  plays  a  very  definite  role,  and  in  a 
number  of  cases  the  symptoms  have  followed  the  lifting  of  a  heavy  weight, 
or  a  full  or  a  blow.  Constii)ation,  overloading  tb'  stomach  with  indigest- 
ible food,  indiscretions  in  diet,  are  mentioned  in  many  cases.  The  tend- 
ency of  tlie  disease  to  recur  is  remarkal)le.  Among  'Z^u'  cases  (Fitz)  eleven 
per  cent  had  had  ])revious  attacks.  In  tlie  recurring  appendicitis  no  fac- 
tor is  of  greater  importance  than  oviriating,  and  attacks  may  follow 
directly  upon  the  taking  of  large  quantities  of  unsuitable  food. 

Morbid  Anatomy. — For  i)ractical  purposes  we  recognize  a  catarrh- 
al and  an  ulcerative  appendicitis.  In  catarrhal  appendirifis  the  entire 
tube  is  thickened,  the  peritoneal  surface  may  be  slightly  injected,  and 
adliesious  may  have  formed,  so  that  there  is  a  slight  circumscril)ed  peri- 
tonitis. The  lumen  may  be  much  contracted,  particularly  toward  the 
Cfecal  cud  ;  the  mucosa  is  thickened,  covered  with  a  tenacious  mucus ;  and 
very  conimonly  faecal  concretions  or  small  enteroliths  arc  present.  The 
coats  are  thickened  throughout,  particularly  the  muscularis,  and  the  entire 
tube  is  firm  and  stilT.  It  may  attain  the  size  of  the  index  finger  or  even 
that  of  the  thumb.  AYhen  laid  open  longitudinally,  it  at  once  assumes  a 
rolled  form  in  the  reverse  direction. 

Ulceration  and  Perforation  of  Appendix. — Many  cases  of  ulcer  present 
no  symptoms.  In  typhoid  fever  and  phthisis  eleven  instsmces  have  come 
under  my  observation  in  which  there  were  no  clinical  indications  of  the 
lesion.  The  dangerous  ulcers  follow  the  irritation  of  the  ftxjoal  oucretions 
or  foreign  bodies.  It  may  result  also  from  obliteration  of  the  cajcal  end 
and  distention  of  the  lumen  with  fluid.  The  perforation  may  have  the 
following  direct  effects :  {a)  The  appendix  may  hang  free  in  the  peritoneal 
cavity,  adhesions  not  having  formed,  when  the  perforation  at  once  excites 
a  dilTuse  and  violent  suppurative  peritonitis. 

[Ii)  ilore  commonly,  in  fact,  almost  as  a  rule,  the  ulcerated  appendix 
becomes  adherent  and  a  localized  peritonitis  results.  Perforation  then 
occurs,  with  the  formation  of  a  circumscribed  intraperitoneal  abscesu 


'^f 


-v,v.l 


408 


r»lSEASES  OP  THE  DIGESTIVE  SYSTKM. 


I'  I, 


•M 


krnk 


( 


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.r^-  i-'Kia 


1' 


cavity,  wliicli  luiiy  Ix^  Hinall  imd  whit'h  vario.s  in  Kitimtioii  with  the  appen- 
dix. Pt'rhup.s  tho  most  comiiioii  nitnation  is  on  the  jwoas  niuscU',  in  the 
iu'ij;hh»)rli(HMl  of  tho  terminal  portion  of  the  iU'uni.  In  cases  of  this  sort  1 
have  most  fri'{|ii('MtIy  foiind  tiie  small  locally  <l  ahscess  just  at  the  »ii<>-|() 
hctweeri  the  ileum  and  tlu!  ca;ciim.  it  may,  however,  he  within  the  pelvis 
or  close  to  the  sacrum.  Adiiesive  peritonitis,  jtcrforation,  and  the  fornui- 
tion  of  u  localized  ahscess  may  go  on  without  tho  jiroduction  of  serious 
symptoms,  and  the  condition  nuiy  he  found  when  death  lias  resulted  from 
accident  or  some  intercurrent  atTection,  In  some  cases  a  larj^e  circtini 
Hcrihed  fa-cal  ahscess  forms  in  the  iliac  regicm  and  points  midway  hetweea 
tho  navel  and  tho  anterior  8U])erior  si)ino  of  tho  ilium. 

Unf(n'tunatoly,  in  nuiny  cases  tho  localized  abscosa  cavity  excites  the 
most  intense  jjcritonitis.  Often  without  actual  rupture  diffuse  snpi)ura- 
tive  disease  occurs.  In  many  instances  the  first  iiulication  of  serious 
trouble  is  the  acute,  agonizing  pain  which  follows  the  diffusion  of  this 
localized  peritoneal  jirocess.  Tho  contents  of  the  limited  abscess  may  not 
ho  more  than  a  few  cubic  centimetres,  arc  usually  darkish  gi-ay  in  color, 
and  excessively  offensive. 

(<•)  When  tlie  ap2)endix  passes  behind  tho  c.Tcum  and  colon  and  is  not 
within  tho  peritonicum,  perforation  at  once  produces  a  retro])eritoiieal 
abscess,  which  may  terminate  iu  many  different  ways;  thus  tho  pus  inny 
pass  beTU'ath  the  iliacus  fascia  and  appear  at  Poupart's  ligament,  in  which 
situation  external  perforation  nuiy  occur  and  recovery  take  place.  The 
pus  may  be  chiefly  in  tho  retroperitoneal  tissue  iu  tho  Hank,  formii 
a  largo  periiu'phritic  abscess.  In  a  case  under  the  care  of  Gardiner,  u^ 
Montreal,  an  enormous  abscess  cavity  developed  in  this  situation,  which 
contained  air,  pushed  up  the  diaphragm  nearly  to  the  second  rib,  aiul  pro- 
duced the  symptoms  of  pneumothorax.  Perforation  of  tho  pleura  may 
occur  in  those  cases,  forming  a  fecal  pdenral  fistula.  The  pus  may  extend 
along  the  psoas  muscle  and  may  perforate  the  hip  joint,  or  pass  to  tho 
neighborhood  of  tho  rectum,  or  produce  multiple  abscesses  of  tho  scrotum, 
or,  passing  through  tho  obturator  foramen,  form  a  large  gluteal  abticess. 
Perforation  into  the  bladder  may  occur,  but  is  not  nearly  so  common  as  per- 
foration into  tho  bowel.  In  both  instances  recovery  may  follow,  though 
there  is  greater  danger  in  perforation  into  tho  latter.  The  appendix  has 
been  discharged  jo<?;'  amnn. 

The  remote  effects  of  perforative  appendicitis  are  interesting.  Ilti^ninr- 
rhage  may  occur.  In  one  of  my  cases  the  appendix  was  adherent  to  the 
promontory  of  tho  sacrum,  and  the  abscess  cavity  had  perforated  in  two 
places  into  the  ileum.  Death  resulted  from  profuse  lia^morrhage.  Cases 
are  on  record  in  which  the  internal  iliac  artery  or  tho  deep  circumflex  iliiio 
artery  has  been  opened.  Suppurative  pylephlebitis  may  result  from  in- 
flammation of  the  mesenteric  veins  near  tho  perforated  appendix.  Two 
instances  of  it  have  come  under  my  notice  ;  in  one  there  was  a  small  local- 
ized abscess  which  had  resulted  from  the  perforation  of  a  typhoid  ulcer 


:'T"'-'-1T!!* 


'••Vrif-  i^ 


I'O- 

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the 
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suoss. 

por- 

.ugh 
X  bus 

Mimr- 

0  the 
\  two 

c  iliac 

in  ill- 
Two 

1  local- 
ulcer 


APPKNDICITIS. 


409 


of  the  ivppoiulix.  In  tlio  other  cuse,  wliifli  I  saw  with  Machell,  of  ToroQ- 
t(i,  till'  symptoms  wuro  tlioso  of  si-pticu'iuiii  uiid  siippiirution  of  tiio  livor. 
'I'lic  abscess  of  tho  appomlix  was  small  and  liati  iii)t  proiiiiocd  symptoms, 
ill  till!  hi'uling  of  t'xtt'i\sivo  intlammatioii  about  tho  mar^'iii  of  tbo  pelvis 
the  iliac  veins  nuiy  bo  greatly  compressed,  and  one  of  my  patients  had 
fur  iiKinths  (edema  of  the  rij,dit  leg,  which  is  still  enlarged. 

Symptoms. — As  already  mentioned,  a  Him{tle  catarrhal  appendicitis 
may  leail  to  a  fatal  result,  and,  on  the  other  hand,  jjcrforation  and  al)scesa 
formation  may  take  place  without  exciting  serious  symptoms.  No  clussi- 
liiulion  into  light,  medium,  and  severe  forms  can  bo  made,  as  tho  most 
severe  of  all  features  of  the  disease — general  peritonitis — may  be  the  very 
lirst  indication  of  tho  existence  of  any  troul)le. 

<'(tl(irr/i(il  injlani Illation  may  induce  tho  most  characteristic  features 
of  appendix  disease.  Tho  facts  on  Avliieh  this  statement  is  made  are  eon- 
elusive.  A  num  aged  twenty-eight  was  admitted  to  the  Johns  Hopkins 
Hospital  with  pains  in  the  abdomen,  localized  in  the  vijrlit  iliuc  fossa, 
wliicli  in  July  became  severe  enough  to  confine  Inni  to  bed  for  several 
weeks.  In  August  tho  attack  returned  Avith  severity.  No  tumor  was  to 
be  felt  externally,  but  on  rectal  examination  a  firm,  rounded  body  could 
1m'  felt  high  up  on  the  right  margin  of  the  pelvis.  Laparotomy  was  ])er- 
t'ornieil  and  the  appendix  found  in  tho  true  peh  's  slightly  adherent,  very 
luui'li  tluckened,  but  without  perforation  or  nlrerati«m.  Bridge  rei)ort8 
an  instance  in  wliich  a  woman  aged  twenty-eight  had  an  attack  of  severe 
abdominal  pain,  vomiting,  constipation,  but  no  tumor.  The  temperature 
rose  as  iiigh  as  101°,  the  thighs  were  flexed,  and  there  was  pain  on  exten- 
sion of  the  psoas.  Ten'pon'ry  im})rovement  followed  and  then  a  recur- 
rence, accompanied  with  rise  of  temperature  and  return  of  the  pain. 
Laj)arotumy  was  performed  and  a  thickened,  dense  appendix  found, 
which  contained  three  small  enteroliths.  In  both  these  instances  per- 
sistent, severe  symptoms  were  caused  by  what  must  be  termed  a  chronic 
inflammation  of  the  appendix,  without  ulceration  and  without  perfora- 
tion. IJoth  cases  recovered.  A  similar  instance  has  occurred  at  the 
Pennsylvania  Hospital,  under  the  care  of  Thomas  G.  >[orton.  A  suppu- 
rative peritonitis  may  also  occur  Avithout  perforation  or  ulceration.  In  a 
rase  njported  by  Fitz  there  had  been  previous  attacks,  from  which  recov- 
ery by  resolution  liad  taken  place ;  then  an  abscess  at  the  brim  of  the  pelvis 
was  opened  and  drained.  After  recovery  again  a  recurrence  occurred,  and 
tiually  the  appendix  was  removed  and  found  to  be  thickened,  but  neither 
uli'erat(Hl  nor  perforated,  and  only  adherent  in  a  limited  extent  to  the 
(imentinn. 

in  iwrforative  appendicitis  there  maybe  initial  symptoms,  such  as 
nausea,  constipation,  sometimes  diarrhoea,  and  a  sense  of  uneasiness  and 
distress  in  the  right  iliac  fossa.  These  may  possibly  be  associated  with  tho 
localized  peritonitis.  A  sudden  violent  pain  in  the  abdomen,  most  com- 
monly in  the  right  iliac  fossa,  is  the  "  most  constant,  first  decided  symp- 
27 


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i".   i    ' 


410 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


torn  of  pc '•■":. Id  Ling  iiiflumniation  of  the  appendix,"  luid  occurred  in  eightv- 
foiir  per  cent  of  tlic  cases  analyzed  byFitz.  It  is  usually  liniitod  to  tlio 
fossa,  but  sometimes  extends  toward  the  navel  or  to  tin-  perinaniin,  testicle, 
or  thigh.  Fever,  furred  tongue,  and  vomiting  may  precede  or  accompany 
this  i)ain.  An  initial  chill  is  rare.  The  temperature  ranges  from  101°  (o 
103°  ;  sometimes  it  is  higher ;  the  pidse  is  iiu-reased  iii  f reciuency.  '\'\\q. 
patient  in  walking  bends  over,  favors  the  right  side,  and  has  difli(;ultv  in 
standing  straight.  When  in  bed  the  patient  usimlly  lies  with  the  rii,flit 
leg  drawn  up  and  complains  of  pain  on  extension.  ^licturition  may  bo 
frequent  or  there  may  be  retentioji  of  urine,  l^iarrlnx'a  seems  to  be  more 
frequent  in  children  than  in  adults. 

Physical  tSir/ns. — I'ympanites  may  be  early  and  interfere  considerahlv 
with  the  examination.  On  the  other  hand,  the  abdomcji  may  be  flat,  hard, 
and  board-like  even  with  diffuse  peritonitis.  In  a  great  majority  of  tiio 
cases  there  is  tenderness  in  the  right  iliac  fossa  and  over  the  region  of  the 
appendix.  jMcliurney  has  called  attention  to  the  value  of  a  special  local- 
ized point  of  tenderness  on  dee]!  pressure  situated  from  one  and  a  half  to 
two  incdies  from  the  anterior  superior  spine  of  the  ileum  on  a  line  (hawii 
between  this  point  and  the  navel.  When  firm,  continuous  pressure  is 
made  with  one  finger  at  this  poiiit  the  pain  may  be  of  the  most  exquisite 
character.  Circumscribed  swelling  may  be  present,  but  it  is  inconstant 
and  is  not  found  in  more  than  one  half  the  cases.  It  is  usually  in  the 
fossa  below  a  ]i)ie  passing  from  the  anterior  superior  spine  to  the  navel 
and  two  or  three  finger-breadths  above  Poupart's  ligament.  In  many  in- 
stances it  is  a  diffuse  thickening  and  induratio]\ ;  in  others  a  well-del'mod 
tumor  mass  can  be  detected.  If  there  is  much  tension  of  the  abdominal 
muscles  aiul  j)ain,  it  is  best  to  make  a  thorough  .examination  under  ether. 
In  the  cases  in  which  the  abscess  is  large,  fluctuation  may  be  felt  above 
Poupart's  ligament  or  in  the  dank,  and  in  some  instances  crepitation. 
Dulness  is  not  present  unless  the  exudation  is  abundant  atul  superficial. 
Usually  the  small  hn^alized  tumors  are  entirely  masked  by  the  distendcil 
intestines.  A  rectal  examination  should  be  made  in  every  instance.  \\  lien 
the  api)endix  is  above  the  1)rim  of  the  pelvis  it  cannot  be  reached,  hut 
when,  as  so  often  happens,  it  curls  over  into  the  pelvis,  it  or  the  tliick- 
ened  indurated  area  about  it  may  be  felt.  After  all,  the  great  danger  is 
not  so  much  in  the  limited  peritonitis  which  results  from  the  perforation, 
as  in  the  extension  of  it  to  the  general  peritonanim.  In  Fitz's  analysi<, 
the  second,  third,  and  fourth  days  included  the  largest  number  of  cases  of 
beginning  perit<mitis.  (Jeneral  abdominal  pain,  tym])anites  and  an  atr,;:iii- 
vation  of  the  geiu^ral  symptoms  indicate  the  onset  of  this  serious  compli- 
cation. 

Diagnosis. — Appendicitis  is  by  far  the  most  common  inflanimutory 
condition  prochwiiig  synip.  )ms,  not  only  in  the  enseal  region  but  in  the 
abdomen,  generally  in  j)ersons  under  thirty.  I^aparotomy  has  taught  us 
that,  almost  without  exception,  sudden  pain  in  the  right  iliac  fossa  with 


APPENDICITIS. 


411 


fovor,  localized  tenderness  with  or  without  tumor,  means  tippondix  disease. 
Almost  the  only  other  local  condition  to  bo  difl'erentiated  is  stercoral 
(';i>citis,  which  is  characterized  by  less  severe  pain,  slighter  fever,  p^'I  the 
proscnce  of  an  elongated  doughy  m"ss  in  the  lumbar  region;  it  i  .it  be 
iviiionibered  that  in  many  of  these  crises  the  a[>pendix  is  probably  aflfected. 

Perinephritic  and  pericaecal  abscess  from  perforation  of  I c l  ,  either 
sim])le  or  cancerous,  and  circumscribed  peritonitis  in  this  re^iOn  from. 
other  causes  can  rarely  bo  :lilferentiatcd  until  an  exploratory  incision  is 
uia<]c. 

Catarrhal  and  perforative  appendicitis  cannot  always  be  differenti- 
ati'il,  as  the  cases  which  I  have  quoted  show  that  in  intensity  of  jiain, 
sevi'i-ily  of  symptoms,  and  even  in  the  production  of  peritonitis,  the  two 
niiiy  lio  identical. 

Briefly  stated,  localized  pain  in  the  right  iliac  fossa  with  or  Avithout 
induration  or  tumor,  the  existence  of  McBurney's  tender  point,  fever, 
furred  tongue,  vomiting,  constipation  or  diarrhtra,  indicate  a})])en<li('itis. 
Tlio  occurrence  of  general  peritonitis  is  suggested  by  increase  and  d illusion 
of  tiio  abdominal  pain,  tympanites  (as  a  rule),  marked  aggravation  of  the 
constitutional  symptoms,  particularly  elevation  of  fever  and  increased  ra- 
])i(lity  of  the  pulse.  Alonzo  Clark's  sign,  obliteration  of  hepatic  dulness, 
is  rarely  present,  as  the  peritonfeum  in  these  cases  does  not  often  contain 

Th"  hypodermic  needle  should  never  be  used  unless  there  is  nuirked 
tumo"  with  dulness  on  percussion  in  the  caecal  region. 

It  uissusception  and  internal  strangulation  may  present  very  similar 
.'^ympti^ins,  and  if  the  patient  is  oidy  seen  at  the  latter  stiiges,  when  there 
is  (iitfuse  peritonitis  and  great  tympany,  the  features  nuiy  be  almost  iden- 
tical. Faecal  vomiting,  which  is  common  in  obstruction,  is  never  seen  in 
a[)i)on(li(itis,  and  in  children  the  marked  tenesmus  and  bloody  stools  are 
irn[inrtiiiit  signs  of  intussusception.  It  is  not  often  difficult  when  the  cases 
arc  seen  early  and  when  the  history  is  clear,  but  mistsikes  iuive  been  made 
by  surgeons  of  the  first  rank. 

In  women,  disease  of  the  tubes  and  j)elvic  peritonitis  from  any  cause 
may  sinuihite  appendicitis ;  but  the  history  and  the  local  examination, 
umler  ether,  should  in  most  cases  enable  tlie  practiticmer  to  discriminate 
between  those  conditions.  In  neurotic  patients  t]'^  odd  aiul  anomalous 
syni]itom(i  produced  by  floating  kidtu>y  may  be  tliought  to  be  due  to  ap- 
pend ieitis. 

Prognosis. — If  we  regard  every  case  of  inflammation  in  tlie  caecal 
rojrioii  ii.>  appendicitis,  a  large  proportion  of  the  cases  recover  The  grav- 
ity of  the  di.sease  is  difficult  to  estimate,  but  it  certainly  must  be  ranked  iis 
one  of  the  most  serious  and  fatal  of  the  abdominal  affections  of  young  per- 
sons, I'ost-mortem  observations  show  that  very  many  instances  get  well, 
often  without  treatment.  As  mentioned,  recuirrenco  is  comnu)n,  so  much 
so  tliat  over  forty  per  cent  of  the  cases  may  be  spoken  of  as  recurrent  ap- 


:v  ^  w 


412 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


pendicitis.  Sixty-eight  per  cent  of  the  fatal  cases  die  during  the  first 
eight  days.  Extension  to  the  general  peritonaexim  is  almost  always  fatal. 
Perforation  into  the  bowel  is  often  followed  by  recovery.  Perforation 
externally  is  still  less  serious.  Nowadays,  with  the  prompt  surgical  inter- 
ference, the  prognosis  is  very  much  better. 

Treatment.— The  studies  of  Pepper,  Noyes,  With,  and  Matterstock, 
and  more  particularly  the  elaborate  and  thorough  study  of  Fitz,  have 
directed  the  attention  of  physicians  to  the  clinical  features  of  the  diseases 
in  the  Cincal  region,  but  to  the  surgeons  we  owe  invaluable  lessons  relating 
to  diagnosis  and,  above  all,  to  treatment. 

The  suggestion  of  Willard  Parker  with  reference  to  early  operatioji  has 
been  carried  out  and  advocated  by  Sands,  Bull,  and  Weir  in  New  York, 
by  Morton  and  Keen  in  Philadelphia,  and  by  Treves  in  London. 

Treatment  of  the  Attach. — The  medical  treatment  of  appendicitis  can 
be  expressed  in  three  words — rest,  opium,  and  eneniata.  The  patient 
should  be  quiet  in  bed  with  an  ice-bag  placed  in  the  right  iliac  fossa.  If 
there  is  much  pain,  opium  sliould  be  given  either  hypodermically  or  by 
the  mouth.  ^ledium-sized  injections  of  warm  water  may  be  given  twice 
daily.  I  would  protest  most  earnestly  against  the  indiscriminate  use  of 
saline  purges,  which  have  been  advocated  nnder  a  total  misapprehension. 
It  cannot  be  too  strongly  emj)hasized  that,  as  a  rule,  the  initial  condition, 
which  produces  the  pain,  the  fe^er,  and  the  local  signs,  is  the  establishment 
after  perforation  of  a  localized  ])eritonitis  So  long  as  the  abscess  cavity 
renuiins  limited,  resolution  is  possible.  Saline  purges  mean  more  or  loss 
disturbance  of  the  local  conditions  and  a  definite  increase  in  the  risk  of 
general  peritonitis.  It  is  an  entirely  ditTerent  matter  when  this  is  estab- 
ished.  Salines  in  some  instances  then  do  good,  but  in  appendicitis,  when 
the  general  peritonaeum  is  involved,  the  mischief  is  done,  and  neither 
salines  nor  laparotomy  materially  influence  the  result. 

The  profession  has  yet  to  learn  the  lesson  that  perforative  appendicitis 
is  in  more  than  three  fourths  of  all  cases  a  surgical  affection,  and  pcrliiijis 
the  most  important  function  of  the  physician,  under  whose  care  the  diseaso 
always  comes  at  first,  is  to  say  whether  the  case  is  suitable  and  when  the 
oper,  ,i(m  should  be  performed. 

Operation  is  indicated  :  {a)  in  all  cases  of  acute  inflammatory  trouble  in 
the  caecal  region  when,  whether  tumor  is  present  or  not,  the  general  symp- 
toms are  severe,  as  shown  by  tympany,  8i)reading  pain,  increase  in  fever, 
and  increase  in  the  ra])idity  of  the  {)ulse.  In  so  many  of  the  cases  no 
tumor  is  to  be  felt  that  stress  cannot  be  laid  upon  its  absence. 

{b)  When  a  definite  tumor  is  present,  associated  with  attacks  sui.'h  us 
have  been  descri))ed,  particularly  if  they  have  been  recurrent.  An  occa- 
sional exception  may  be  made  to  this  rule  when,  even  with  small  tnnuir, 
the  symptoms  rapidly  subside  and  the  patient  improves.  We  are  here  on 
the  horns  of  a  dilemma.  On  the  one  hand,  it  is  in  just  such  cases  tliiii 
perforation  and  fatal  peritonitis  may  at  any  moment  occur,  and,  on  the 


INTESTINAL  OBSTRUCTION. 


413 


other,  the  tumor  may  gradually  disappear  and  the  patient  may  have  no 
liuthor  trouble. 

(r)  In  recurrent  appendicitis,  when  the  attacks  are  of  such  severity 
iiiul  frequency  as  seriously  to  interrupt  the  patient's  occuimtion.  Is  the 
interim  operation  advisable  or  shall  the  patient  be  advised  to  wait  until  an 
attack?  Opinions  dilfer  on  this  point.  It  is  best,  I  think,  to  wait.  The 
operation  has  risks ;  patients  have  died  from  the  interim  laparotomy ;  and 
tliere  is  always  a  chance  that  the  recovery  from  an  attjick  may  prove  per- 
luaiient.  Both  clinical  observation  and  morbid  anatomy  show  that  com- 
])lete  healing  is  by  no  means  rare.  The  i)1iysieian  must  be  guided  too  ])y 
tlie  eluiraeter  of  the  surgical  tecliinque  at  liis  command,  and  could  haiul 
over  his  patient  without  qualms  to  a  modern  operator  whose  success  has 
demonstrated  the  safety  of  his  methods. 


IV.    INTESTINAL  OBSTRUCTION. 

Intestinal  obstruction  may  be  caused  by  strangulation,  intussusception, 
twistr*  and  knots,  strictures  and  tumors,  and  by  abnormal  contents. 

Etiology  and  Pathology.— (r?)  Strangulation.— This  is  tlie  most 
fiT(|iieiit  cause  of  acute  obstruction,  and  occurred  in  thirty-four  per  cent 
of  the  21)5  cases  analyzed  by  Fitz,*  and  in  thirty-five  per  cent  of  the  1,134 
cases  of  Leichtensteni.f  Of  the  101  cases  of  strangulation  in  Fitz's  table, 
whieh  has  the  special  value  of  having  been  carefully  selected  from  the 
literature  since  ISSO,  the  following  were  the  causes:  Adhesions,  (i;j ;  vitel- 
line remains,  21 ;  adherent  appendix,  0 ;  mesenteric  and  omental  slits,  G; 
peritoneal  pouches  and  openings,  13;  adherent  tube,  1;  peduncular  tu- 
mor, 1.  The  bands  and  adhesions  result,  in  ;  ajority  of  cases,  from  for- 
mer pientonitis.  A  number  of  instances  h.. ,  Iwcn  reported  following 
operations  upon  the  pelvic  organs  in  women.  The  strangulation  may  be 
rereiit  and  due  to  adhesion  of  the  bowel  to  the  abdoniiiial  wound  or  a 
foil  maybe  caught  between  the  pedicle  of  a  tumor  and  th  j)elvic  wail. 
Sueli  eases  are  only  too  common.  Late  occlusion  after  recovery  from  the 
operation  is  due  to  bands  and  adhesions. 

The  vitelline  remains  are  represented  by  ^leckel's  diverticulum,  hich 
forms  a  finger-like  projection  from  the  ileum,  usually  Avithin  eiglitwn 
iiiclus  of  the  ileo-ciwal  valve.  It  is  a  remnant  of  the  omphalo-mesenteric 
duct,  through  which,  in  the  early  embryo,  the  intestine  communicated 
with  the  yolk-sac.  The  end,  though  commonly  free,  may  be  attach'  d  •  - 
the  ahdominal  wall  near  the  navel,  or  to  the  mesentery,  and  u  ring  is  tuns 
formed  through  which  the  gut  may  jiass. 

Seventy  per  cent  of  the  cases  of  obstruction  from  strangulation  occur 


*  Triinsiutions  of  the  Congress  of  American  Physicians  and  Surgeons,  vol.  i,  1869. 
The  iicri'('ntiif,'('s  of  his  tiiblos  are  used  llirougliout  this  section, 
t  Vuii  Ziumssun's  Encyclopoidia  of  Prticticul  Modiciue. 


f>iW 


ik^hi^ 


414 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


in  males ;  forty  per  cent  of  all  the  cases  occur  between  the  ages  of  fifteen 
and  thirty  years.  In  niiiety  per  cent  of  the  cases  of  obstruction  from 
these  causes  the  site  of  the  trouble  is  in  the  small  bowel ;  the  position 
of  the  strangulated  portion  Avas  in  the  right  iliac  fossa  in  sixty-seven 
per  cent  of  tlie  eases,  and  in  the  lower  abdomen  in  eighty-three  per 
cent. 

(/>)  Intussusception. — In  tliis  condition  oiuj  jjortion  of  the  intestine 
slips  into  an  adjacent  portion,  forming  an  invagination  or  intussusception. 
The  two  pcu'tions  make  a  cyiinch'ieal  tumor,  which  varies  in  lengtli  I'rorn  a 
half-inch  to  a  foot  or  more.  The  condition  is  always  a  descending  iulus- 
8Usce])tion,  and  as  the  process  proceeds,  the  middle  and  inner  layers  in- 
crease at  the  expense  of  the  outer  layer.  An  intussusception  consists  of 
three  layei's  of  1)owel :  the  outermost,  known  as  the  intussuscipiens,  or  i-e- 
ceiving  layer;  a  ndddle  or  returning  layer;  and  the  innermost  or  entering 
layer.  The  student  can  obtain  a  clear  ilea  of  the  arrangement  by  making 
tlie  end  of  a  glove-finger  pass  into  the  lower  portion.  The  actual  condi- 
tion can  be  very  clearly  studied  in  the  post-mortem  invagimitions  Avliich 
are  so  common  in  the  small  bowel  of  children.  In  the  statistics  of  Fit/., 
S);j  of  2'.)5  cases  of  acute  intestinal  obstruction  were  due  to  this  cause.  Of 
these,  52  were  in  males  and  27  in  fenudes.  The  cases  are  most  common  in 
early  life,  thirty-four  per  cent  under  one  year  and  fifty-six  per  cent  under 
the  tenth  year.  No  deilnite  causes  could  be  assigned  in  42  of  the  cases; 
in  the  others  diarrluea  or  habitual  constipation  had  existed. 

The  site  of  the  invagination  varies.  We  nuiy  recognize  (1)  an  ilco-vivral, 
when  tji"  ileo-ca?cal  valve  descends  into  the  colon.  There  are  cases  in 
which  this  is  so  extensive  that  the  valve  has  been  felt  per  rectum,  'i'liis 
fori  occurred  in  seventy-five  .i)er  cent  of  the  cases.  Iji  iha  ilco-rnUc  {\m 
lower  i)art  of  the  ileum  jiasses  tiu'ough  the  ileo-ca^cal  valve.  (2)  The  ileal, 
in  which  the  ileum  is  alone  involved.  (3)  The  colic,  in  which  it  is  con- 
fined to  the  large  intestine.  And  (4)  colico-rectal,  in  which  the  colon  and 
rectum  are  involved. 

Irregular  jieristalsis  is  the  essential  cause  of  intussusception.  No'li- 
nagel  found  in  the  localized  ])i'ristalsis  caused  by  the  faradic  current  tluit 
it  was  not  the  descent  of  one  portion  into  the  other,  but  the  drawing  \\{) 
of  the  receiving  layer  by  contraction  of  the  longitudinal  coat.  Invagina- 
tion may  follow  any  limited,  sudden,  and  severe  lu-ristalsis. 

In  the  post-mortem  exandnation,  in  a  ease  of  death  from  intussuscep- 
tion, the  condition  is  very  characteristic.  Peritointis  may  be  jjresent  or 
an  acute  injection  of  the  serous  niembrane.  "When  death  occurs  early,  as 
it  may  do  from  shock,  there  is  little  to  be  seen.  The  ])ortion  of  linwd 
affected  is  larg(>  and  thick,  and  forms  an  elongated  tumor  with  a  curved 
outline.  Tlie  parts  are  swollen  and  congested,  owing  to  tlie  constrieti.ni 
of  the  mesentery  between  the  layers.  The  eiitire  mass  vuvy  be  of  a  der]i 
livid-red  color.  If  very  recent  there  is  otdy  congestion,  and  perhaps  a 
slight  layer  of  lymph,  and  the  intussusception  can  be  reduceil,  but  when  it 


INTESTINAL  OBSTRUCTION. 


415 


his  lasted  for  a  few  days,  lymph  is  thrown  out,  the  layers  arc  glued  to- 
f^cthor,  and  tho  entering  portion  of  the  gut  cannot  be  withdrawn. 

The  anatomical  condition  accounts  for  the  presence  of  the  tumor,  which 
exists  in  two  thirds  of  all  cases ;  and  the  engorgement,  which  results  from 
tli(!  compression  of  the  mesenteric  vessels,  exi)lains  the  frequent  occurrence 
of  blood  in  the  discharges,  which  has  so  imjxirtant  a  diagnostic  value.  If 
the  patient  survives,  necrosis  and  sloughing  of  the  invaginated  portion 
may  occur,  and  if  union  has  taken  i)lace  between  the  middle  and  outer 
hivor,  the  calibre  of  the  gut  may  be  restored  and  a  cure  in  this  way  ef- 
fi'.'ted.  Many  cases  of  the  kind  iire  on  record.  In  the  ^Museum  of  the 
Medical  Faculty  of  McGill  University  are  17  inches  of  small  intestine, 
which  were  passed  by  a  lad  who  had  had  symptoms  of  internal  strangula- 
tion, and  who  made  a  c()m])lete  recovery. 

{(')  Twists  and  Knots. — Volvulus  or  twist  occurred  in  42  of  tho  295 
cases.  Sixty-eight  i)er  cent  were  in  males.  It  is  most  frequent  between 
the  ages  of  thirty  and  forty.  In  the  great  majority  of  all  cases  the  twist 
is  axial  and  associated  with  an  unusually  long  mesentery.  In  fifty  per 
ci'ut  of  the  cases  it  was  in  the  sigmoid  ilexure.  The  next  most  common 
situation  is  about  the  civcum,  which  nuiy  be  twisted  upon  its  axis  or  bent 
upon  itself.  As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply  twis+od 
upon  its  long  axis,  and  the  portions  at  the  end  of  the  loop  cross  each  other 
and  so  cause  the  strangulation.  It  occasionally  happens  that  one  portion 
of  the  bowel  is  twisted  about  another. 

{(I)  Strictures  and  Tumors. — These  are  very  much  less  important 
causes  of  acute  obstruction,  as  may  be  judged  by  the  fact  that  tliere  are 
only  1")  instances  out  oi  tho  205  cases,  in  1-1  of  Avhich  the  obstruction  oc- 
curred in  the  large  intestine.  On  the  other  hand,  they  are  common  causes 
of  chronic  obstruction. 

The  obstruction  may  result  from:  (1)  Conyenital  stricture.  These 
arc  exceedingly  rare,  iluch  more  commonly  the  condition  is  that  of  com- 
plete occlusion,  either  forming  the  imi)erforate  anus  or  the  congenital 
defect  by  which  the  duodenum  is  not  united  to  the  jiylorus.  (2)  Simple 
ciatlriciifl  ff/cnasis,  wliich  results  from  xdceration,  tuberculous  or  syphi- 
litic, more  rarely  from  dysentery,  and  most  rarely  of  all  from  tyi)hoid 
ulceration.  (15)  Xcw  groivths.  The  nudignant  strictures  are  due  chiefly 
to  cylindrical  ejjithclioma,  which  forms  an  annular  tumor,  nu)st  com- 
monly nu't  with  in  tlie  large  bowel,  about  the  sigmoid  flexure,  or  the 
(li'sceiidiug  colon.  Of  benign  growths,  j)apillomata,  adenomata,  li])omata, 
and  llhroinata  occasionally  induce  obstruction.  (4)  Cinupressian  and  trac- 
tion. Tumors  of  neighboring  organs,  particularly  of  tho  pelvic  viscera, 
may  cause  oltstrnction  l»y  adhesion  and  traction  ;  more  rarely,  a  coil,  such 
as  the  sigmoid  flexure,  filled  with  fares,  comi)rcsscs  and  obstructs  a 
neighboring  coil.  In  the  healing  of  tuberculous  i)eritonitis  the  contrac- 
tion of  the  thick  exudate  may  cause  compression  and  narrowing  of  tho 
coils. 


41 C 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


!     !■ 


(c)  Abnormal  Contents.— Foreign  bodies,  such  as  fruit  stones,  coins, 
pins,  needles,  or  false  teeth,  are  occasionally  swallowed  accidentally,  or  by 
lunatics  on  purpose.  Round  worms  may  become  rolled  into  a  tangled 
mass  and  cause  obstruction.  In  reality,  however,  the  majority  of  forci-rn 
bodies,  such  as  coins,  buttons,  and  pins,  swallowed  by  children,  cause  no 
inconvenience  whatever,  but  in  a  day  or  tAVo  are  found  in  the  stools.  Occa- 
sionally such  a  foreign  body  as  a  pin  will  pass  through  the  o'sophagus  and 
will  be  found  lodged  in  some  adjacent  organ,  as  in  the  heart  (Peabodx), 
or  a  barley  ear  may  reach  the  liver  (Dock). 

Medicines,  sucdi  as  magnesia  or  bismuth,  have  been  known  to  accunni- 
late  in  the  bowels  and  produce  obstruction,  but  in  the  great  majority  of 
the  cases  the  coiulition  is  caused  by  faeces,  gall-stones,  or  enteroliths.  Of 
44  cases,  in  23  the  obstruction  was  by  gall-stones,  in  19  by  faeces,  and  in  -^ 
by  enteroliths.  Obstruction  by  ffeces  may  hajipen  at  any  period  of  life. 
As  mentioned  Avhen  speaking  of  dilatation  of  the  colon,  it  may  occur  in 
young  children  and  jiersist  for  weeks.  In  fajcal  accumulation  the  large 
bowel  may  reach  an  enormous  size  and  the  contents  become  very  hard. 
The  retained  masses  may  be  channeled,  and  small  quantities  of  fa>cal  mat- 
ter are  passed  until  a  mass  too  large  enters  the  lumen  and  causes  obstruc- 
tion. There  may  be  very  few  symptoms,  as  the  condition  may  be  born? 
for  weeks  or  even  for  months. 

Obstruction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathon  d 
from  the  fact  that  twenty-three  cases  were  reported  in  the  literature  in 
eight  years.  Eighteen  of  these  were  in  women  and  five  in  men.  In  six 
sevenths  of  the  cases  it  occurred  after  the  fiftieth  year.  The  obstructioji 
is  usually  in  the  ileo-cfBfal  region,  but  it  may  be  in  the  duodenum.  I'liese 
large  solitary  gall-stones  ulcerate  through  the  gall-bladder,  usually  into 
the  small  intestine,  occasionally  into  the  colon.  In  the  latter  case  they 
rarely  cause  obstruction.  Courvoisier  has  collected  one  hundred  and  thirty- 
one  cases  in  the  literature. 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the 
phosj)hatos  of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body 
or  of  hardened  fasces.  Nearly  every  museum  possesses  specimens  of  tliis 
kind.  They  are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated 
iu  Fitz's  statistics,  are  very  rare  causes  of  obstruction. 

Symptoms. — (a)  Acute  Obstruction. — Constipation,  pain  in  the  alido- 
men,  and  vomiting  are  the  three  important  symptoms.  Pain  sets  in  caily 
and  may  come  on  abruptly  while  the  patient  is  walking  or,  more  com- 
monly, during  the  perfonnance  of  some  action.  It  is  at  first  colicky  in 
character,  but  subsequently  it  becomes  continuous  and  very  intense.  \'om- 
iting  follows  quickly  and  is  a  constant  and  most  distressing  symptom.  At 
first  the  contents  of  the  stomach  are  voided,  and  then  greenish,  hilo- 
stained  material,  and  soon,  in  cases  of  acute  and  permanent  obstruction, 
the  material  vomited  is  a  brownish -black  liquid,  with  a  distinctly  fivcal 
odor.     This  sequence  of  gastric,  bilious,  and,  finally,  stercoraceous  vomit- 


INTESTINAL  OBSTRUCTION. 


417 


ins;  is  perhaps  the  most  important  diagnostic  feature  of  acute  ohstraction. 
Tlic  constipation  may  be  absohite,  Avithout  the  discharge  of  eitlier  fivces 
or  gas.  Very  often  the  contents  of  tlie  bowel  below  the  stricture  are  dis- 
charged. Distention  of  the  abdomen  usually  occurs,  and  wheii  the  large 
bowel  is  involved  it  is  extreme.  On  the  other  hand,  if  the  obstruction  is 
liiLjli  up  in  the  small  intestine,  there  may  be  very  slight  tympany.  At 
first  the  abdomen  is  not  painful,  but  subsequently  it  may  become  acutely 
k'Utlcr. 

The  constitutional  symptoms  from  the  outset  are  severe.  The  face  is 
pallid  and  anxious,  aiid  filially  collapse  symjitoms  suiifrveno.  The  eyes 
l)(((?iiie  uunken,  the  features  pinched,  and  the  skin  is  i  jvcred  with  a  cold, 
cluiiiiuy  sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no 
fever;  the  axillary  temperature  is  often  subnormal.  The  tongue  is  dry 
and  parched  and  the  thirst  is  incessant.  The  urine  is  high-colored,  scanty, 
and  there  may  be  suppression,  particularly  Avhen  the  obstruction  is  high 
up  in  tlie  bowel.  This  is  probably  due  to  the  constant  vomiting  and  the 
smiill  amount  of  lirpiid  which  is  absorbed.  The  caso  terminates  as  a  rule 
in  from  three  to  six  days.  In  some  instances  the  patient  dies  from  shock 
or  sinks  into  coma. 

(h)  Symptoms  of  Chronic  Obstruction.— When  due  to  fa>cal  impaction, 
there  is  a  history  of  l 'iig-standing  constipation.  There  may  have  been 
discliarge  of  mucus,  or  in  some  instances  the  fa3cal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  portion  of  thet 
bowol  to  pass  through.  In  elderly  persons  this  is  not  infrequent;  but 
exiiniination,  either  per  rectum  or  externally,  in  the  course  of  the  colon, 
will  reveal  the  presence  of  hard  scybalous  masses.  There  may  be  retention 
of  faeces  for  weeks  without  exciting  serious  symptoms.  In  other  instances 
there  are  vomiting,  pain  ir.  the  abdomen,  gradual  distention,  and  finally 
the  ojecta  become  f«cal.  The  hardened  nuisses  may  excite  an  intense 
colitis  or  even  peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  obstruc- 
tion arc  very  diverse.  Constipation  gradually  comes  on,  is  extremely  varia- 
ble, and  it  may  be  months  or  even  years  before  there  is  complete  obstruc- 
tion. There  are  transient  attacks,  in  which  from  some  cause  the  faeces 
accumulate  above  the  stricture,  the  intestine  becomes  greatly  distended, 
and  in  the  swollen  abdomen  the  coils  can  be  seen  in  active  peristalsis.  In 
such  attacks  there  may  be  vomiting,  but  it  is  very  rarely  of  a  fjccal  char- 
actor.  In  the  majority  of  these  cases  the  general  health  is  seriously  im- 
Itiiircd ;  the  patient  gradually  becomes  anaemic  and  emaciated,  and  finally, 
in  an  attack  in  which  the  obstruction  is  complete,  death  occurs  with  all 
the  features  of  acute  occlusion  or  the  case  may  be  prolonged  for  ten  or 
twelve  days. 

Diagnosis.— (rt)  The  Situation  of  the  Obstruction.— Hernia  must 
be  cx(  luded,  which  is  by  no  means  always  easy,  as  fatal  obstruction  may 
occur  from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the 


I; 


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I 

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i  'Wit        ''      '>( 


418 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


oxternul  ring  or  in  the  obturator  foramen.  Mistakes  from  both  of  tlu^se 
cuusea  liave  come  under  my  observation  ;  they  were  oases  in  which  it  was 
impossible  to  make  a  dia^aiosis  other  than  acute  obstruction.  Timely 
o])eration  would  liave  saved  both  lives.  A  thorough  rei-tal  and  vaginal 
examination  should  l)e  made,  wliicii  will  give  important  information  as  to 
the  condition  of  the  pelvic  and  rectal  contents,  parti(;ularly  in  cases  of 
intussuscej)ti(m, in  which  the  descending  bowel  can  sometimes  be  felt,  in 
cases  of  obstruction  high  up  the  empty  coils  sink  into  the  pelvis  and  can 
there  be  detected.  Kectal  exph)ration  with  the  entire  hand  is  of  doubirul 
value.  In  the  inspection  of  the  abdomen  there  are  important  indications, 
as  the  s])ecial  prominence  in  certain  regions,  the  occurrence  of  delinite, 
well-defined  masses,  and  the  i)resence  of  hypertroi)hied  coils  in  active 
peristalsis.  In  obstruction  in  the  duodenum  or  jejunum  there  mav  only 
be  slight  distention  in  the  ujjper  part  of  the  abdomen,  associated  usually 
with  rapid  collapse  and  anuria. 

In  the  ileum  and  ca'cum  the  distention  is  more  in  the  central  portic^n 
of  the  abdomen;  the  vomiting  is  distinctly  fajcal  and  occurs  early.  In 
obstruction  of  the  colon,  tym})anites  is  much  more  extensive  and  general. 
Tenesmus  is  more  common,  with  the  passage  of  mucus  and  blood.  'J'lio 
course  is  not  so  quick,  the  collapse  does  not  supervene  so  rapidly,  and  the 
urinary  secretion  is  iu)t  so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases 
be  accurately  localized,  but  in  others  it  is  very  difficult.  Digital  examina- 
tion of  the  rectum  should  first  be  made.  The  rectal  tube  nuiy  then  be 
passed,  but  it  is  impossible  to  get  beyond  the  sigmoid  flexure.  In  the  use 
of  the  rigid  tube  there  is  danger  of  perforation  of  the  bowel  iu  the  neigh- 
borhood of  a  stricture.  The  quantity  of  fluiil  which  can  be  })assed  into 
the  large  intestine  should  be  estinuited.  The  caj'^acity  of  the  large  bowel 
is  about  six  quarts'.  The  safe  limits  of  pressure  have  been  determined  to 
be  under  ten  feet  in  an  infant  aiul  twenty  feet  in  an  adult.  To  thorough- 
ly irrigate  the  bowel  the  patient  should  be  chloroformed  aiul  should  lie  on 
the  back  or  on  the  side ;  best  on  the  back  with  the  hips  elevated.  Ti'cves 
suggests  that  the  csecal  region  should  be  auscultated  during  the  passage  of 
the  fluid.  For  diagnostic  purposes  the  rectum  may  be  inflated,  either  by 
the  bellows  or  by  the  use  of  bicarbonate  of  soda  and  tartaric  acid.  In  cci- 
tain  cases  these  measures  give  important  indications  as  to  the  situation  of 
the  obstruction  in  the  large  bowel. 

(/j)  Nature  of  the  Obstruction. — This  is  often  difficult,  not  infrequent- 
ly impossible,  to  determine.  Strnngidntion  is  not  common  in  very  early 
life.  In  many  instances  there  have  been  previous  attacks  of  abdominal 
pain,  or  there  are  etiologicial  factors  which  give  a  clew,  such  as  oki  jieri- 
tonitis  or  operation  on  the  pelvic  viscera.  Neither  the  onset  nor  the  char- 
acter of  the  pain  gives  us  any  infornuition.  In  rare  instances  nausea  and 
vomiting  may  be  absent.  The  vomiting  usually  becomes  fajcal  from  the 
third  to  the  fifth  day.     A  tumor  is  not  common  in  strangulation,  and 


INTESTINAL  OBSTRUCTION. 


419 


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wiis  present  in  only  one  lifth  of  the  cases.     Fever  is  not  of  diagnostic 

Viiliie. 

IntusHUsception  is  an  alYection  of  cliildliood,  and  is  of  all  forms  of  in- 
tcriiul  obstrnction  the  one  most  readily  diagnosed.  Tlie^jresence  of  tumor, 
!)lo()(ly  stools,  ami  tenesmus  are  the  im])ortaiit  factors.  The  tumor  \s 
usually  sausage-shaped  and  felt  in  the  region  of  the  transverse  colon.  It 
existed  in  00  of  U3  cases.  It  was  present  on  the  first  day  in  more  than  one 
ihird  of  the  cases,  on  the  second  day  in  more  than  one  fourth,  and  on  the 
third  day  in  more  than  one  fifth.  Blood  in  the  stools  occurs  in  at  least 
lliree  fifths  of  the  (;a  ««,  eitlier  spontaneously  or  following  the  use  of  an 
ciu'iiia.  'riie  blood  may  be  mixed  with  mucus.  Tenesmus  is  i)resent  in 
one  third  of  the  cases.  Fajcal  vomiting  is  not  very  common  aiul  was  pres- 
ent in  only  Vi  of  the  93  instances.  Abdominal  tymj)any  is  a  symptom  of 
sliulit  iin])ortance,  occurring  in  only  one  third  of  the  cases. 

Viili'iiliis  can  rarely  be  diagnosed.  The  frequency  with  which  it  in- 
volves the  sigmoid  flexure  is  to  be  borne  in  mind.  The  passage  of  a  flex- 
ilile  tube  or  injecting  fluids  might  in  these  cases  give  valualde  iiulieations. 
An  absolute  diagnosis  can  probal)ly  be  made  only  by  an  abdominal  section. 

In  fiiical  okstruction  the  condition  is  usually  clear,  as  the  faices  can  be 
felt  per  rectum  and  also  in  the  distended  colon.  Ftvcal  vomiting,  tym- 
pany, aljdominal  pain,  nausea,  and  vomiting  are  late  and  are  not  so  con- 
stant. In  obstruction  by  gall-stone  a  few  of  the  cases  gave  a  previous  his- 
tory of  gall-stone  colic.  Jaundice  was  present  in  only  two  of  the  twenty- 
tlirei'  cases.  Pain  and  vomiting,  as  a  rule,  occur  early  and  are  severe,  and 
fiL'cal  vomiting  is  present  in  two  thirds  of  the  cases.  A  tumor  is  rarely 
evident. 

(' )  Diagnosis  from  other  Conditions.— Acute  enteritis  with  great  re- 
liixalion  of  the  intestinal  coils,  vomiting,  ami  pain  maybe  mistaken  for 
ol)strnction.  In  an  autopsy  on  a  case  of  this  kind  the  small  and  large 
bowels  were  intensely  inflamed,  relaxed,  sodden,  and  eiu)rmously  distended. 
Tlie  syni))toms  were  those  of  acute  obstruction,  but  the  intestine  was  free 
from  duodenum  to  rectum.  Of  late  years  many  instances  have  been  re- 
[lorted  in  which  peritonitis  following  disease  of  the  appeiulix  has  been 
mistaken  for  acute  obstruction.  The  intense  vomiting,  the  general  tym- 
])any  and  abdominal  tenderness,  and  in  some  instances  the  suddeniiess  of 
the  onset  are  very  deceptive,  and  in  two  cases  which  have  come  uiuler  my 
notice  the  sym])toms  ))ointed  very  strongly  to  internal  strangulation.  In 
appendix  disease  the  temperature  is  more  frequently  elevated,  the  vomit- 
iiii;  is  never  I'iecal,  and  in  many  cases  there  is  a  histoiy  of  previous  attacks 
in  the  ciBcal  region.  Acute  htemorrhiigic  pancreatitis  may  i)roduce  symp- 
toms which  simulate  closely  intestinal  obstruction.  A  boy  was  admitted 
to  the  Johns  Hopkins  Hospital  with  a  history  of  obstiiuite  vomiting,  in- 
tense al)dominal  pain,  gradually  increasing  tympany,  and  no  passage  for 
st'voral  days,  llis  condition  seemed  serious  and  he  was  transferred  at  once 
to  the  surgical  wards.     At  the  operation  the  coils  were  found  uniformly 


w 


J  m  - 


420 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


distended  and  covered  in  jdiicea  M'itli  t\w  thinnest  fdm  of  lynij)!!.  Xo 
obstruction  existed,  but  there  was  a.  tunior-like  mass  surr()undin<;  the  pan- 
creas, hrni,  liard,and  deei)ly  infiltrated  with  blood.  The  patient  inii)rov((l 
after  the  operation  and  recovered  conipletely. 

Treatment. — Purf^atives  should  not  be  j^iven.  For  the  ])ain  hyi)o- 
dennies  of  morphia  are  indicated.  To  allay  the  distressin<^  voniitinjr,  the 
stomach  should  be  washed  out.  Not  only  is  this  directly  bcneliciul,  Itiit 
Kiissmaul  claims  that  the  abdominal  distention  is  relieved,  tlie  pressure  in 
the  bowel  above  the  seat  of  obstruction  is  lessened,  and  the  violent  peri- 
stalsis is  diminished.  It  may  be  practised  three  or  four  times  a  diiv,  ii)iil 
in  some  instances  has  ])roved  benelicial ;  in  others  curative,  'riionm;:!! 
irri;^atio7i  of  the  large  bowel  with  injections  shoidd  be  j)raetised,  the  iliiid 
being  allowed  to  flow  in  from  a  siphon  syringe,  and  the  amount  carefullv 
estimated.  .loiuithan  Hutchinson  recommends  that  the  patient  be  i)liic((i 
under  an  ana'sthetic,  the  abdomen  thoroughly  kneaded,  and  a  copious 
eiuana  given  while  in  the  inverted  position.  Then,  with  the  aid  of  tlireo 
or  four  strong  men,  the  i)atient  is  to  be  thoroughly  shaken,  first  with  tlio 
abdomen  held  tlownward,  aiul  subscc|ueutly  in  the  inverted  position. 

Inllation  may  also  be  tried,  by  forcing  the  air  into  the  rectum  with  tiic 
bellows  or  with  a  Davidson's  syringe.  It  is  a  measure  not  without  risk, 
as  instances  of  rupture  of  the  bowel  have  been  reported.  Fitz's  figures 
show  that  in  the  first  eight  years  of  the  last  decade  there  were  thirty-three 
cases  of  recovery  after  injection  or  inflation  in  cases  of  certain  or  i)robjil)lc 
intussusception,  and  eleven  deaths.  In  cases  of  acute  obstruction,  if  these 
means  do  not  prove  successful  by  the  third  day,  surgical  nu'asures  should 
be  resorted  to,  and  when  the  obstruction  seems  jjorsistent  and  the  condi- 
tion serious,  laparotomy  should  be  performed  at  o.Tice. 

For  the  tympanites  turpentine  stu})es  and  hot  a])plications  may  he 
applied ;  if  extreme,  the  bowel  nuiy  be  punctured  with  a  snudl  aspinitoi' 
needle.  In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regu- 
lated, and  opium  and  belladonna  are  useful  for  the  paroxysmal  ])aiiis. 
Enemata  should  be  employed,  and  if  the  obstruction  becomes  comj)letc, 
resort  must  be  had  to  surgical  measures. 


V.  CONSTIPATION  {Costiveness). 

Definition. — Retention  of  faeces  from  any  cau.se. 

Constipation  in  Adults. — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

General  Causes. — (a)  Constitutional  peculiarities :  Torpidity  of  tlu' 
bowels  is  often  a  family  complaint  and  is  found  more  often  in  da'-k  than 
in  fair  persons.  (/;)  Sedentary  habits,  particularly  in  persons  who  eat  tdo 
much  and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  aiue- 
mia,  neurasthenia  and  hysteria,  chronic  affections  of  the  liver,  stomach, 


CONSTIPATION. 


421 


niid  intestines,  and  tlie  aouto  fevers.  Under  this  heudinj;  may  appropri- 
atiiv  be  placed  tluit  most  injurious  of  all  \m])\\.A,<lriii/-f(d-in;/.  {(()  Kilher 
a  coarse  diet,  which  leaves  too  much  residue,  or  u  diet  which  leaves  too 
little  may  he  a  cause  of  costiveness. 

LoPdl  Cnu/ies. —  Weakness  of  the  ahdomiiuil  muscles  in  ohesity  or  from 
ovcnlistention  in  rei)eated  pregnancies.  Atony  of  the  lar<^e  bowel  from 
chronic  disease  of  the  mucosa;  the  preseiu'e  ()f  tumors,  physiological  or 
piitliological,  pressing  upon  the  bowel;  enteritis;  foreign  bodies,  large 
masses  of  scybala,  aiul  strictures  of  all  kinds.  By  far  the  most  important 
Ideal  cause  is  atony  of  the  colon,  particularly  of  the  nuisclos  of  the  sig- 
niuid  Hcxure  by  which  the  faices  are  propelled  into  the  rectum. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even 
months  may  exist  with  fair  health.  All  kinds  of  evils  have  been  attrib- 
uted to  poisoning  by  the  resorption  of  noxious  nuitters  from  the  retained 
fu'ces — copnvmia — but  it  is  not  likely  that  this  takes  jylace  to  any  extent. 
Chlorosis,  which  Sir  Andrew  Clark  attributes  to  fajcal  poiscming,  is  not 
always  associated  with  constipation,  and  if  due  to  this  cause  should  be  iu 
men,  women,  und  children  the  most  common  of  all  disorders.  Debility, 
lassitude,  and  mental  depression  are  frequent  symptoms  in  constii)ation, 
particiilarly  in  persons  of  a  nervous  temperament.  Headache,  loss  of  ap- 
petite, and  a  furred  tongue  may  also  occur.  Iiulividiuils  differ  extraor- 
dinarily in  this  matter;  one  feels  wretched  all  day  without  the  accustomed 
evacuation;  another  is  comfortable  all  the  week  except  on  the.  day  on 
wliicli  by  purge  or  enema  the  bowels  are  relieved. 

When  persistent,  the  accumulation  of  faeces  leads  to  unpleasant,  some- 
times serious  symptoms,  such  as  piles,  ulceration  of  the  colon,  distention 
of  the  sacculi,  perforation,  enteritis,  and  occlusion.  In  women  pressure 
may  cause  pain  at  the  time  of  menstruation  and  a  sensation  of  fulness 
and  distention  in  the  pelvic  organs.  Neuralgia  of  the  sacral  nerves  nuiy 
be  caused  by  an  overloaded  sigmoid  flexure.  The  fasces  collect  chiefly  in 
the  colon.  Even  in  extreme  grades  of  constipation  it  is  rare  to  find  dry 
ficees  in  the  caecum.  The  faeces  may  form  large  tumors  at  the  liepatic  or 
splenic  flexures,  or  a  sausage-like,  doughy  mass  above  the  navel,  or  an 
irregular  lumpy  tumor  in  the  left  inguiiuil  region.  In  old  persons  the 
sacculi  of  the  colon  become  distended  and  the  scybala  may  remain  in 
them  and  undergo  calcification,  forming  enterolitlis. 

In  cases  with  prolonged  retention  the  fiBcal  masses  become  channelled 
and  (liarrluwi  may  occur  for  days  before  the  true  condition  is  discovered 
by  rectal  or  external  examination.  In  women  who  have  been  habitually 
constipated,  attacks  of  diarrhoea  with  nausea  and  vomiting  should  excite 
suspicion  and  lead  to  a  thorough  examination  of  the  large  bowel.  Fever 
may  occur  in  these  cases,  and  Meigs  has  reported  an  instance  in  which 
the  condition  simulated  typhoid  fever. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.     There  are  instances  in  which 


ifli 


L' 


422 


DISEASES  OF  THE  DIOESTIVE  SYSTEM. 


the  cliiM  is  ('r»iistipat('(l  from  birtli  iind  may  not  have  a  natural  movpnicut 
for  years  and  yet  thrive  ami  (loveh)p.  An  instanco  of  the  kind  was  in  my 
ward  recently  in  which  a  hahy  of  seven  months  hail  never  had  a  movement 
without  preliminary  injections.  The  ahdomen  heeanu^  swollen  everv  dav, 
hut  suhsided  after  an  iiijeetion  and  the  passa;^e  ot  a  Ion;;  catheter.  N'n 
stricture  could  l)e  I'elt.  I  iiave  already  refei'i-ed  to  u  case  of  W.  E.  IIuf,dies's, 
in  which  there  was  enormous  dilatation  of  the  lar^jfe  howel  with  persistent 
constipation.  Tn  some  of  these  patients  there  nuiy  ho  constricting  hands, 
or,  as  in  a  case  of  (Mieever's,  a  congenital  stricture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from 
an  unnatural  dryness  of  the  snudl  residue  which  i)assos  into  the  colon,  and 
it  may  he  very  dillicult  to  decide  whether  the  fault  is  in  the  mother's  milk 
or  in  the  digestion  (»f  the  child.  Most  prohably  it  is  the  latter,  as  some 
babies  may  he  persistently  costive  on  natural  or  artilicial  foods.  Tint 
much  casein  in  the  milk  is  believed  by  some  M'riters  to  be  the  cause.  In 
older  <'hildren  it  is  of  the  greatest  importance  that  regular  habits  should 
be  enjoined.  Carelessness  on  the  })art  of  the  mother  in  this  matter  often 
lays  the  foundation  of  tnmble.some  constipation  in  after  life.  Jmpairnu  nt 
of  the  contractihility  of  the  intestinal  wall  in  conseciuence  of  inflamma- 
tion, disturbance  in  the  normal  intestinal  secretions,  and  mechanical 
obstruction  by  tumors,  twists,  and  intussusception  are  the  chief  local 
causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly 
in  the  young.  The  desire  to  go  to  stool  should  always  be  granted.  Exer- 
cise in  moderation  is  helpful.  In  stout  persons  and  in  women  with  pend- 
ulous abdomens  the  muscles  should  have  the  su})port  of  a  bandage. 
Friction  or  regularly  applied  nuissage  is  invaluable  in  the  more  chronic 
cases.  A  good  substitute  is  a  metal  ball  weighing  from  four  to  six  pounds, 
which  may  be  rolled  over  the  abdomen  every  morning  for  five  or  ten  min- 
utes. The  diet  should  be  light,  with  plenty  of  fruit  and  vegetables,  par- 
ticularly salads  ard  tomatoes.  Oatmeal  is  usually  laxative,  though  not  to 
all;  brown  bread  is  better  than  that  made  from  fine  white  Hour.  Of 
liquids,  water  and  the  aerated  mineral  waters  may  be  taken  freely.  A 
tumblerful  of  cold  water  on  rising,  taken  slowly,  is  cflficacious  in  many 
cases.  A  glass  of  hot  water  at  night  may  also  be  tried  alone.  A  i)ipe  or 
a  cigar  after  breakfast  is  with  many  men  an  infallible  remedy. 

When  the  condition  is  not  very  obstinate  it  is  wdl  to  try  to  relieve 
it  by  hygienic  and  dietetic  measure?.  If  drugs  must  be  used  they  should 
be  the  milder  saline  laxatives  or  the  compound  liquorice  powder.  Eneniata 
are  often  necessary,  and  it  is  much  jireferable  to  employ  them  early  tliiin 
to  constantly  use  purgative  pills.  (Jlycerine  either  in  the  form  of  sup- 
pository or  as  a  snuUl  injection  is  very  valuable.  Half  a  drachm  of  boric 
acid  placed  within  the  rectum  is  sometimes  efficacious.  The  injections  of 
tepid  water,  with  or  without  soap,  may  be  used  for  a  prolonged  period 
with  good  elfect  and  without  damage.     The  patient  should  be  in  the 


JAUNDICE. 


123 


(Idi'-iiil  position  witli  tlu'  ]iii)a  clovatod,  atul  it  is  lu-st  t(»  let  llir  lluid  llow  in 
hluwiy  from  u  I'ountiiin  syriiij;(>. 

Tlu'iv  iiro  various  druj^'s  wliich  arc  of  special  service,  particularly  tlio 
conihination  of  i]ieciu'tuitiliii,  uux  vonii<'a,  or  ItcUadouiia,  with  aloes,  rliu- 
barli,  colocyntli,  or  j)odopliylliii.  Mcij^'s  recoinuu'nds  particularly  tlu» 
(•(itid)ination  of  extract  of  l»elladoiina  (trr.  ^K),  extract  of  mix  vouiica  (;;r. 
I),  and  extract  of  colocyntli  (^'r.  ij),  one  pill  to  he  taken  thi'ce  times  a 
(lay.  Id  aiia'tnia  and  chlorosis  a  sulphur  confection  taken  in  the  morn- 
ing;, and  a  pill  of  iron,  rliuharb,  and  aloes  thr()u<,diout  the  day  are  very 
scrviceahle. 

Im  children  the  indications  should  he  met,  as  far  as  possihie,  hy  hy;,Menic 
and  dietetic  measures.  Jn  the  constipation  of  sueklinj^s  a  ehaJi^^e  in  the 
diet  of  the  mother  may  be  tried.  Drinkijig  of  water,  barley  water,  or  oat- 
meal water  will  sometimes  obviate  the  ditJiculty.  If  laxatives  are  recpiired 
simple  syruj),  manna,  or  olive  oil  may  be  sutbcient.  The  conical  piece  of 
soap,  so  often  seen  in  nurseries,  is  sometimes  etlicacious.  Small  iiijedioua 
of  cold  water  may  be  used.  Lar^'e  injections  should  be  avoided  if  possi- 
ble. If  it  is  necessary  to  {jive  a  laxative  by  the  mouth  the  castor  oil  or 
fluid  lunuMiesia  is  the  best.  If  there  are  sijjns  of  pustro-intestiiuil  irritation 
rliuhitrl)  and  soda  or  jjray  ])Owder  may  be  given.  In  older  children  the 
diet  ahould  be  carefully  regulated. 


VIII.  DISEASES   OF  THE  LIVER. 


I.  JAUNDICE  (Icterus). 

1.  Jaundice  as  a  Symptom. — Cases  with  icterus  may  bo  divided  into 
two  grei't  groups:  Those  in  which  there  is  obstruction,  either  in  the  small- 
er or  in  the  larger  ducts — the  ?iepnto(/t'nous  form  ;  eases  in  which  the  jaun- 
dice is  due  to  suppression  of  the  function  of  the  liver-cells,  as  in  the  widc- 
^ip^'ad  necrosis  of  acute  yellow  atrophy,  or  to  an  excess  of  the  ehroma- 
tojjfiious  material,  as  in  malaria,  pernicious  anaemia,  and  certain  fevers,  in 
which  the  liver  function  cannot  keep  pace  with  the  blooil  destruction 
(luemolysis) — hivmafof/euous  or  non-obstructive  jaundice. 

The  following  classification  of  the  causes  of  hepatogenous  jaundice  is 
anuuged  by  Murchison,  to  whose  writings  on  the  liver  we  owe  so  much : 
Oltstruction  (1)  by  foreign  bodies  within  the  ducts,  us  gall-stones  and 
parasites;  (2)  by  inflammatory  tumefaction  of  the  duodenum  or  of  the 
lining  membrane  of  the  duct;  (3)  by  stricture  or  obliteration  of  the  duct; 
(4)  hy  tumors  closing  the  orifice  of  the  duct  or  growing  in  its  interior ; 
(•'))  by  pressure  on  the  duct  from  without,  as  by  tumors  of  the  liver  itself, 
of  the  stomach,  pancreas,  kidney,  or  omentum;  by  pressure  of  enlarged 
glands  in  the  fissure  of  the  liver,  and,  more  rarely,  of  abdominal  an  .urism, 


■trm 


&,;?!.  i  i: 


424 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


fffical  accumulation,  or  tlie  pregnant  uterus ;  (G)  to  these  may  be  added 
lowering  of  the  blood  pressure  in  the  liver,  so  that  the  tension  in  the 
smaller  bile-ducts  is  greater  than  in  the  blood-vessels.  In  this  class  very 
probably  may  be  placed  the  cases  resulting  from  mental  shock  or  depress- 
ing emotions. 

General  ,Si/nij)foms  of  Obstructive  Jaundice. — (1)  Icterus,  or  tintiii<( 
of  the  skin  and  conjunctivae.  The  color  ranges  from  a  lemon-yellow  in 
catarrhal  jaundice  to  a  deep  olive-green  or  bronzed  hue  in  perniani'ut 
obstruction.  In  some  instances  the  coloi  of  tlie  skin  is  greenish  black, 
the  so-called  "  black  jaundice." 

(2)  Of  other  cutaneous  symptoms,  pruritus  in  the  more  chronic  forms 
may  be  intense  and  cause  the  greatest  distress.  It  may  precede  the  onset 
of  the  jaundice,  but  as  a  rule  it  is  not  very  marked  except  in  cases  of  jjro- 
longed  obstruction.  Swea^^mg  is  common,  and  may  be  curiously  localized 
to  the  abdomen  or  to  the  palms  of  the  hands.  Lichen,  urticaria,  and 
boils  may  develop,  and  the  skin  disease  known  as  xanthelasma  or  vitili- 
goidea. 

(;3)  The  .secretions  are  colored  with  bile-pigment.  The  sweat  tinges 
the  linen  ;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  exj)c(to- 
ration  is  not  often  tinted  unless  there  is  inflammation,  as  when  i)neumonia 
coexists  with  jauiulice.  The  urine  may  contain  the  pigment  before  it  is 
apparent  in  the  skin  or  conjunctiva.  The  color  varies  from  light  groonisli 
yellow  to  a  dee])  black-green.  (Jn^eliri's  test  is  made  by  allowing  five  or 
six  drops  of  urine  and  a  similar  amount  of  common  nitric  acid  to  flow 
together  slowly  on  the  flat  sui'face  of  u  white  plate.  A  j)lay  of  colors  i- 
produced — various  shades  of  green,  yellow,  violet,  and  red.  In  cases  oi 
jaundice  cf  lojig  standing  or  great  intensity  the  urine  usually  contains 
albumen  and  always  bile-stained  tube-casts. 

(4)  No  bile  passes  into  the  intestine.  The  stools  thereiore  are  of  .'i 
pale  drab  or  slate-gray  color,  and  usually  very  fetid  and  ;;asty.  There 
may  be  constii)ation ;  in  many  instances,  owing  to  decomposition,  there  is 
diarrha'a. 

(5)  Slow  pulse.  The  heart's  action  may  fall  to  40,  30.  or  even  to  5}0 
per  minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  jaun- 
dice, and  is  not  as  a  ruU-  an  unfavorable  symptom. 

((J)  Ilrt'inorrhage.  Ecchymoses  are  iu)t  uncommon  in  severe  jaundice, 
particularly  in  the  more  n^aligniint  forms. 

(7)  Cerebral  symptomS:  Irritability,  great  lepression  of  spirits,  or 
even  melancholia  may  be  present.  In  any  cas^  of  persistent  jaundice 
special  nervous  jdicnoinena  may  develop  and  rapidly  ^)rove  fatal — such  as 
sudden  c(»ma,  acute  (Llirium  or  convulsions.  Usually  the  patient  liiis  a 
rapid  pnl.'^e,  sligi\t  fever,  and  a  dry  tongue,  and  ho  passes  into  the  r-o-callcd 
"  t"pl:(Md  state."  These  features  are  not  nearly  so  common  in  obstructive 
us  in  febrile  jaundice,  but  they  not  infrerjuently  terminate  a  chrnlc  icicras 
in  whatever  way  i)roduced.     The  group  of  symptoms  has  been  termed 


JAUNDICE, 


425 


chnlmnia  or,  on  the  supposition  tliat  cliolosterin  is  the  poison,  cholester- 
a>mia;  but  the  true  nature  of  the  poison  has  not  }'et  been  determined.    In 
some  of  tlie  cases  the  symptoms  may  be  due  to  uraimia. 
Xon-obst ruclive  jaundice  may  bo  thus  ehissified  : 

(1)  The  form  in  wliich  there  is  wide-spread  necrosis  of  tlic  liver-cells 
and  direct  interference  with  their  bile-forming  function,  as  in  acute  yellow 
atrophy,  and  possibly  in  certain  cases  of  hypertrophic  cirrhosis.  Strictly 
upeakiug,  this  is  a  hepatogenous  jaundice. 

(2)  The  toxic  form.  The  poisons  of  yellow  fever,  malaria,  typhoid, 
epideniic  jaundice,  and  pyaemia ;  snake  virus,  as  well  as  chloroform,  ether, 
phosphorus,  and  mercury,  act  by  causing  increased  destruction  of  the  red 
blood-corpuscles.  More  blood-pigment  is  set  free  than  can  be  disposed  of 
by  liver,  spleen,  or  kidneys,  and  the  bilirubin  (transformed  hiemoglobin) 
is  deposited  in  the  tissues.  The  symptoms  of  ha'niatogenous  jaundice  are 
not  nearly  so  striking  as  in  the  cLstructive  variety.  The  skin  has  in  many 
cases  only  a  light  lemon  tint.  In  the  severer  forms,  as  in  acute  yellow 
atrophy,  the  color  may  be  more  intense,  but  in  malariii  and  pernicious 
iin.x'inia  the  tint  is  usually  light.  In  these  mild  cases  the  urine  may  con- 
tain little  or  no  bile-pigment,  but  the  urinary  pignients  are  considerably 
increased.  The  stools  are  not  clay-colored  and  may  in  some  insttinces  be 
very  dark.  In  the  toxic  forms  of  this  variety  the  cerebral  symptoms  are 
marked  and  there  may  be  active  delirium,  coma,  or  convulsions. 


2.  Icterus  Neonatorum. — Xe\v-l)orn  infants  arc  liable  to  jaundice,  which 
in  some  instances  rapidly  proves  fatal.  A  mild  and  a  severe  form  may  be 
recognized. 

The  mild  idenis  of  the  new-born  is  a  common  disease  in  foundling 
hospitals  and  is  not  very  infrequent  in  private  jiractiee.  The  discoloration 
appears  early,  usually  on  the  first  or  second  day,  and  is  of  moderate  inten- 
Hity.  The  urine  may  be  bile-stained  and  the  fajces  colorless.  The  nutri- 
tion of  the  child  is  not  seriously  disturbed,  and  in  the  majority  of  cases 
the  janndice  disappears  within  two  weeks.  It  is  supposed  that  the  dimin- 
ished pressure  in  the  portal  vessels,  following  the  severance  of  the  placental 
oircuhition,  allows  absorption  from  the  bile  capillaries,  in  which  the  tension 
is  greater.  Possibly  too,  as  Quincke  suggests,  the  ductus  venosus  may 
remain  open,  allowing  some  of  the  portal  blood  containing  l)ile  to  flow 
into  tl'o  systemic  circulati  n.  On  the  other  hand,  it  is  held  tluit  the  jaun- 
dice Ks  hannatogenous  and  due  to  tlie  destruction  of  large  numbers  of  red 
bli'Hl-corpuscles  during  the  first  few  days  after  birth. 

The  severe  form  of  icterus  in  the  new-born  may  depend  upon  (a)  con- 
genital al)sence  of  the  comn  on  or  hepatic  duct  of  which  there  are  sev- 
eral instances  on  record;  (b)  congenital  syphilitic  hepatitis;  and  (r)  sep- 
tic p(  isoning,  associated  with  phlebitis  of  the  uml)ilical  vein.  This  is  a 
severe  and  fatal  form,  in  which  also  haBmorrhago  from  the  cord  may 


occur. 


28 


I  'v. 


426 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tWB  1 1 


Occasionally  janmlice  sets  in  and  persists  for  many  weeks,  or  even 
months,  without  interfering  seriously  with  the  nutrition  of  the  child. 

3.  Acute  Yellow  Atrophy  of  the  Liver ;  Malignant  Jaundice  5  Icterus 
Gravis. 

Definition. — .Jaundice  associated  with  marked  cerebral  symj)tonis 
and  characterized  anatomically  by  extensive  necrosis  of  the  liver-cells  with 
reduction  in  volume  of  the  organ. 

Etiology. — This  is  a  rare  disease.  In  a  somewhat  varied  post-mor- 
tem and  clinical  experience  no  instance  has  fallen  under  my  observation. 
On  the  other  hand,  a  physician  may  see  several  cases  within  a  few  years, 
or  even  within  a  few  months,  as  happened  to  Riess,  who  saw  five  cases 
within  three  months  at  the  Charite,  in  Berlin.  1'he  disease  seems  to 
be  rare  in  this  country.  No  case  is  reported  in  the  Transactions  of  the 
Pathological  Societies  of  New  York  (Vols.  I  to  III)  or  of  I*hiladeli)hia 
(Vols.  I  to  AIII).  The  disease  is  more  comnu)n  in  women  than  in  men. 
Of  the  100  cases  collected  by  Legg,  09  were  in  females ;  and  of  Thierl'el- 
der's  143  cases,  88  were  in  women.  There  is  a  remarkable  association 
between  the  disease  and  pregnancy,  which  was  present  in  25  of  the  (il» 
women  in  Legg's  statistics,  and  in  33  of  the  88  women  in  Thierfelder's 
collection.  It  is  most  common  between  the  ages  of  twenty  and  thirtv,  but 
is  occasionally  seen  in  young  children.  It  has  followed  fright  or  profound 
mental  emotion.  Though  the  symptoms  produced  by  phosphorus  })oison- 
ing  closely  sinndate  those  of  acute  yellow  atrophy,  the  two  conditions  are 
not  identical. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size,  looks  thin 
and  flattened,  and  sojnetimes  does  not  reach  more  than  one  half  or  even 
one  third  of  its  normal  weight.  It  is  flabl)y  and  the  capsule  is  wrinkled. 
On  section  the  color  is  of  a  yellowisli  brown,  yellowish  red,  or  mottled, 
and  the  outlines  of  the  lobules  are  indistinct.  The  yellow  and  dark-nd 
portions  represent  different  stages  of  the  same  process — the  yellow  an  ear- 
lier, the  red  a  more  advanced  stage.  The  organ  may  cut  with  eonsideralilc 
firmness.  Microscopically  the  liver-cells  are  seen  in  all  stages  of  necrosis, 
and  in  spots  a]ipear  to  have  undergone  comjilete  destruction,  leaving  a 
fatty,  granuhir  dihris  with  pigment  grains  and  crystals  of  leuciu  and  tyro- 
sin.  The  interlobular  tissue  may  be  normal,  but  in  many  cases  tlicre  is  a 
marked  proliferation  of  small  cells,  whicli  was  present  in  9  of  the  VI  cases 
examined  by  Kiess.  Micro-organisms  have  been  noted  by  several  observ- 
ers.   The  bile-ii nets  and  gall-bladder  are  empty. 

The  other  organs  show  extensive  bile  staining,  and  there  are  numerous 
haemorrhages.  The  kidneys  may  show  marked  grajiular  degeneration  ( f 
the  epithelium,  ami  usually  there  is  fatty  degeneration  of  the  heart.  In  n 
majority  of  the  cases  the  spleen  is  enlarged. 

Symptoma. — In  the  initial  stage  there  is  a  gastro-duodcnal  catanli, 
and  at  first  the  jaundice  is  thought  to  be  of  a  simple  nature.     In  some  in- 


AFFKCTIONS  OF  THE  BLOOD-VESSELS  OP  THE  LIVER.        427 

stanfos  this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then 
sivire  symptoms  set  in — headache,  delirium,  trembling  of  the  muscles,  and, 
in  some  instances,  convulsions.  Vomiting  is  a  constant  symptom,  and 
l)lo(i(l  may  be  brought  np.  Ilasmorrhages  occur  into  the  skin  or  from  the 
niiiious  surfaces;  in  pregnant  women  abortion  may  occur.  With  the  de- 
velopment of  the  head  symptoms  tlie  jaundice  usually  increases.  Coma  sets 
in  a!!'l  gnidiially  deepens  until  death.  The  body  temperature  is  variable', 
ill  a  nuijority  of  the  cases  the  disease  runs  an  afebrile  course,  though  some- 
times just  before  death  there  is  an  elevation.  In  some  instances,  however, 
tlicre  has  lx>en  marked  pyrexia.  The  pulse  is  usually  rapid,  the  tongue 
(■(»at(Hl  and  dry,  atul  tlie  patient  is  in  a  "  typhoid  state." 

Tliu  urine  is  bile-stained  and  often  contains  tube-casts.  Leucin  and 
tyrosin  are  constantly  present ;  the  former  as  rounded  disks,  the  latter  in 
noedlo-shaped  crystals,  arranged  either  in  bundles  or  in  groups.  The 
tvrosin  may  sometimes  be  seen  in  the  urine  sediment,  but  it  is  best  first  to 
evaporate  a  few  drops  of  urine  on  a  cover-glass.  In  the  majority  of  cases 
no  bile  enters  the  intestines,  and  the  stools  are  clay-colored.  The  dis- 
ease is  almost  invariably  fatal.  In  a  few  instances  recovery  has  been 
nciti'd.  I  saw  in  Leube's  clinic,  at  Wurzburg,  a  case  which  was  convales- 
cent. 

Diagnosis. — Jaundice  with  delirium,  diminution  of  the  liver  volume, 
(leliruini,  and  the  presence  of  leuoin  and  tyrosin  in  the  urine,  form  a  char- 
acteristic and  unmistakable  group  of  symptoms. 

It  is  not  to  bo  forgotten  that  any  severe  jaundice  may  be  associattid 
Avitli  intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of 
liy[H'itroiiliic  cirrhosis  are  almost  identical,  but  the  enlargement  of  the 
liver,  the  more  constant  occurrence  of  fever,  and  the  absence  of  leucin 
and  tyrosin  are  distinguishing  signs.  Phosphorus  poisoning  may  closely 
simulate  acute  yellow  atrophy,  particularly  in  the  hicmorrhages,  jaundice, 
ami  the  diminution  in  the  liver  volume,  but  the  gastric  symptoms  are 
usually  more  marked,  and  leucin  and  tyrosin  are  stated  not  to  occur  in  the 
urine. 

No  known  remedies  have  anv  influence  on  the  course  of  the  disease. 


m^ 


II.  AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 


(1)  AnaBinia. — On  the  jiost-mortcm  table,  when  the  liver  looks  ana?mic, 
as  ill  the  fatty  or  amyloid  organ,  the  blood-vessels,  which  during  life  were 
prohalily  Avell  filled,  can  be  readily  injected.  There  are  no  symptoms  in- 
(liealiv(>  of  this  coiulition. 

(.')  HyperaBmla. — This  occurs  in  two  forms,  (n)  Active  hyperfrmia. 
After  each  meal  the  rapid  absoq>tion  by  the  portal  vessels  induces  transient 
confrestlon  of  the  organ,  which,  however,  is  entirely  physiological ;  but  it 
is  quite  possible  that  in  persona  who  persistently  e«t  and  drink  too  much 


im 


DISEASES  OF  TnE  DIGESTIVE  SYSTEM. 


this  active  hyperaemia  may  lead  to  fimctional  disturbunco  or,  iu  the  cuso 
of  drinking  too  freely  of  alcohol,  to  organic  change. 

The  symptoms  of  active  hyperemia  are  indefinite.  Possil)ly  the  sonse 
of  distress  or  fulness  in  the  right  hypoehondrium,  so  often  mentioned  hy 
dyspeptics  and  by  those  who  eat  and  drink  freely,  may  bo  due  to  this 
cause.  There  are  probably  diurnal  variations  in  the  volume  of  the  liver. 
In  cirrhosis  with  enlargement  the  rapid  reduction  in  volume  after  a  copi- 
ous haemorrhage  indicates  the  important  part  which  hyperaimia  ])hiys  oven 
in  organic  troubles.  It  is  stated  that  supjiression  of  the  menses  or  sup- 
pression of  a  ha?morrhoidal  flow  is  followed  by  hypertemia  of  the  liver. 
Andrew  II.  Smith  has  described  a  case  of  periodical  enlargement  of  the 
liver. 

{b)  Passive  Congestion. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  eiTerent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart 
at  once  affects  these  veins. 

In  chronic  valvular  disease,  in  emidiysema,  cirrhosis  of  the  lung,  and 
in  intrathoracic  tumors  mechanical  congestion  occurs  and  finally  leads  to 
very  definite  changes.  The  liver  is  eidarged,  firm,  and  of  a  deep-red  color ; 
the  liepatic  vessels  are  greatly  engorged,  particularly  the  central  vein  in 
each  lobule  and  its  adjacent  capillaries.  On  section  the  organ  i)reseiits  a 
peculiar  mottled  appearance,  owing  to  the  deeply  congested  hejiatic  and 
the  anfemic  portal  territories;  lience  the  term  nutmeg  which  has  been 
given  to  this  condition.  Gradually  the  distention  of  the  central  ca])ilhines 
reaches  such  a  grade  that  atrophy  of  the  intervening  liver-cells  is  induicd. 
Brown  pigment  is  deposited  about  the  centre  of  the  lobules  and  the  con- 
nective tissue  is  greatly  increased.  In  this  cyanotic  induration  or  cardiac 
liver  the  organ  is  large  in  the  early  stage,  but  later  it  may  become  con- 
tracted. Occasionally  in  this  form  the  connective  tissue  is  increased  about 
the  lobules  as  well,  but  the  process  usually  extends  from  the  sublubular  and 
central  veins. 

Tlie  symptoms  of  this  form  are  not  always  to  be  separated  from  those 
of  the  associated  conditions.  (Jastro-intestinal  catarrh  is  usually  present 
and  ha^niatemesis  may  occur.  The  portal  obstruction  in  advanced  cases 
leads  to  ascites,  which  may  precede  the  development  of  general  dropsy. 
There  is  often  slight  jaundice,  the  stools  may  be  clay-colored,  and  the 
urine  contains  bile-pigment. 

On  exr.  lination  the  organ  is  found  to  be  increased  in  size.  It  may  be 
a  full  hand  s-breadth  below  the  costal  margin  and  tender  on  prci^sure.  It 
is  in  this  condition  ])articularly  that  we  meet  with  ])ulsation  of  the  liver. 
We  must  distinguish  the  c<mimunicattHl  throbbing  of  the  heart,  which  is 
very  common,  from  the  heaving,  diffuse  impulse  due  to  regurgitation  into 
the  hepatic  veins,  in  M'hich,  when  one  hand  is  upon  the  ensiform  cartilage 
and  the  other  upon  the  right  side  at  the  margin  of  the  ribs,  the  whulo 
liver  can  be  felt  to  dilate  with  each  impulse. 


AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 


429 


The  indications  for  treatment  in  piissive  hyperaemia  aro  to  restore  the 
Imhiucc  of  the  circulation  and  to  iinload  the  engorged  portal  vessels.  In 
("11S03  of  inteuse  hyperaemia  eighteen  or  twenty  ounces  of  blood  may  be 
directly  asi)irated  from  the  liver,  as  advised  by  George  llarley  and  j)rac- 
tirfod  by  many  Anglo-Indian  physicians.  (lood  results  sometimes  follow 
this  hepato-phlebotomy.  The  prompt  relief  and  marked  reduction  in  the 
VdliiMie  of  the  organ  Avhich  follow  an  attack  of  haematemesis  or  bleeding 
from  piles  suggests  this  practice.  Salts  administered  by  Matthew  Hay's 
method  deplete  the  portal  system  freely  and  thoroughly.  As  a  rule,  the 
tmitmont  must  be  that  of  the  condition  with  -which  it  is  associated. 

(;;)  Diseases  of  the  Portal  Vein. — {a)  Thrombosis;  Adhesive  Pi/le- 
phlc/n/is. — Coagulation  of  blood  in  the  portal  vein  is  rarely  seen  exx'ept  in 
cirrhosis.  Exceptional  causes  are  invasion  of  the  branches  by  cancer,  pro- 
liferative peritonitis  involving  the  gastro-hejiati(;  omentum,  and  perfora- 
tion (if  the  vein  by  gall-stones.  In  rare  instances  a  complete  collateral  cir- 
culation is  established,  the  thrombus  xindergoes  the  usual  changes,  and 
ultimately  the  vein  is  represented  by  a  fibrous  cord,  a  condition  which  has 
liccii  called  pylephlebitis  adhesira.  In  a  case  of  this  kind  which  I  dissect- 
ed the  portal  vein  was  re[)reseutcd  by  a  narrow  fibrous  cord  ;  the  coUateral 
circulation,  which  must  have  been  completely  established  for  years,  ulti- 
mately failed,  ascites  and  hajmatemesis  supervened  and  rapidly  proved 
fatal.*  The  diagnosis  of  obstruction  of  the  portal  vein  can  rarely  be 
made.  A  suggestive  symptom,  however,  is  a  sudden  onset  of  the  most 
intense  engorgement  of  the  branches  of  the  portal  system. 

luuboli  in  the  branches  of  the  portal  vein  do  not,  as  a  rule,  produce 
infarction,  for  blood  reaches  the  lobular  capillary  plexus,  as  shown  by 
Cdhnlieini  and  Litten,  through  the  free  anastomosis  M'ith  the  hei)atic 
iirtci  y.  In  rare  instances,  however,  a  condition  resembling  infarction  does 
(iccur,  sometimes  in  snudl  areas,  at  others  in  quite  extensive  territories. 
Septic  emboli,  on  the  other  hand,  may  induce  suppuration. 

(//)  Suppurative  pylephlebitis  will  bo  considered  in  iiie  section  on 
ahsoess. 

(4)  Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation 
occurs  in  cases  of  chronic  enlargement  of  the  right  heart,  from  whatever 
eauso  produced.  Emboli  occasionally  pass  from  the  right  auricle  into  the 
he[)atic  veins.  A  rare  and  unusual  event  is  stenosis  of  the  oriRcee  of  the 
hepatic  veins,  which  I  met  in  a  case  of  fibroid  obliteration  of  the  inferior 
vena  cava  and  was  associated  with  a  greatly  enlarged  and  inilurated  liver.f 

(•'')  Hepatic  Artery. — Eidargement  of  this  vessel  is  seen  in  cases  of 
cirrhosis  of  the  liver.  It  may  bo  the  seat  of  extensive  sclerosis.  Aneurism 
of  the  lie])atic  artery  is  rare,  but  instances  are  on  record,  and  will  be  ro- 
forrod  to  in  the  section  on  arteries. 


*  Journal  of  Anatomy  and  Pliysiology,  vol.  xvil. 
f  Ibid.,  vol.  xvi. 


430 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


III.  DISEASES  OF  THE   BILE-PASSAGES. 


n  \ 


^^*3 


'  t 


Catarrhal  Jaukdice. 

Definition. — Jaundice  due  to  swelling  and  obstruction  of  the  terminal 
portion  of  the  common  duct. 

Etiology. — General  catarrhal  inflammation  of  the  bile-ducts  is  usu- 
ally associated  with  gall-stones.  The  catarrhal  ])r(icess  now  under  consid- 
eration is  i)robably  always  an  extension  of  a  gastro-duodenal  catarrh,  and 
the  process  is  most  intense  in  the  pars  intcstinalis  of  the  duct,  which 
projects  into  the  duodenum.  The  mucous  membrane  is  swollen,  and  a 
j)lug  of  inspissated  mucus  fills  the  diverticulum  of  Vater,  arid  the  narrower 
portion  just  at  the  orifice,  completely  obstructing  the  outflow  of  bile.  It 
is  not  known  how  wide-spread  this  catarrh  is  in  the  bile-passagos,  and 
whether  it  really  passes  up  the  ducts.  It  would,  of  course,  be  possible  to 
have  a  catarrh  of  the  finer  ducts  within  the  liver,  which  some  French  writ- 
ers think  may  initiate  the  attack,  but  the  evidence  of  this  is  not  stronj;, 
and  it  seems  more  likely  that  the  terminal  portion  of  the  duct  is  always 
first  involved.  In  the  only  instance  which  I  have  had  an  opportunity  to 
examine  post  mortem  the  orifice  was  plugged  with  inspissated  mucus,  the 
common  and  hepatic  ducts  were  slightly  distended  and  contained  a  bile- 
tinged,  not  a  clear,  mucus,  and  there  were  no  observable  changes  in  tlie 
mucosa  of  the  ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  following  causes : 
(1)  Duodenal  catarrh,  in  whatever  way  produced,  most  commonly  fol- 
lowing an  attack  of  indigestion.  It  is  most  frequently  met  with  in  young 
persons,  but  may  occur  at  any  age,  and  may  follow  not  only  errors  in  diet, 
but  also  cold,  exposure,  and  malaria,  as  well  as  the  conditions  associated 
with  portal  obstruction,  chronic  heart-disease,  aiul  Bright's  disease,  {'i) 
Emotional  disturbances  may  be  followed  by  jaundice,  ■which  is  believed  to 
be  due  to  catarrhal  swelling.  Cases  of  this  kind  are  rare  and  the  anatom- 
ical condition  is  unknown.  (3)  Simi)le  or  catarrhal  jaundice  may  occur 
in  epidemic  form.  (4)  Catarrhal  jaundice  is  occasionally  seen  in  the  in- 
fectious fevers,  such  as  pneumonia,  and  typhoid  fever. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  tlio 
patient's  friends  may  first  notice  the  yellow  tint,  or  the  patient  himself 
may  observe  it  in  the  looking-glass.  In  other  instances  there  are  dysjiep- 
tic  symptoms  and  uneasy  sensations  in  the  hepatic  region  or  pains  in  the 
back  and  limbs.  In  the  epidemic  form,  the  onset  may  bo  more  severe, 
with  headache,  chill,  and  vomiting.  Fever  is  rarely  present,  though  the 
temperature  may  reach  101°,  sometimes  102°.  All  the  signs  of  obstruct- 
ive jaundice  already  mentioned  are  present,  the  stools  are  clay-colored, 
and  the  urine  contains  bile-pigment.  The  jaundice  has  a  bright-yellow 
tint ;  the  greenish,  bronzed  color  is  never  seen  in  the  simple  form.  Tlio 
pulse  may  bo  normal,  but  occasionally  it  is  remarkably  slow,  and  may  fall 


''^^k^' 


DISEASES  OF  THE  BILE-PASS  AGES. 


431 


t(i  forty  or  thirty  beats  in  tho  minute.  Tlie  livor  may  bo  normal  in  size, 
but  is  usually  slightly  enlarged,  and  the  edge  can  be  felt  below  the  costal 
iiKirgin.  Occasionally  the  enlargement  is  more  marked.  Tho  duration 
of  the  disease  is  from  four  to  eight  weeks.  There  are  mild  cases  in  which 
llu'  jaundice  disapj)ears  within  two  weeks ;  on  the  other  hand,  it  may  per- 
sist for  three  months.  The  stools  should  be  carefully  watched,  for  they 
give  tho  first  intimation  of  removal  of  the  obstructi(;n. 

The  diaynofiis  is  rarely  ditlicult.  The  onset  in  young,  comparatively 
healthy  persons,  the  moderate  grade  of  icterus,  tho  absence  of  emaciation 
or  of  evidences  of  cirrhosis  or  cancer,  usually  make  tho  diagnosis  easy. 
I'lises  which  i)ersist  for  two  and  three  months  cause  uneasiness,  as  the  sus- 
picion is  aroused  that  it  may  bo  more  than  simple  catarrh.  The  absence 
of  ))ain,  the  negative  character  of  the  physical  examination,  and  the  main- 
tonaiicc  of  the  general  nutrition  are  the  j)oints  in  favor  of  simple  jaundice. 
There  are  instances  in  which  time  alone  can  determine  the  true  nature  of 
the  case. 

Treatment. — As  a  rule  tho  patient  can  keep  on  his  feet  from  the 
outset.  Measures  should  be  used  to  allay  the  gastric  catarrh,  if  it  is  pres- 
ent. A  dose  of  calomel  may  be  given,  and  the  bowels  kept  open  subse- 
quently by  salines.  The  patient  should  not  bo  violently  purged.  Bismuth 
and  bicarbonate  of  soda  may  be  given,  and  the  i)atient  should  drink  freely 
of  tiie  alkaline  mineral  waters,  of  which  Vichy  is  tlie  best.  Irrigation  of 
tho  large  bowel  with  cold  water  may  be  practised.  The  cold  is  supposed 
to  excite  peristalsis  of  the  gall-bladder  and  ducts,  and  thus  aid  in  the  ex- 
pulsion of  the  mucus.  This  practice  has  been  followed  in  my  wards  for 
several  years,  but  I  cannot  speak  warmly  of  the  results. 


Cholelithiasis  {Gall- Stones). 

Calculi  are  formed  in  the  gall-bladder.  Evidence  is  wanting  to  show 
that  they  are  formed  within  the  liver  ducts,  except  in  very  rare  instances. 
They  may  be  single,  in  which  case  the  stone  is  usually  ovoid  and  may  at- 
tain a  very  large  size.  Instances  are  on  record  of  gall-stones  measuring 
more  than  five  inches  in  length.  They  may  be  extremely  numerous,  rang- 
ing from  a  score  to  several  hundreds  or  even  several  thousaiuls,  in  which 
case  the  stones  are  very  small.  When  moderately  numerous,  they  show 
signs  of  mutual  pressure  and  have  a  polygonal  form,  with  smooth  facets ; 
occasionally,  however,  five  or  six  gall-stones  of  medium  size  are  met  with 
in  the  bladder  which  are  round  or  ovoid  and  without  facets.  They  aro 
sometimes  mulberry-shaped  and  very  dark,  consisting  largely  of  bile-pig- 
ment. Again  there  are  small,  black  calculi,  rough  and  irregular  in  shape, 
and  varying  in  size  from  sand  to  small  shot.  These  are  sometimes  known 
as  {jall-sand.  On  section,  a  calculus  contains  a  nucleus,  which  consists 
of  l)ile-pigment,  rarely  a  foreign  body.  The  greater  portion  of  tho  stone 
is  made  up  of  cholesterin,  which  may  form  the  entire  calculus  and  is  ar- 


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432 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


ranged  in  concentric  luminjc  sliowing  also  rudiuting  lines.  Salts  of  linic 
uiul  magncaiu,  bile  ac-ids,  fatty  acids,  and  traces  of  iroji  and  copper  are  also 
found  in  them.  A  majority  of  gall-stones  consist  of  from  seventy  to 
eighty  per  cent  of  cholesterin,  in  either  the  amorphous  or  the  crystaniiu- 
form.  As  above  stated,  it  is  sometinuis  pure,  but  more  commonly  it  is 
mixed  with  the  bile-pigment.  The  outer  layer  of  the  stoiu?  is  usually 
harder  and  brownish  in  color,  and  contains  a  larger  proportion  of  linif 
salts. 

The  mode  of  formation  is  by  no  means  clear.  A  defect  in  the  sodium 
salts  seems  to  favor  the  precipitation  of  the  cholesterin  and  of  the  bilf- 
pigment.  The  lime  exists  in  such  slight  quantities  in  the  bile  that  it  is 
l)robably  a  pathological  product  of  the  mucous  glands  of  the  gall-bladdir. 
When  the  bile  is  retained  long  in  the  gall-bhulder  its  concentration  favors 
the  deposition. 

Etiology.— Three  fourths  of  the  cases  of  gall-stones  occur  in  women, 
most  frequently  between  the  ages  of  thirty  and  sixty.  Sedentary  occupa- 
tions, particularly  when  condjincd  with  overindulgence  in  eating,  seem 
important  factors.  The  subjects  are  often  stout,  and  usually  very  fond  of 
starchy  and  saccharine  food.  The  conditions  which  induce  lithic  acitl  also 
favor  the  development  of  gall-stones.  Tight-lacing  is  regarded  by  Marchaiul 
us  an  important  factor  in  retarding  the  flow  of  the  bile.  Pregnancy  has  a 
similar  influence.  Naunyn  states  that  ninety  per  cent  of  women  with 
gall-stones  have  borne  children.  Constipation  and  dejjressing  mental  in- 
fluences have  been  regarded  as  favoring  circumstances. 

Symptoms. — In  a  majority  of  the  cases,  gall-stones  cause  no  symp- 
toms. The  gall-bladder  will  tolerate  the  presence  of  largo  numbers  for  an 
indefinite  period  of  time,  and  jjost-mortem  examinations  show  that  liny 
arc  present  in  twenty-five  per  cent  of  all  women  over  sixty  years  of  ago 
(Naunyii). 

The  effects  of  gall-stones  may  be  considered  under  the  following  head- 
ings :  The  symptoms  produced  by  the  passage  of  a  stone  through  the 
ducts — biliary  colic  ;  the  effects  of  permanent  plugging  of  the  duct ;  and 
the  more  remote  effects,  due  to  ulceration  and  perforation,  and  the  eslal)- 
lishment  of  fistulas. 

1.  Biliary  Colic. — It  would  appear  that  gall-stones  may  become  en- 
gaged in  the  cystic  or  the  common  duct  Avithout  producing  jiaiii  or 
severe  symi)toms.  More  commonly  the  passage  of  a  stone  excites  llio 
violent  symptoms  known  as  biliary  colic.  The  attack  sets  in  abmiitly 
with  agonizing  pain  in  the  right  hypochondriac  region,  which  radiates  to 
the  shoulder,  or  is  very  intense  in  the  epigastric  and  in  the  lower  thoracit^ 
regions.  It  is  often  associated  with  a  rigor  and  a  rise  in  temperature  from 
102°  to  103°.  The  pain  is  usually  so  intense  that  the  patient  rolls  about  in 
agony.  There  are  vomiting,  profuse  sweating,  and  great  depression  of  the 
circulation.  There  may  be  marked  tenderness  in  the  region  of  the  liver, 
which  may  become  enlarged.     In  a  largo  number  of  the  cases  jaundice 


DISEASES  OF  THE  BILE-PASSAGES. 


433 


develops,  but  it  is  not  a  necessary  symptom.  Of  course  it  does  not  occur 
liming  the  passage  of  the  stone  through  the  cystic  duct,  hut  only  when  it 
hiMomo?  lodged  in  the  common  duct.  Probably  the  intense  pain  is  due  to 
the  slow  progress  in  the  (lystic  duct,  in  which  the  stone  takes  a  roUiry 
course  owing  to  the  arrangement  of  the  lleistcrian  valve. 

The  attack  varies  in  duration.  It  nuiy  last  for  a  few  hours,  several 
(lavs,  or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the 
oritice  of  the  common  duct,  the  jaundice  becomes  intense ;  much  nu)re 
(loininonly  it  is  a  slight,  transient  icterus.  The  attack  of  colic  may  be  re- 
jH'iitcil  at  intervals  for  some  tinu",  but  llnally  the  stone  passes  ami  the 
symptoms  rapidly  disappear. 

Occasionally  accidents  occur,  sudi  as  rupture  of  the  duct  with  fatal 
peritonitis.  Syncope,  owing  to  the  intensity  of  the  pain,  nuiy  follow  aiul 
1ms  been  known  to  i)rove  fatal,  aiul  epilepsy  has  been  seen.  These  are, 
liowevor,  rare  events.  Palpitation  and  distress  about  the  heart  may  be 
prosetit,  and  occasionally  a  mitral  murmur  develops  during  the  paroxysm ; 
but  the  cardiac  conditions  described  by  some  writers  as  coming  on  acutely 
ill  liiliary  colic  are  ])robably  pre-existeut  in  these  patients. 

The  (li<if/7insix  of  acute  hepatic  colic  is  generally  easy.  The  i)ain  is  in 
till'  upper  abdominal  aiul  thoracic  regions,  whereas  the  i)ain  in  nei)hritic 
oolic  is  in  the  lower  al^domen.  A  chill,  with  fever,  is  much  more  frequent 
in  biliary  colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be 
oonfounded.  A  history  of  previous  attacks  is  an  important  guide,  and  the 
(H'lurrence  of  jaundice,  however  slight,  determines  the  diagnosis.  To  look 
for  the  gall-stones,  the  stools  should  be  thoroughly  mixed  with  water  and 
carefully  liltered  through  a  narrow-meshed  sieve. 

^.  Chronic  Obstruction  of  the  Ducts  by  Gall-stones.— 0/  fJic  Cystic 
Duel. — The  elfects  nuiy  be  thus  enumerated  : 

Dilatation  of  the  gall-bladder — hydrops  vesica;  fellcae.  This  occurs 
much  more  frequently  than  in  obstruction  of  the  common  duct.  The 
fluid  is  almost  invariably  of  a  thin  mucoid  nature,  thrtugh  it  may  bo 
mixed  with  bile.  In  all  cases,  when  the  obstruction  persists,  the  bile  is 
loplacod  by  a  clear  fluid.  This  is  an  important  point  in  diagnosis,  par- 
ticularly as  a  dropsical  gall-bladder  may  form  a  very  large  tumor.  The 
reaction  is  not  always  constant.  It  is  either  alkaline  or  neutral ;  the  con- 
sistence is  thin  and  mucoid.  Albumen  is  usually  present.  The  organ 
may  roach  an  enormous  size,  and  in  one  instance  Tait  found  it  occupying 
the  greater  part  of  the  abdomen.  In  such  cases,  as  is  not  unnatural,  it 
lias  l)een-  mistaken  for  an  ovarian  tumor.  In  one  of  my  cases  it  was 
iidlierent  to  the  broad  ligament,  and  had  been  mistaken  for  a  cyst  of  the 
left  (ivarv.  The  dilated  gall-bladder  can  usually  be  felt  below  the  edge  of 
the  liver,  and  in  many  instances  it  has  a  characteristic  outline  like  a 
^'iHird.  It  usually  projects  directly  downward,  rarely  to  one  side  or  the 
other,  though  occasionally  toward  the  middle  line.  It  may  reach  below 
♦^^he  navel,  and  in  persons  with  thin  walls  the  outline  can  bo  accurately 


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434 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


dofhied.  It  is  to  ho  rorneinln'rod  tliiit  distention  of  tljo  gidl-bladdcr  may 
occur  without  jiiundice ;  indeed,  the  givutest  enlargement  has  been  met 
with  in  Kuch  cases. 

Jn  obstruction  of  the  coninion  duct  the  gull-bhidder  is  not  necessurilv 
greatly  eidarged.  Occasionally  it  may  be  much  distended  Avithoul  the 
occurrence  of  any  tumor  which  can  be  felt  during  life.  In  one  case 
(operation)  eigliteen  ounces  were  removed  from  a  gall-bladik-r,  the  ed^c 
of  which  barely  ])rojectcd  below  the  margin  of  Hit'  right  Inbo. 

Acute  phlegmonous  cystitis.  'J'his  is  a  rare  event.  Only  seven  in- 
stances of  it  have  been  collected  in  the  enornu)UF  statistics  of  Courvoi- 
sier.  lu  a  case  which  I  have  reported  the  patient  died  on  the  iifth  day 
with  symptoms  of  the  most  inten.sti  ])rostration,  fever,  and  abdominal  pain. 
Perforation  may  occur  with  fatal  jjcritonitis. 

Suppurative  cholecystitis,  empyeimi  of  the  gall-bladder,  is  mueli  more 
common,  and  in  the  great  nuijority  of  cases  is  associated  with  gall-stones 
— 41  in  55  cases  (Courvoisier).  There  may  be  enormous  dilatation,  and 
oyer  a  litre  of  pus  has  been  found.  Perforation  aiul  the  formation  (>[ 
abscesses  in  the  neighborhood  arc  not  uncommon. 

Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the  pre- 
vious condition.  There  are  two  separate  forms,  incrustation  of  the  mucosa 
with  lime  salts  and  the  true  infiltration  of  the  wall  with  lime,  the  so-called 
ossification.  A  renuirkal)le  examj)le  of  tin  iter  sent  to  me  by  (i roves, 
of  Carp,  is  now  in  the  ^IcOill  Medical  ^luseum. 

Atrojjliy  of  the  gall-l)ladder.  This  is  by  no  means  uncommon.  The 
organ  shrinks  into  a  small  fibroid  nuiss,  not  larger,  perhajis,  than  a  good- 
sized  pea  <»r  walnut,  or  even  has  the  form  of  a  narrow  fibrous  string; 
more  commojdy  the  gall-bladder  tightly  embraces  a  .stone.  This  condition 
is  usually  preceded  by  hydrops  of  the  bladder.  In  un  interesting  case  of 
the  kind,  the  patient,  nearly  twenty  years  before,  liad  had  an  obseiu'e 
abdominal  tumor,  which  caused  so  much  difference  of  opinion  nmong  his 
physicians  that  instruction  was  left  in  his  will  that  the  body  should  he 
examined.  The  gall-bladder  was  entirely  obliterated  and  closely  encircled 
a  large  gall-stone. 

Occasionally  the  gall-bladder  presents  diverticula,  which  may  be  cut 
off  from  the  main  i)orti<)n,  and  usually  contain  calculi. 

Obstrtiction  of  the  Common  Duct. 

The  stone  usually  lies  at  the  termination  of  the  duct,  just  at  the  orifice 
of  the  papilla,  within  a  sort  of  pouch  formed  by  the  diverticulum  of  Vater. 
Examined  from  the  duodenum,  it  seems  to  be  directly  beneath  the  niu- 
eosa.  It  is  as  a  rule  single;  but  two  and,  in  some  instances,  a  series  of 
stones  may  occupy  the  entire  duct.  The  effect  of  the  obstruction  is  dila- 
tation, with  catarrhal  or  suppurative  cholangitis. 

(1)  Obstruction,  with  catarrhal  cholangitis. 

The  common  duct  may  be  as  large  as  the  thumb ;  the  hepatic  duct  and 
its  branches  through  the  liver  arc  greatly  dilated,  and  the  distention  may 


DISEASES  OF  THE  BILE- PASSAGES. 


435 


even  I)o  apparent  bonciith  the  liver  (•u|)8ul('.  (Irciit  cnliirfifonu'iit  of  the 
(Mll-l)lii<ltlt'r  is  rare.  The  mucous  mt'iiibniiie  of  the  ducts  may  be  smooth 
mill  dear,  and  the  contents  a  thin,  colorless  mucua. 

Catarrhal  cholangitis  with  pill-stones  is  characterized  by  a  spet  ial 
svmiitoni  f,'roup:  (ii)  A;;ue-like  parox\ snis,  chills,  fever,  and  sweating; 
(//)  jaundice  of  varying  intensity,  which  persists  fur  months  or  even  years, 
ami  dee])ens  after  each  paroxysm  ;  (r)  at  the  time  of  the  paroxysms,  pains 
in  the  region  of  the  liver  with  gastrii'  disturbance.  These  symptoms  nuiy 
eniitii\ue  on  and  olT  I'or  three  or  four  years,  without  tlu^  ilevelopuient  of 
suppurative  cholangitis.  In  one  of  my  eases  the  jaundice  and  recurring 
hcitatic  intermittent  fever  existed  from  July,  18T!),  until  August,  Ihb*^ ; 
the  patient  recovered  and  still  lives.  The  condition  has  lasted  from  eight 
niduths  to  tlwee  years.  The  rigors  are  of  intense  severity,  and  the  U  ni- 
perature  rises  to  10;3°  or  105°.  The  chills  nuiy  recur  ilaily  for  weeks,  and 
pit'si'iit  a  tertian  or  quartan  type,  so  that  they  often  are  mistaken  for 
malaria,  with  which,  however,  they  have  no  connection.  1'lie  jaundice 
is  variable,  and  deepens  after  each  paroxysm.  Pain,  which  is  sometimes 
intense  aiul  colicky,  does  not  always  occur.  There  may  be  nuirked  vomit- 
ini;  and  nausea.  As  a  rule  there  is  no  ])rogressive  deterioration  of  health. 
In  the  intervals  between  the  attacks  the  temperature  is  normal. 

The  clinical  history  and  the  post-mortem  exanumitions  in  my  eases  * 
have  shown  conclusively  that  this  condition  may  persist  for  years  without 
a  trace  of  suppuration  within  the  ducts. 

The  luiture  of  the  hepatic  intermittent  fever  is  iu)t  settled.  Charcot 
holds  that  it  is  due  to  the  production  of  a  ferment  in  the  bile-passages, 
and  a  bacillus,  probably  the  dac/'riuin  coU  commune,  baa  been  found  in 
the  ducts  in  several  cases.  Both  Murchison  and  Ord  hold  that  it  is  simply 
duo  to  local  irritation  of  the  mucous  membrane,  and  that  the  fever  is 
really  of  a  nervous  character. 

The  etTect  upon  the  liver  of  chronic  obstruction  of  the  bile-duct  is 
very  variable.  The  organ  is  rarely  enlarged.  It  is  firm  and  the  con- 
nective tissue  is  moderately  increased.  In  none  of  my  cases  of  persistent 
(tbstruction  by  gall-stones  was  the  liver  greatly  enlarged,  nor  did  it  present 
macroscopically  the  features  of  cirrhosis.  On  this  point  my  experience  is 
in  accord  with  that  of  Sharkey,  who  has  recently  called  in  question  the 
statements  of  Charcot  and  Wickham  Legg  as  to  the  occurrence  of  cirrhosis 
uudiT  these  circumstances. 

i'i)  Obstruction,  witli  suppurative  cholangitis. 

W  hen  suppurative  cholangitis  exists  the  mucosa  is  thickened,  often 
eroded  or  ulcerated;  there  may  be  extensive  suppuration  in  the  ducts 
throughout  the  liver,  and  even  empyema  of  the  gall-bladder.    Occasionally 


*  On  Fever  of  Hepatic  Oripin,  particularly  the  Intermittent  Pyrexia  associated  with 
riall-stoiies,  Johns  Hopkins  Hospital  Reports,  vol.  ii,  No.  1,  1800 ;  and  in  Annals  of 
Surgory,  1800. 


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430 


DISKASKS  OK  TIIK  DIOKSTIVK  SYSTEM. 


the  suppnrntion  cxUmds  boyond  the  ducts,  and  there  in  h)ralizc'd  liver 
ub(4(!('H,s,  or  there  is  perfnnition  of  the  gall-bliuhlor  witli  the  forinatioti  of 
ul)ScesH  bctwccti  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intertnittciit,  luit 
more  commonly  is  remittent  and  without  prolonj^ed  ijitervals  of  apyrcxia. 
Tlu!  jaundice  is  rarely  so  intense,  nor  do  we  see  the  deej)enin;f  of  the  color 
after  the  paroxysms.  There  is  usually  ^'reater  enlargement  of  the  liver 
and  tenderness  and  more  definite  signs  of  septicaMiiia.  The  cases  run  a 
shorter  (iotirse,  aiul  recovery  never  tjikes  plac(!. 

;{.  The  More  Remote  Effects  of  Gall-stones.  —  («)  liiliary  Fistidie. 
These  are  not  uiU!ommon.  'I'liere  may,  for  instance,  be  abnormal  com- 
munication between  tlie  gall-bladder  and  the  hepalic;  duct  or  the  gall- 
bladder and  a  cavity  in  the  liver  itself.  ^More  rarely  perforation  occurs 
between  the  common  duet  aiul  the  portal  vein.  Of  this  there  are  at  least 
four  instuncea  on  record,  anu)ng  them  the  celebrated  ease  of  Ignatius 
lioyola.  IVrforation  into  the  abdominal  cavity  is  not  uncommon;  11(» 
cases  exist  in  the  literature  (Courvoisier),  in  70  (»f  which  the  rupture 
occurred  directly  into  the  peritoneal  cavity;  in  4!>  there  was  eiu-ajtsulated 
abscess.  Perforation  nuiy  take  place  from  an  intrahepatic  branch  or 
from  the  hepatic,  common,  or  cystic  ducts.  Perforation  from  the  gall- 
bladder is  the  most  common. 

Fistulous  cf)mmunications  between  the  bile-passages  and  the  gastro-in- 
testinal  canal  are  fre(|uent.  ()])etiiugs  into  the  stomach  are  rare.  Between 
the  duodenum  and  bile-passages  they  are  much  more  common.  Cour- 
voisier has  collected  10  instances  of  communication  between  the  ductus 
communis  aiul  the  duodenum,  and  1',i  cases  between  the  gall-bladder  and 
the  duodeiuini.  Communication  with  the  ileum  and  jejunum  is  extreuuiy 
rare.  Of  listulous  opening  into  the  colon  yj  cases  are  on  record.  These 
communications  can  rarely  be  diagnosed  ;  they  may  be  present  without 
any  symptoms  whatever.  It  is  jtrobably  by  ulceration  into  the  duodemirn 
or  colon  that  the  large  gall-stones  escape. 

Occasi(mally  fistulous  communication  exists  between  the  gall-bladder 
and  the  urinary  passages,  and  the  stones  nuiy  be  found  in  the  bladder. 
The  opening  has  been  either  into  the  pelvis  of  the  kidney  or,  as  has 
been  supposed,  the  gall-bladder  has  become  adherent  in  the  neighbor- 
hood of  the  navel,  and  the  Btonc  has  escaped  through  an  open  urachus. 
It  is  possilde  that  adhesions  may  form  between  the  distended  gall-bladder 
and  urinary  bladder,  since  the  former  has  been  found  adherent  as  low  as 
the  broad  ligament. 

Many  instances  are  on  record  of  fistuhe  between  the  bile-passages  and 
the  lungs,  ('ourvoisier  has  collected  twenty-four  eases.  Bile  may  he 
couglu'd  up  Avith  the  expectoration,  sometimes  in  considerable  quantities. 
In  only  seven  cases  did  recovery  take  place.  In  some  of  these  the  abscess 
formation  was  due  to  hydatids,  in  some  to  ascaridcs.  The  perforation  usu- 
ally takes  j)lace  through  the  lung,  by  a  liver  abscess  communicating  with 


DISEASES  OP  THE   niLK-PASSAOES. 


437 


tlii^  pUnira,  or  ofcuHioimlly  tho  ubscees  untcra  the  mcHliafltiuuiu  uml  por- 
fomtort  «i  bronchus. 

Uf  uU  llHtiiloiia  coininuniciitioiH  tlio  oxtcrnul  or  ciitiinoous  in  tlio  moat 
(•oiiiinoii.  Coiirvoisicr'rt  statistics  niimluT  IS4  ciiscs,  in  fifty  por  cont  of 
wliicli  tlio  porforation  tooiv  place  in  tlio  ri^'lit  iiypocliomlriuni ;  in  twcnty- 
iiiiic  per  c(>nt  in  tlio  rcfjion  of  the  navel,  'i'lio  inunhcr  of  wtoncs  dis- 
cliarjiiHl  varied  from  ono  or  two  to  many  hundreds.  Kecovory  took  place 
in  78  eases;  Home  with,  some  without  operation. 

(/y)  Obstruction  of  the  bowel  by  gall-stones.  licferenee  has  alri'ady 
been  made  to  this,  the  freciuency  which  ai)i)eurs  from  tiie  fact  that  of  ^!I5 
(•uses  of  obstruction,  occurring  during  the  jjast  eight  years,  amvlyzed  by 
Fitz,  23  were  by  gall-stone.  Courvoisier's  statistics  give  a  total  number 
of  i:U  cases,  in  six  of  which  the  calculi  had  a  peculiar  t-ituation,  as  in  a 
(jivevticuhun  or  in  the  appendix.  Of  the  remaining  VI')  cases,  in  70  the 
stiMii;  was  spontaneously  passed,  usually  with  .severe  symptoms.  The  post- 
mortem reports  show  that  in  .some  of  these  ea.ses  oven  very  large  stones 
have  pas.sed  per  viam  mttitmlnn,  as  the  gall-duct  has  l)een  onornumsly  dis- 
tended, its  orifice  admitting  the  finger  fretdy.  This,  however,  is  extremely 
rare.    The  stones  have  been  fouuil  most  commonly  in  the  ileum. 


Othkk  Affection's  of  tiik  Ijile-ducts. 

Cancrr  will  be  considered  later. 

SIcnosis  or  (;omj)lete  occlusion  may  follow  nh^eration,  most  commoidy 
iiftiT  tlu^  passage  of  iv  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  tho  common  duct.  Instances  of  this  are 
I'xtreniely  rare.  Foreign  bodies,  .such  as  the  seed.s  of  various  fn  its,  nuiy 
enter  the  duct,  and  occasionally  round  worms  crawl  into  it.  In  the  Wistar- 
llonier  Museum  of  the  Univt.'rsity  of  Pennsylvania  there  is  a  remarkable 
s])iH'iinen  showing  the  common  and  hepatic  ducts  enormously  distended 
1111(1  densely  packed  with  a  dozen  or  more  Inmbricoid  worm.s.  A  similar 
sjH'ciiiien  exists  in  one  of  the  Paris  mu.seums.  Liver-flukes  and  echino- 
ooeci  are  rare  causes  of  obstruction  in  man. 

Obstruction  by  prcs,nire  from  without  is  more  frefjuont.  Naturally 
cancer  of  the  head  of  the  pancreas  is  apt  to  involve  the  terminal  portion 
of  the  duct ;  less  often  cancer  of  the  jiylorns.  Secondary  involvement 
of  tlie  lymph  glands  of  tho  liver  is  a  common  cause  of  occlusion  of  the 
duct,  and  is  met  with  in  many  cases  of  cancer  of  tho  stomach  and  other 
ulx'.oniinal  organs.  I{aro  causes  of  obstruction  are  aneurism  of  a  branch  of 
tlu'  c(eliac  axis  or  of  the  aorta,  or  pressure  of  very  large  abdominal  tumors. 

The  symptoms  produced  are  those  of  chronic  obstructive  jaundice. 
At  first,  the  liver  is  usually  enlarged,  but  in  chronic  cases  it  may  be  re- 
flueed  in  size,  and  of  a  deeply  bronzed  color,  and  firm,  owing  tt)  slight 
increase  in  the  connective  tissue.  The  hepatic  intermittent  fever  may  bo 
associated  with  occlusion  of  tho  duct  from  any  cau20,  but  it  is  most  fro- 


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438 


I)ISP]AHES  OV  TIIK  DIGESTIVE  SYSTEM. 


qiiontlj'  mot  with  in  chronic  obstruction  by  f^all-stoiips.  Permuncnt  occlu- 
sion of  the  (hict  tcrniiiiiitcs  in  lisuith  In  a  majority  of  the  case?  the  con- 
ditions which  h'ud  to  Mic  obstrui-tion  are  in  tliemselvos  fatal.  Cases  of 
cicatricial  occlusion  uuiy  last  for  years  A  jiatient  under  my  care,  who 
wi's  nerinauently  jaundiced  for  nearly  three  years,  had  a  libroid  occlusion 
of  the  duct. 

The  (i.tKjnosIx  of  the  nature  of  th'>  occlunion  is  often  very  difficult.  A 
liistory  of  colic,  jaundice  of  varyiuf^  intensity,  paroxysms  of  pain,  and  in- 
termittent fi'ver  p<»int  to  gall-stones.  In  cancerous  obstructicm  the  tuin<ir 
mass  can  sometimes  be  felt  in  tho  eri^astric  region.  In  cases  in  which 
the  lymph  glands  in  the  transverse  lissure  are  cancerous,  the  primary 
disease  may  be  in  the  pelvic  organs  or  the  rectum,  or  there  i  ;ay  he  a 
limitetl  caiu-er  of  the  stomach,  which  has  not  given  any  symptoms.  In 
these  cases  the  examination  of  the  other  lymphatic;  glaiuld  may  he  of 
value.  In  a  case,  recently  under  observation,  with  jaundice  of  seven 
weeks'  duration,  and  iK'lieved  to  he  catarrhal  (as  the  |)atient's  general  con- 
dition was  good  and  l;e  was  said  not  to  have  lost  tlesh),  a  snudl  nodular 
mass  was  detecteil  at  the  navel,  which  on  removal  ]»rovi'd  to  be  scirrluis. 
Involvement  of  the  i'..ivicular  groups  of  lymjih  glands  nuiy  also  be  service- 
able in  diagnosis.  As  already  nu'ntit)ned,  the  gall-bladiler  is  often  Imt 
little  eiilargcfl  in  obstruction  of  the  comnmn  duct.  (Ireat  and  progressive 
enlargement  of  the  liver  with  jaundice  and  moderate  ctuitinued  fever  is 
more  commonly  met  with  in  caiu'cr.  In  hypertrophic  cirrhosis  a  siiuilar 
conditio!!  exists,  but  tho  organ  is  smooth  and  there  is  rarely  progrestiive 
oidargement  while  under  observation. 

Treatment  of  Gall-stones  and  their  Eflfects.— In  an  attac  k 

of  biliary  colic  the  patient  sliouM  be  kejtt  under  nu)rphia,  ;Mven  hypo(ler- 
mically,  in  (piarter-grain  doses.  In  aii  agonizing  paroxysm  it  is  well  to 
give  a  whitT  or  two  of  chloroform  until  the  moriihia  has  had  tinu>  to  ;ict. 
Croat  relief  is  exi)erienced  from  the  hot  bath  and  from  fomentations  \\\ 
the  region  of  the  liver.  The  patient  should  be  given  laxatives  and  sliould 
drink  copiously  of  alkaliiu'  niiiieral  waters.  Olive  oil  bus  proved  useless 
in  my  hands.  When  taken  in  large  (pumtities,  fatty  concretions  are  passed 
with  the  stools,  which  have  been  mistaken  for  calculi.  Since  the  days  cf 
Durantle,  whose  mixture  of  ether  and  turpentine  is  still  largely  used  in 
France,  various  remedies  have  been  advised  to  dissolve  the  stones  within 
the  gall-bladder,  none  of  which  are  ofHcacious. 

Tho  tliet  shouM  bo  regu!ate<l,  the  patient  should  take  regular  exercise. 
and  avoid,  as  miudi  as  possible,  the  Ht^-irchy  and  saccharin^^  foods.  Tlie 
soda  salts  recommended  by  I'rout  are  believed  to  prevent  the  concentra- 
tion of  the  bile  and  the  fornuitioi\  of  gall-sUmos.  Either  the  sulphate  or 
the  phos[)hato  may  be  taken  in  doses  of  from  one  to  two  drachms  dinly. 

Expression  of  gall-stoiu's  from  the  bladder  by  digital  manipulation,  n.'< 
reeomn\etuled  by  (Jeorge  Ilarley,  is  a  highly  irrational  ])rocedure,  not  t'l 
be  followed.     So  long  as  guU-stcnes  remain  in  tho  bladder  they  do  littl  • 


DISEASES  OF  THE  BILE-PASSAGES. 


439 


or  IK)  harm  in  a  great  majority  of  cases.  To  foivc  them  on  into  tin  duct 
i.s  to  rcnilcf  the  i)atient  liable  to  severe  colic  or  to  the  still  more  scriou.^ 
ti;iii,i,'er  of  permanent  obstruction. 

When  tlie  cystic  duct  is  occluded  and  the  gall-bladder  distended,  an 
cxiiloratory  j)uncture  may  be  nuide,  as  practiseil  by  the  elder  IVpper,  in 
1H,")T,  in  a  case  of  empyenui  of  the  gall-bladder,  and  by  Hartludow  in  1818. 
Tlio  puncture  may  be  nuule  either  to  draw  oiT  fluid  from  a  distended  blad- 
der or  to  explore  for  gall-stones.  Asj)iration  is  usually  a  safe  procedure, 
tlioiigh  a  fatal  result  has  followed.  When  the  gall-bladder  is  distended 
uiiil  plainly  palpable,  to  sound  for  stones  by  an  exploratory  puiu'ture  is 
jiistiliable,  but  umler  no  other  circumstances.  "  'I'hc  easy  and  safe  method 
of  sounding  for  imi>a(!ted  stones,"  recommended  a  few  years  ago  by  a  Lon- 
(loi\  pliysician,  in  which  it  is  advised  to  thrust  a  sharjt  needle  six  iiu-hes 
long  l)etween  the  navel  and  the  marg'ii  of  the  liver,  nuiy  be  characterized 
as  one  of  the  most  extraordiiuiry  opcr^itions  ever  ad.ocatcd,  and  would 
jirohiibly  always  j)rove  fatal,  as  in  the  case  of  the  unhapjjy  victim  upon 
will  nil  it  was  practised. 

Tlie  surgical  treatnu-nt  of  gall-stones  has  of  late  years  made  rapid 
j)iui;ress.  The  operation  of  cholocystotomy,  or  opening  the  gall-l)laddcr 
uiul  removing  tho  stones,  which  was  advised  by  Sims,  lias  been  remark- 
iil)!/  successful,  particularlj  in  the  hands  of  Lawson  Tait.  The  removal 
of  the  gall-bladder,  cholecy.stectomy,  has  also  been  practised  with  success. 
Tlie  indiiations  for  operation  are:  (a)  lve])eated  attacks  of  gall-stone  colic, 
of  great  severity  and  danger,  (b)  The  presence  of  a  disteiuled  gall-bladder, 
iissociated  with  attacks  of  jMiin  or  with  fever.  Many  cases  of  obstruction 
(if  the  cystii'  duct  with  moderate  distention  of  the  gall-bladder  produce 
lilllc  or  no  inconverJence,  and  ])erfect  re<'overy  may  take  places  with  con- 
trailiitii  and  oblitv^ration.  (r)  When  a  gall-stone  is  permaiuMitly  lodged  in 
tiu!  cotninon  duct,  and  i)resenis  the  group  of  symptoms  above  described. 
It  must,  however,  be  borno  in  mind  that,  contrary  to  the  ex|)erienceH  of 
Clmrcot  and  other  Freiu'h  writers,  three  of  my  cases  recovered — one  after 
IKT.si.steuce  of  the  condition  for  eight  months,  another  for  three  years ;  two 
•lii'd  of  the  elTects  of  the  i)rolonged  jaundice,  and  two  after  operation. 
'!'!;•'  (|H'"^tion,  then,  of  jwlvisiug  removal  in  sucdi  cases  should  depend 
iiirirdy  upon  the  personal  methods  and  success  of  the  surgeon  who  is 
iivuilahle.  The  common  duct  has  been  exj)lored  and  gall-stoiu's  removed 
i'l'Dm  it.  The  o]>eration  is  necessarily  much  more  serious  and  ditliculfc 
than  tliat  upon  tho  gall-bladder. 


'-'V 


.  1 


.4- 


:^ii"  ' 


'H- 


440 


DISEASES  OF  THE  DIGivSTIVE  SYSTEM. 


IV.  CIRRHOSIS. 


Definition. — A  dironic  disoasc  of  tlio  liver,  cliaracterizod  by  a  gradual 
(lestnictiou  of  liver-cL-lls  and  an  overgrowth  of  comu'c^tivo-tisijuo  eleiiunts. 
ill  coiiseciiu'iu'c  of  wliicli  tlic  organ  boeonu-s  hard  and  usually  small. 

Etiology. — Tho  disease  occurs  nuist  frequently  in  miiUUe-aged  nial(>f . 
It  has  been  regarded  as  ra.e  in  children,  except  in  tho  Ky])hilitic  form,  but 
Palmer  Howard  collected  (J.'}  cases,  to  which  list  llatlield,  in  a  fnrllur 
search  of  the  literature,  has  been  able  to  add  !):»,  so  that  its  occurrence  iu 
early  life  is  more  common  than  has  been  supposed. 

The  following  are  tho  recognized  factors  in  iiulucing  the  disease :  {(/) 
Alcohol. — The  abuse  of  spirits  is  the  common  cause.  It  is  more  fre(|U('iit 
in  countries  in  which  strong  spirits  are  taken  than  in  those  in  which  lunlt 
li(juors  and  wines  are  used.  The  change  results  from  the  irritative  ctfcL't 
of  the  strong  solution  of  alcohol  absorbed  from  tho  stomach.  The  fusel 
oil  is  thought  to  be  tho  oH'cnding  nuiterial.  Similar  elTects  are  doubth'ss 
produced  by  other  substances,  such  as  rich,  highly  .seasoned  foods,  or,  as 
has  been  suggested,  by  jitomaines  and  other  alkaloids. 

(l))  i>'i/p/iil{s. — We  have  already  considered  (under  Syphilis)  the  forms 
of  cirrhosis,  ditfuse  and  gununatous,  produced  by  this  poison. 

(f)  Cyanolic  CuiKjcstion. — In  cases  of  chronic  disease  of  tho  heart  and 
lungs  the  liver  is  in  a  condition  of  ])ersistent  venous  hy])eraMnia,  in  conse- 
quence of  which  tiie  central  cells  of  the  liver  lobules  atrophy  aiul  there  is 
hyperplasia  oi  the  connective  tissue. 

{d)  Malariii. — Sclerosis  of  the  liver  may  follow  prolonged  malarial 
poisoning.     In  this  country  it  is  very  rare. 

((•)  Tnhrrrfdiisis. — We  have  already  referred  to  the  sclerotic  changes  in 
the  liver  pro(liiccd  by  tuberculosis.  It  rarely,  if  ever,  induoea  u  condition 
which  can  be  "ccognized  clinically. 

■(/)  Scarht  Fetrr. — The  fact  noted  by  Klein  that  in  Bcarlot  fever  there 
was  an  infiltration  with  small  cidls,  an  acute  interstitial  hepatitis,  gives  a 
clew  to  the  occurrence  of  some  of  the  cases  of  cirrhosis  of  the  'iver  in  cliil- 
dren.  In  other  infectious  diseases,  too,  such  as  typhoid,  there  are  localizcil 
necrotic  areas  which  must  be  reitlaced  by  connective  tissue.  In  the  cir- 
rhosis of  early  life,  excluding  the  ah'oholic  and  syphilitic  ruses,  the  acute 
infectious  diseases  arc  pri  bahly  the  important  antecedents. 

(//)  UirkctH. — The  enlargement  of  the  liver  in  this  disease  is  associated 
with  iiuTease  in  the  connective  tissue,  which  surrounds  tho  indiviilual 
lobules  an<l  ]>roduces  changes  in  the  bile-ducts  (Hodgbei!). 

(//)  Jiif/iniro.sis. — It  occasionally  hiipp<'ns  in  coal-r.iiners  that  the  car- 
bon ])ignu'nt  reaclics  the  liver  in  large  (|uantities,  is  <l(posited  in  the  coti- 
iicctivc  tissue  aliout  the  jiortal  canal, and  nuiy  lem!  to  u  variety  of  cirrhosis, 
which  has  been  described  by  Welch. 

In  animals, artilieial  obstruction  of  the  bile-pas.s,iges results  in  cirrhosis, 
but  in  num  there  nuiy  bo  persistent  stenosis  of  tho  common  duct  or  ol»- 


CIRRHOSIS. 


441 


St  ruction  without  marked  increase  in  the  connective  tissue.  The  causes 
whicli  induce  the  cirrhosis  which  we  meet  at  the  hxlside  are  alcoliol  and 
sypliilirf. 

Morbid  Anatomy. — Practically  on  the  post-mortem  table  we  see 
cinlinsis  in  four  well-charatiterized  forms  : 

(ii)  The  Atrophic  Cirrhosis  of  Laennec. — The  organ  is  greatly  re- 
duced in  size  and  may  be  deformed.  'J'he  weight  is  scjmetimes  not  more 
than  a  pound  or  a  pound  and  a  lialf.  It  presents  numerous  granula- 
tions on  the  surface ;  is  firm,  hard,  and  cuts  with  great  resistance.  The 
sul)stancc  is  seen  to  bo  made  up  of  greenish-yellow  islands,  surrounded  by 
griivish-white  connective  tissue.  This  yellow  appearance  of  the  liver  in- 
(luci'd  Lueniujc  to  give  it  the  name  of  cirrhosi-s. 

(//)  Fatty  Cirrhosis. — Even  in  the  atmphic  form  the  fat  is  increased, 
hut  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in  size, 
hut  iri  enlarged,  smooth  or  very  slightly  granular,  anitmic,  yellowish  white 
in  color,  and  resembles  an  ordinary  fatty  liver.  It  is,  however,  firm,  cuta 
wiili  rt'siitance,  and  microscopically  shows  a  groat  increase  in  the  connoct- 
ivi'  tissue.  This  form  is  quite  as  common  in  this  country  as  the  atrophic 
viiricly.     It  occurs  most  frequently  in  beer-drinkers. 

{(■)  Ififpertrophic  (Urrhosis. — p]n3argeinont  of  the  liver  occurs  in  the 
earlv  i^tago  of  the  ordinary  atrophic  cirrhosis,  but  the  increase  is  moderate 
iiiid  largely  duo  to  hypenemia.  The  fatty  cirrhotic  liver  is  also  large,  and 
may  reach  a  land's-breadth  below  the  costal  margin.  The  term  hyper- 
trophic cirrhosis  should  be  restricted  to  the  form  descrilx'd  ]»y  French 
wiiteis,  which  is  also  known  as  hiUnnj  cirrhosis.  Unfortunately,  this  haii« 
been  used  l)y  some  writers  to  include  as  well  the  cases  in  which  there  has 
l)ciMi  i)ermanent  occlusion  of  the  duct,  either  by  stricture  or  a  calculus  ( 
tlic  induration,  however,  is  slight  under  these  circumstances  and  hyper- 
tmiiiiy  very  rare.  It  seems  best  to  limit  the  terms  hilinn/  and  hyvrrtrophie 
(■irrlid.sis  to  the  form  chariicterized  Viy  permanent  enlargement  of  the  liver, 
;i  luiirked  involvement  of  the  smaller  biliary  I'anaiiculi.  and  retention  in 
iin  unusual  degree,  in  comparison  with  atnijihic  cirrhosis,  of  the  numl)er 
aiiti  form  of  the  liver-cells,  in  spite  of  the  great  ineroa.s(>  of  the  lobular 
connective  tissue.  In  tliis  form  the  liver  is  greatly  enlarged  ;  in  one  of 
my  cases  it  weighed  seven  pounds.  The  surface  is  smooth,  it  is  exceed- 
inirly  firm,  resists  cnitting,  and  presents  on  section  a  dwp  greenish-yeUow 
color.     All  of  my  cases  have  been  in  hard  <lrinker8. 

((/)  Perihepatitis  ;  Glissonian  Cirrhosis. — In  this  form  the  liver  m 
irrcatly  reduced  in  size,  much  altered  in  shape,  and  everywhere  surrnundnd 
l»y  a  lirni  ;,niyish-whitc  ro»nibrane.  sometimes  "f  semi-cartilaginous  con- 
."^istence,  varying  from  10  t*i  ..">  mm.  in  thickness.  This  fibrous  investment 
can  he  strippt-d  off  reiwlily,  and  the  liver  aul>*"Uince  may  look  almost  noi- 
nial,  Init  usuafly  shows  cirrhotic  changes.  The  (.'apsiilar  thickeniiig  may 
ho  slii:lit,  and  the  portal  connective  tissu"  chiefiy  itivolveil.  Th(>  capsule 
"f  the  s]tlecn  is,  as  a  rule,  similarly  allectt-u,  and  both  processes  are  mwo- 


'v-m 


mi 

Pi 


.1 


«■,  I' .; 


442 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


ciatcd  with  a  proliferative  peritonitis.     Tlie  condition  is  most  frequent  as 
a  result  of  alcohol,  but  occurs  also  in  instances  of  cyanotic  induration. 

The  two  essential  olenients  in  cirrhosis  are  destruction  of  livor-cclls 
and  obstruction  to  the  portal  circulation. 

In  an  autoj)sy  on  a  case  of  atrophic  cirrhosis  the  i)eritonrtium  is  ukuuIIv 
found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opaque,  and 
there  is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  I'lm 
kidneys  are  sometimes  cirrhotic,  the  bases  of  the  lungs  may  l)e  much  com- 
pressed by  the  ascitic  fluid,  the  heart  often  shows  marked  degeneration, 
and  arterio-sclcrosis  is  usiudly  present.  A  remarkable  feature  is  the  asso- 
ciation of  acute  tuberculosis  with  cirrhosis.  In  seven  cases  of  my  series 
the  patients  died  witli  eitlier  acute  tuberculous  ])eritonitis  or  acute  tiihor- 
culous  pleurisy.  Pitt  states  that  twenty-two  and  a  half  per  cent  of  the 
ciuses  of  cirrhosis  dying  in  Guy's  Hospital  during  twelve  years  had  acute 
tuberculosis. 

The  compensatory  c  irculation  is  usually  readily  demonstrated.  It  is 
carried  out  by  the  following  set  of  vessels  :  (1)  The  accessory  portal  systnu 
of  Sappey,  of  which  important  branches  pass  in  the  round  and  suspensory 
ligaments  and  unite  with  the  epigastric  and  mammary  systems.  TIk'sc 
vessels  are  numerous  and  small.  Occasionally  a  large  single  vein,  which 
may  attiun  the  size  of  the  little  finger,  passes  from  the  hilus  of  the  liver  in 
the  round  ligament,  and  joins  the  epigastric  veins  at  the  mivel.  Ah  hough 
this  has  the  position  of  the  umbilical  vein,  it  is  usually,  as  8a])pey  showed, 
a  para-umbilical  vein— that  is,  an  enlarged  vein  by  the  side  of  the  oliHter- 
ated  und)ilical  vessel.  There  may  be  produced  about  tlie  navel  a  large 
bunch  of  varices,  the  so-called  cai)ut  iyiedusa\  Other  blanches  of  this 
system  occur  in  the  gastro-epiploic  omentum,  about  the  gall-blaflder,  and, 
most  important  of  all,  in  the  susj)ensory  liganu>nt.  These  latter  I'oiiii 
large  branches,  which  amistomose  freely  with  the  diaphragmatic  veins,  and 
so  unite  with  the  vena  azygos.  {'i)  By  the  anastonmsis  between  the  o-soph- 
ageal  and  gastric  veins.  The  veins  at  the  lower  end  of  the  O'sopiiagus 
may  bo  enormously  enlarged,  producing  varices  which  project  on  the 
mucous  meml)rane.  (3)  The  communications  between  the  luemorrhoidal 
and  the  inferior  mesenteric  veins.  The  freedom  of  communication  in  this 
direction  is  very  variable,  and  in  some  instances  the  ha'morrhoidal  veins 
are  not  much  enlarged.  (4)  The  veins  of  Retzius,  wliich  unite  tiu'  radi<les 
of  the  portal  branches  in  the  intcstiiu^s  and  mesentery  with  the  inferior 
vena  cava  anil  its  br inches.  To  this  system  belo.ig  the  whole  grouj)  of 
retroperitoneal  veins,  which  are  in  most  instances  enormously  eidarged, 
particularly  about  the  kidneys,  and  wliich  serve  to  carry  oil  a  consideral)!o 
proportion  of  the  portal  blood. 

S3nnptoms.— ('f)  Of  the  Atrophic  Form.— Tho  most  extreme  grade  of 
atrophic  cirrhosis  may  exist  without  symptoms.  So  loufi  as  the  compen- 
satory circulation  is  maintained  the  patient  may  suffer  little  or  no  iiudii- 
veniencc.     The  remarkable  efficiency  of  this  collateral  circulation  is  well 


CIRRHOSIS. 


443 


seen  in  those  rare  instances  of  permanent  obliteration  of  the  portal  vein, 
which  may  exist  for  many  years. 

Tlie  symptoms  may  be  divided  into  two  groups — obstructive  and  toxic;. 
Obstructive. — The  overfilling  of  the  blood-vessels  of  the  stomach  and 
iiito.-^tinc  leads  to  clironic  catarrh,  and  the  jiatients  suffer  with  nausea 
iiiul  vomiting,  particularly  in  tlie  morning ;  the  tongue  is  furred  and  the 
bowels  arc  irregular,  lliemurrhage  from  the  stomach  may  be  an  early 
sviiiptom ;  it  is  often  profuse  and  liable  to  recur.  It  seldom  i)roves  fatal. 
The  amount  vomited  may  be  renuxrkable,  as  in  a  etuse  already  referred  to, 
in  which  ten  pounds  were  ejected  in  seven  days.  Following  the  luenuitc- 
niesis  meliiMia  is  common.  Eidargement  of  the  si)leen  occurs  from  the 
chronic  congestion.  The  organ  can  usually  be  felt.  Evidences  of  the 
establishment  of  the  collateral  circulation  are  seen  in  the  enlarged  epigas- 
tric and  mammary  veins,  more  rarely  in  the  presence  of  the  caput  Meduste 
and  in  the  development  of  haemorrhoids.  The  distended  venules  in  the 
lower  thoracic  zone  along  the  line  of  attachment  of  the  diaphragm  are  not 
specially  marked  in  cirrhosis.  The  most  striking  feature  of  failure  in  the 
e()ni|)eusatory  circulation  is  ascntes,  the  effusion  of  serous  fluid  into  the 
peritoneal  'uivity.  The  conditions  under  which  thi'5  occurs  are  still  ob- 
scure. The  abdomen  gradually  distends,  nuiy  reach  a  large  size,  and  con- 
Uiin  as  much  as  15  or  20  litres.  (Edenui  of  the  feet  may  precede  or  develop 
with  the  ascites.    The  dropsy  rarely  becomes  general. 

Jaundice  is  usually  slight,  and  was  present  in  only  35  of  130  cases  of 
cirrhosis  reported  by  Fagge.  The  skin  hjis  frequently  a  sallow,  slightly 
ictcroid  tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in 
ahiuulance,  often  a  slight  amount  of  albumen,  and,  if  jaundice  is  intense, 
tube-easts.  The  disease  may  be  afebrile  throughout,  but  in  many  cases, 
lis  shown  by  Carrington,  there  is  slight  fever,  from  100°  to  102-5°. 

Examination  in  the  early  stage  of  the  disetise  may  show  moderate  cn- 
liirgetnent  of  the  liver,  which  may  be  jjainful  on  pressure.  At  this  period 
tlic  patient  may  come  under  observation  for  dyspepsia,  luvmatemesis,  slight 
jaiuuliee,  or  nervous  symptoms,  l^ater  in  the  disetise,  the  patient  has  an 
iiiiinistakable  hepatic  facics;  he  is  thin,  the  eyes  are  sunken,  the  conjunc- 
tivae watery,  the  nose  and  cheek-!  show  distended  veniUes,  and  the  complex- 
inn  is  muddy  or  ictcroid.  On  the  enlarged  abdomen  the  vessels  are  dis- 
t^'uded,  and  a  bunch  of  dilated  veins  may  surround  the  navel.  When 
much  fluid  is  in  the  peritonivum  it  is  impossible  to  make  a  satisfactory  ex- 
.iininatioii,  but  after  withdrawal  the  area  of  liver  dulness  is  found  to  lie 
diniinislied,  particularly  in  the  middle  line,  and  on  deef.  pressure  tlie  edge 
'  '  tlie  liver  can  be  detected,  and  occiisionally  the  hard,  ilrm,  and  even 
K.iinidar  surface.  The  spleen  can  be  felt  in  the  left  liypochondriai;  region. 
Exuni illation  of  the  anus  may  reveal  the  presence  of  h.iMnorrhoids. 

ToTic  Siimptnms. — At  any  stage  of  atn»phic  cirrhosis  the  patient  may 
•develop  cerebral  symptoms,  cither  a  noisy,  joyous  delirium,  or  stupor, 
comu,  or  even  convulsions.     The  condition  is  not  infrecjuently  mistaken  for 


'5  ■,*':«.  ■'.■■-*■'■    ' 


444 


DISKASES  OP  THE   DIGESTIVE  SYSTEM. 


!  |!l;rl 


urieinla.  The  nature  of  tlie  toxic  agent  is  not  yet  settled.  TIio  symptonirt 
rnay  develop  without  jaundice,  and  cannot  be  attributed  to  chola>niia,  and 
they  may  come  on  in  hospital  when  the  j)atient  has  not  had  alcohol  for 
weeks. 

The  fatty  cirrhotic  liver  nuiy  produce  symptoms  similar  to  those  of  the 
atrophic  form,  but  it  more  frequently  is  latent  and  is  found  accidentally 
in  topers  who  have  died  from  various  diseases.  The  greater  number  of 
the  cases  clinically  diagnosed  as  cirrh(jsis  with  enlargement  come  in  this 
division. 

(b)  Hypertrophic  or  biliary  cirrhosis  has  a  definite  and  distinctive 
symptomatology.  The  liver  may  be  enlarged  for  months  or  even  years. 
Jaundice  persists  for  some  time,  on  which  point  French  writers  lay  great 
stress.  It  may,  however,  come  on  acutely  with  the  other  symptoms.  It, 
is  intense,  like  an  obstructive  jaundice,  but,  as  a  rule,  the  stools  are  bilo- 
stained.  It  may  continue  for  u  long  time  without  the  development  of 
other  symptoms;  then  delirium  sets  in  and  all  the  features  of  an  acute 
febrile  jaundice.  'IMio  tongue  is  dry,  the  pulse  ra\)'u],  the  temperature 
ranges  from  102°  to  104°,  and  petechiie  occur  on  the  skin.  The  patient 
may  present  every  feature  of  acute  yellow  atrophy,  including  even  the 
convulsive  seizures.  The  attack  in  one  of  my  cases  proved  fatal  within 
ten  days ;  in  another  it  was  prolonged  for  three  weeks.  Ascites  does  not 
develop.  The  enlargement  of  the  liver  nuiy  be  the  sole  diagnostic  crite- 
rion between  these  cases  and  acute  yellow  atrophy.  I  do  not  know,  how- 
ever, of  the  occurrence  of  Icucin  or  tyrosin  in  the  urine  in  this  conditijii. 

(c)  The  perihepatitis  with  cirrhosis  cannot  be  distinguished  from  t!ie 
ordinary  atrophic  form. 

Diagnosis. — With  »iscitea,  a  well-marked  history  of  alcoholism,  the 
hepatic  facies,  and  haemorrhage  from  the  stomach  or  bowels,  the  diag- 
nosis is  rarely  doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is 
found  to  be  enlarged  and  the  liver  either  not  palpable  or,  if  it  is  en- 
larged, hard  and  regular,  the  probabilities  in  favor  of  cirrhosis  are  very 
great.  In  the  early  stages  of  the  disease,  when  the  liver  is  increased  in 
size,  it  may  be  impossible  to  say  whether  it  is  a  cirrhotic  or  a  fatty  liver. 
The  differential  diagnosis  between  (common  and  syphilitic  cirrhosis  can 
sometimes  be  made.  A  marked  history  of  syphilis  or  the  existence  of 
other  syphilitic  lesions,  with  great  irregularity  in  the  surface  or  at  the 
edge  of  the  liver,  are  the  points  in  favor  of  the  latter.  Thrombosis  or 
obliteration  of  the  portal  vein  can  rarely  be  differentiated  In  the  case  of 
fibroid  transformation  of  the  portal  vein  wliich  came  under  my  observa- 
tion, the  collateral  circulation  had  been  established  for  years,  and  llio 
symptoms  were  simply  those  of  extreme  portal  obstrui'tion,  such  as  occur 
in  cirrhosis.  Thrombosis  of  the  portal  vein  is  freipient  in  cirrhosis  ami 
may  bo  characterized  by  a  rapidly  developing  ascites. 

Prognosis. — The  prognosis  is,  as  a  rule,  bad.  When  the  collateral 
circulation  is  fully  establinhod  the  patient  may  have  no  symptoms  what- 


CIRHHOSIS. 


445 


ever.  Throo  cases  of  lulvancod  atr(»pluR  cirrhosis  have  died  imder  my  ob- 
servation of  other  alTe(!tioii8  .vithout  prosciitiiig  during  life  any  aymptoms 
|K)iiiting  to  disease  of  the  liver.  There  are  instaneea,  too,  of  enlargement 
(if  the  liver,  sligiit  jaundice,  cerebral  symittonis,  and  even  haimatemesis,  in 
which  the  liver  becomes  reduced  in  size,  the  symptoms  disappear,  and  the 
jiiitient  may  live  in  comparative  comfort  for  many  years.  There  are  many 
(Uses,  too,  in  which,  after  one  or  two  tappings,  the  symptoms  have  disap- 
jieared  anil  the  patients  have  ai)parently  recovered. 

Treatment. — Ordinary  trirrhosis  of  the  liver  is  an  incurable  disea.se. 
Many  writers,  speaking  of  the  curability  of  certain  forms,  show  a  lack  of 
iilipreciation  of  the  essential  conditions  upon  which  the  symptoms  depend. 
So  far  as  we  have  aTiy  knowledge,  no  remedies  at  our  (lisposal  can  alter  or 
removo  the  cicatricial  connective  tissue  Avhich  ccmstitutes  the  viaterin 
pecrans  in  ordinary  cirrhosis.  On  the  other  hand,  Ave  know  that  extreme 
grades  of  contraction  of  the  liver  may  persist  for  years  without  symptoms 
wiicn  the  compensatory  circulation  exists.  The  so-called  (uire  of  cirrhosis 
means  the  re-establishmont  of  this  compensation;  and  it  would  be  as  un- 
reasonable to  speak  of  healing  a  chronic  valvular  lesion  when  with  digi- 
talis we  have  restored  the  circulatory  balance  as  it  is  to  speak  of  curing 
cirrhosis  of  the  liver  Avhen  by  tapping  and  other  measures  the  compensa- 
tion has  in  some  way  been  restored. 

The  patient  should  abstiiin  entirely  from  alcohol,  and,  if  j)ossible,  should 
take  a  milk  diet,  which  has  been  highl}'  recommended  by  Semmola.  In 
any  case,  the  diet  should  be  nutritious,  l»ut  not  too  rich.  Measures  should 
he  employed  to  reduce  the  gastro-ititestinal  catarrh.,  and  the  patient  should 
lead  a  quiet,  out-of-door  life  and  keep  the  skin  active,  the  bowels  regular, 
and  the  urine  abundant.  In  non-syphilitic  cases  it  is  useless  to  give  either 
mercury  or  iodide  of  potassium.  When  a  well-nuirked  history  of  syphilis 
exists  these  remedies  should  be  used,  but  neither  of  them  has  any  more 
inlhience  upon  the  development  of  a  new  growth  of  connective  tissue  iu 
tlu!  liver  than  it  has  upon  the  progressive  development  of  a  scar  tissue  in 
a  keloid  or  in  an  ordinary  developing  cicatrix.  The  ascites  should  be 
tapiied  early,  and  the  (^peraticm  may  be  repeated  so  soon  as  the  distention 
heconies  distressing.  The  continuous  drainage  with  a  So'ithey's  tube  may 
be  employed.  It  is  much  better  to  resort  to  tapping  early  if  after  a  few 
(lays'  trial  the  fluid  does  not  subside  rapidly  under  the  use  of  saline  purges. 
I'rom  half  an  ounce  to  an  ounce  and  a  half  of  sulphate  of  magnesia  may 
he  jjiveu  in  as  little  water  as  possible  half  an  hour  before  breakfast.  Elatc- 
rinm,  the  compound  jalap  powder,  or  the  bitartrate  of  ])otash  may  also  he 
emj)loyod.  Digitalis  and  squills  are  often  useful.  In  the  syphilitic  cases 
or  when  syphilis  is  suspected  iodide  of  potussiem  may  b(  given  in  doses  of 
fntm  fifteen  to  thirty  droi)s  of  the  saturated  solution  three  times  a  day, 
iuid  iiiercury,  which  is  conveniently  given  with  stiuills  and  digitalis  in  the 
fiinn  of  Addison's  or  Niemeyer's  pill.  A  case  of  well-marked  syphilitic 
cirrhosis  with  recurring  ascites,  iu  which  l4ipj)ing  was  resorted  to  on  eight 


r  ti 

r       W 

fi  ►.  ^ 

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if' 

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tl 


446 


DISRASES  OP  THE   DIOESTIVE  SYSTEM. 


or  ten  occasions,  took  thiH  pill  iit  iiitnrvuls  for  a  year  with  tho  gruutost  bono- 
tit,  und  subsequontly  liud  four  yours  of  tolerably  good  healtli. 


V.  ABSCESS   OF  THE   LIVER. 

Etiology.— Suppuration  within  tho  liver,  either  in  tho  parenchyiiiii 
or  in  the  blood  or  bile  paHsages,  occurs  under  the  following  conditions: 

(1)  The  iiopical  abscess.  In  hot  climates  this  form  may  develop)  idio- 
pathically,  but  more  commonly  follows  dysentery.  It  frequently  occurs 
anu)ng  Europeans  in  India,  jiarticulurly  tliose  who  drink  alcohol  freely  and 
are  exposed  to  great  heat.  The  relation  of  this  form  of  abscess  to  dysen- 
tery is  still  under  discussion,  and  Anglo-Indian  practitioners  are  l)y  no 
means  unanimous  on  the  subject.  Certainly  (lases  may  develop  without 
a  history  of  previous  dysentery,  and  there  have  been  fatal  cusos  without 
any  affection  of  tho  large  bowel.  In  this  country  the  large  solitary  tropi- 
cal abscess  also  occurs,  oftenest  in  the  Southern  States.  In  Baltimore  it 
is  not  very  infrequent,  as  may  be  judged  from  tho  fact  that  during  two 
years  there  have  been  at  my  clinic  five  cases,  and  I  know  of  the  oecun-ence 
of  three  or  four  additional  cases  during  this  time  in  the  city. 

The  relation  of  this  form  of  abscess  to  the  amoeba  coli  has  been  care- 
fully studied  by  Kartulis  and  exhaustively  considered  in  a  monograph  l)y 
Councilman  and  Lafleur.  Tho  descriptions  and  illustrations  of  tlusc 
authors  are  most  convincing  as  to  the  direct  etiological  association  of  this 
organism  with  liver  abscess.  Clinically  the  patient  may  liave  ammba  coli 
in  the  stools  and  well-nuirked  signs  of  liver  abscess  without  marked  symp- 
toms of  dysentery  and  oven  with  tho  fajces  well  formed. 

(2)  Traumatism  is  an  occasional  cause.  The  injury  is  generally  in  the 
hepatic  region.  Two  instances  have  come  under  my  notice  of  it  in  brake- 
men  who  were  injured  while  coui)ling  cars.  Injury  of  the  head  is  not  iu- 
frequently  followed  by  liver  abscess. 

(3)  Embolic  or  pya?mic  abscesses  are  tho  most  numerous,  and  may  de- 
velop in  a  general  pyamiia  from  any  cause  or  follow  foci  of  supj)urati(>n  in 
tho  territory  of  the  portal  vessels.  The  infective  agents  nuiy  reach  tlio 
liver  through  tho  hepatic  artery,  as  in  those  cases  in  which  the  origiiuil 
focus  of  infection  is  in  the  area  of  the  systemic  circulation  ;  though  it  niiiy 
happen  occasionally  that  the  infecttivo  agent,  instead  of  passing  throu;,'li 
tho  lungs,  reaches  tho  liver  through  tho  inferior  vena  cava  and  the  hepatin 
veins.  A  remarkable  infiance  of  multiple  abscesses  of  arterial  origin  was 
aiTorded  by  the  case  of  aneurism  of  the  hepatic  artery  reported  by  Iloss 
and  myself.  Infection  through  the  portal  vein  is  much  more  comniou. 
It  results  from  dysentery  and  other  uhHM'ative  alTections  of  tho  bowc;]^, 
appendicitis,  occasiomdly  after  typhoid  fever,  in  rectal  affections,  and  in 
abscesses  in  tho  pelvis.  In  those  cases  tho  abscesses  are  multiple  and,  as  a 
rale,  within  tho  branches  of  tho  portal  vein— suppurative  pylephlebitis. 


%      !I 


..'t 


ABSCESS  OF  THE  LIVEIl. 


447 


( i)  A  not  uncommon  cause  of  Huppurution  in  inflammution  of  tlio  bilo- 
|iiis.-<a^'('S  caused  by  gall-stones,  more  rarely  by  jmrasites — 8upj)urativc  cho 
liiiifjitis. 

In  some  instances  of  tuberculosis  of  the  liver  the  affccticm  is  chiefly  of 
tat'  l)ilo-(lucts,  with  the  forniutioji  of  multiple  tuberculous  abscesses  con- 
taining a  bile-stained  jms. 

(,'))  Foreign  bodies  and  parasites.  In  rare  instances  foreign  bodies, 
Kuch  as  a  needle,  nuiy  pass  from  tiie  stomach  or  gullet,  lodge  in  the  liver, 
and  excite  an  abscess,  or,  as  in  several  instances  whicii  have  been  reported, 

II  foreign  body,  such  as  a  needle  or  a  fish-bone,  may  i)erforate  a  branch  or 
the  portal  vein  itsc^lf  and  induce  extensive  pylephlebitis.  Echinococcus 
ovsts  frequently  cause  suppuration ;  the  penetration  of  round  worms  into 
till'  liver  less  commonly;  and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. — (a)  OftheSoUtnryor  Tropical  Abscess. — This 
is  not  always  single  ;  there  may  be  < ,wo  or  ev(Mi  more  large  abscess  cavities, 
ranging  in  size  from  an  orange  to  a  child's  head.  The  largest-sized  ab- 
scess may  contain  from  three  to  six  litres  of  pus  and  involve  more  than 
tln'i'O  fourths  of  the  entire  organ.  In  AVariiig's  statistic?,  sixty-two  per 
otnt  of  the  cases  were  single.  The  abscess  in  nearly  seventy  per  cent  of 
the  eases  was  in  the  right  lobe,  more  toward  the  convexity  than  the  con- 
cave side.  In  lon/5-standing  cases  the  abscess-wall  nuiy  be  firm  and  thick, 
hut,  as  a  rule,  the  cavity  possesses  no  definite  limiting  nu'mbrane,  and  sec- 
tion of  the  wall  shows  an  internal  layer,  grayish  in  color,  shreddy,  and 
made  up  of  necrotic  liver  substance,  pus-cells,  and  anuj^ba";  a  middle 
layer,  brownish  red  in  color;  and  an  external  zom;  of  liyperaMuif!  liver  tis- 
sui".  The  pus  is  often  reddish  brown  in  color,  closely  resembling  anchovy 
same.  In  other  instances  it  is  grayish  white,  mucoid,  and  may  be  quite 
creamy.  The  odor  is  at  times  very  jieculiar.  In  one  instance  it  had  the 
sour  smell  of  chyme,  though  no  connection  with  the  stonuich  was  f(mnd. 

III  a  recent  case  of  amcebic  dysentery  there  were  multiple  miliary  abscesses 
ill  the  liver,  all  of  which  contained  anuebii}. 

The  bacteriological  examinatitm  of  the  co!ltent^^  show  that  as  a  rule 
tlio  i)us  is  sterile  (Kartulis).  The  terminaticju  of  this  form  of  aitscess  may 
1)0  as  follows,  as  noted  \\\  Waring's  3(iO  cases :  Kemained  intact,  fifty-six 
per  cent;  opened  by  operation,  sixteen  ])er  cent;  j)erforated  the  right 
lileiira,  nearly  five  per  cent;  ruptured  into  the  right  lung,  nine  per  cent; 
ruiitiu'cd  into  the  peritona'uni,  five  per  cent;  ruptured  into  the  colon, 
iiwirly  three  percent;  and  there  were  in  addition  instances  which  ru])t- 
ured  into  the  hepatic  and  bile-vessels  and  into  the  gall-bladder. 

{b)  Of  Septic  and  Pywrnic  Abscesses. — These  arc  always  nndtiple, 
thouirh  occasionally,  following  injury,  there  may  bo  a  large  solitary  collec- 
tion ot  pus. 

In  suppurative  pylephlebitis  the  liver  is  uniformly  enlarged.  The  cap- 
sule may  bo  smooth  and  the  external  surface  of  the  organ  of  normal 
iippearanco.    In  other  instances,  numerous  yellowish-whito  points  appear 


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448 


DISEASKS  OF  THE   DIGESTIVE  SYSTEM. 


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bencuth  the  oapKulc.  On  section  there  nro  isolated  pockets  of  pus,  either 
liaving  a  round  outline  or  in  some  places  distinctly  dendritic,  and  from 
these  tiie  pns  may  bo  squeezed.  They  look  like  small,  solitary  abscessoH, 
but,  on  probinj;,  are  found  to  communicate  with  the  portal  vein  and  U> 
represent  its  branches,  distended  and  supjjuratin^'.  The  entire  ])ortal  sys- 
tem within  the  liver  may  he  involved  ;  sometimes  tiTritorics  are  cut  otT  Iiy 
thrond)i.  The  suppuration  may  extend  into  tlio  main  branch  or  even  into 
the  mesenteric  and  gastric  veins.  'J'he  ])uh  nuiy  be  fetid  and  is  often  bile- 
stained  ;  it  may,  however,  bo  thick,  tenacious,  and  laudable.  In  suppuni- 
tivo  cholanj^'itis  there  is  usiudly  obstruction  by  gall-stones,  the  ducts  am 
greatly  distended,  the  gall-bladder  enlarged  and  full  of  jtus,  and  tlic 
branches  within  the  liver  are  extremely  distended,  so  that  on  section  tlicrc 
is  an  appearance  not  unlike  that  described  in  pyle])hlebitis. 

Suppuration  about  ccliinocoecua  cysts  nuiy  bo  very  extensive,  fctrniiiij,' 
enormous  al)scesses,  the  characters  of  which  are  at  once  recognized  by  tlio 
remnants  of  the  cysts. 

Symptoms. — («)  0/  the  Lan/r  SoUtnry  Abscemt. — In  tlu;  tropics 
there  are  instances  in  which  the  abscess  ap|)eara  to  bo  latent  ajid  to  run  a 
course  without  definite  sym])loms,  and  death  may  occur  suddenly  from 
rupture. 

Fever,  i)ain,  enlargement  of  the  liver,  ami  the  development  of  a  septic 
condition  are  the  im])ortant  symptoms  of  hepatic  abscess  The  temixni- 
turo  is  elevated  at  the  ontset  and  is  of  an  intermittent  or  stptic  type.  It 
is  irregular,  and  may  remain  normal  or  even  subnormal  f<!r  a  few  da\s; 
then  the  i>atient  has  a  rigor  and  the  temjuTaturc  rises  to  10;]°  or  hi^'licr. 
Owing  to  this  intermittt'iit  character  of  the  fever  the  cases  arc  usually,  in 
this  latitude,  mi.staken  for  malaria.  The  fever  may  riso  every  afternoon 
without  a  rigor.  Profuse  sweating  is  common,  particularly  Avhcn  the 
patient  falls  asleep.  In  chronic  cases  there  may  bo  little  or  no  fever.  A I 
the  time  of  writing,  there  is  in  one  of  my  wards  a  patient  with  liver 
abscess  which  has  perforated  the  lung  who  still  coughs  np  pus,  but 
whose  tcmi)eraturc  has  been  normal  for  weeks.  The  pain  is  variable,  .iiitl 
is  usmvUy  referred  to  the  back  or  shoulder;  or  there  i.j  a  dull  aching  sen- 
sation in  the  right  hypochondrium.  A\  hen  turi\cd  on  the  left  side,  the 
patiei\t  often  complains  of  a  heavy,  dragging  sensation,  so  that  he  usually 
l)refers  to  lie  on  the  right  side;  at  least,  this  has  been  the  case  in  a  major- 
ity of  the  instances  which  have  come  under  my  observation.  Pain  on 
pressure  over  the  liver  is  nsually  present,  particularly  deep  pressure  at  tlio 
costal  margin  in  the  nij)ple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  and,  lis 
the  abscess  cavity  is  usually  situated  more  toward  the  upper  than  tlic  un- 
der surface,  the  increase  in  volume  is  upward  and  to  the  right,  not  down- 
ward, as  in  cancer  and  the  other  aflcctions  ])roducing  enlargement.  Wv- 
eu'^sion  in  the  mid-sternal  and  parasternal  lines  may  show  a  normal  limit. 
At  the  nipple-liuo  the  curve  of  liver  dulncss  begins  to  rise,  and  in  the  inid- 


ABSCESS  OF  TIIK  LIVKR. 


449 


axillary  it  may  roach  tlio  fifth  rib,  wliilo  lu'liiiul,  near  tho  spine,  tho  arwt 
of  (liiliicss  may  bo  almost  on  u  levol  v»ith  tho  anglo  of  tho  ecuimla.  (>f 
coiirso  there  are  instances  in  whidi  tbis  clmracteriatic  feature  is  not  prcH- 
ciit,  as  wlien  tho  abscess  occupies  the  left  l(»be.  Tlie  enlargement  of  tbe 
liver  may  bo  so  great  as  to  cause  bulging  of  tlio  rigbt  side,  and  tho  edge 
niav  jtroject  a  liaiid's-breadth  or  more  below  tbe  costal  margin.  In  such 
iiiHtanix>3  tho  surface  is  smooth.  Palpation  is  jjainful,  and  there  may  be 
fri'initus  on  deep  inspiratioii.  In  some  insta!jces  iluctuation  may  bo  de- 
tected. Adbesions  nuiy  form  to,  tbe  abdominal  M'all  and  tbe  abscess  may 
jMiint  below  the  margin  of  tbe  ribs,  or  even  in  tbe  epigastric  region.  In 
iiiaiiy  cases  tlio  appearance  of  tho  j)ationt  i.s  suggestive.  Tbe  skin  has  a 
sallow,  slightly  icteroid  tint,  the  face  is  i)ale,  tbe  compl»>xion  muddy,  the 
coTijunitivio  aro  infiltrated,  and  often  sligbtly  bile-tinged,  'i'bere  is  in  tbe 
fucies  and  in  the  general  appearance  of  tbe  jiatient  a  strong  suggestion  of 
the  existen(!0  of  abscess.  Tbere  is  no  internal  alTection  associated  with 
suppuration  which  gives,  I  think,  just  tho  same  hno  as  certain  instances 
of  abscess  of  tho  liver.  Marked  jaundice  is  rare.  Diarrlura  may  bo  j^resent 
iiiul  may  give  an  important  clew  to  tlie  nature  of  the  case,  j)articularly  if 
aimi'liiv  are  found  in  this  stools,     ('onstij)atiori  nniy  occur. 

Remarkable  and  characteristic  symptoms  arise  when  the  abscess  in- 
vades tho  lung.  The  extension  inay  o('(Mir  through  the  diaphragm,  with- 
out actual  rui)ture,  and  with  tho  j)roduction  of  a  piirtileiit  pleurisy  and 
invasion  of  the  lung.  In  four  cases  of  this  kind,  which  have  been  under 
oljservation  recently,  tho  patients  gradually  dcvelo[K'(l  a  .severe  cough, 
usually  of  an  aggravated  and  convulsive  charactor,  there  were  signs  of  in- 
volvement at  tho  base  of  tho  right  lung,  defective  rosoiumco,  feeble  tubular 
breathing,  and  increase  in  tho  tactile  fremitus;  but  the  most  characteristic 
feature  was  tho  presence  of  a  reddish-brown  expectoration  of  a  brick-dust 
folor,  reseud)ling  anchovy  sauce.  This,  which  was  noted  originally  by 
Hudd,  was  present  in  our  cases,  and  in  additirm  Reese  and  Lafieur  found 
in  all  <vii(pb(e  coli  identical  with  those  which  exist  in  the  liver  abscess  and 
in  the  stools,  'i'bey  aro  present  in  variable  numbers  and  dis[)lay  active 
auKeliic  movements.  Tho  browjiish  tint  of  the  expectoration  is  due  to 
liloo(l-[)iginent  and  blood -corpuscles,  and  there  may  be  orangoM-cd  crystals 
of  ha'inatoidin. 

The  abscess  may  perforate  exteriudly,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  'J'ho  duration  of 
tliis  form  is  very  variable.  It  may  run  it.s  course  and  prove  fatal  in  six 
or  eight  weeks  or  may  persist  for  several  years. 

The  prognosis  is  serious,  as  the  mortality  is  more  than  fifty  per  cent. 
riie  death-rat  ■  /las  boon  lowered  of  late  years,  owing  to  the  greater  fear- 
li'ssiiess  with  m  hich    argcons  now  attack  these  cases. 

(h)  Of  the  Pywm'c  Abscess  and  Snppiirntivc  PylcphJcbit^''^. — Clinically 
tncso  conditions  ^aunot  be  separated.  Occurring  in  a  general  pyiemia, 
no  spooial  features  may  be  added  to  the  case.     When  there  is  suppuration 


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450 


DISEASES  OF  THE  DIGESTIVE  SYSTExM. 


within  tlie  portal  veiu  tlio  liver  is  uniformly  enlarged  and  tender,  though 
pain  may  not  be  a  marked  fe^iure.  There  is  an  irregulai,  septic  fever, 
and  the  complexion  is  muddy,  sometimes  distinctly  icteroid.  The  features 
are  indeed  those  of  pytvmia,  plus  a  slight  icteroid  tinge,  and  an  eidargcd 
and  painful  liver.  The  latter  features  alone  are  peculiar.  The  sweats, 
chills,  prostration,  and  fever  have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  may  bo  confounded  with  intermit- 
tent fever,  a  common  mistake  in  malarial  regions.  Practically  an  inter- 
mittent fever  which  resists  (luinine  is  not  inalarial.  Laveran's  organisms 
are  also  absent  from  the  blood.  When  the  abscess  bursts  into  the  pleura 
a  right-sided  em])yema  is  i)roduced  and  perforation  of  the  lung  usually 
follows.  AVlien  the  liver  abscess  has  been  latent  and  dysenteric  symptoms 
not  marked,  the  condition  may  be  considered  empyema  or  abscess  of  the 
lung.  In  such  cases  the  anchovy-sauce-like  color  of  the  ^nis  and  tlie 
presence  of  the  ama'bai  will  enable  one  to  make  a  definite  diagnosis,  as 
luis  been  done  in  cases  by  Lafleur.  Perforation  externally  is  readily  recog- 
nized, and  yet  in  an  abscess  cavity  in  the  epigastric  region  it  may  be  diflii  iilt 
to  say  Avhether  it  has  proceeded  from  the  liver  or  is  in  the  abdominal  wall. 
When  the  abscess  is  large,  and  the  adhesions  are  so  firm  that  the  liver 
does  not  descend  during  inspiration,  the  exploratory  needle  does  not  make 
an  up-and-down  movement  during  aspiration.  In  an  instance  of  tliis 
kind  which  I  saw  with  Ilcarn  at  the  Philadelphia  Hospital,  all  the  feat- 
ures, local  and  general,  seemed  to  point  to  abscess  in  the  abdominal  wall, 
but  the  operation  revealed  a  large  perforating  abscess  cavity  in  the  loft 
lobe  of  the  liver.  The  diagnosis  of  suppurating  echinococcus  cyst  is 
rar  ly  possible,  except  in  Australia  and  Iceland,  Avhere  hydatids  are  so 
common.  In  the  only  case  Avnich  has  come  under  my  observation,  the  in- 
numerable tumors  scattered  throughout  the  abdomen  and  the  great  f-hv  of 
the  liver  led,  not  unnaturally,  in  spite  of  the  occurrence  of  septic  symp- 
toms, to  the  diagnosis  of  cancer. 

Perhaps  the  most  important  affection  from  which  suppuration  within 
the  iiver  is  to  be  separated  is  the  intermittent  hepatic  fever  associated  with 
gall-stones.  Of  the  cases  reported  a  majority  have  been  considered  due  to 
suppuration,  and  in  two  of  my  cases  the  liver  had  been  repeatedly  as]iirateii. 
Post-mortem  examinations  have  shown  conclusively  that  the  high  fever 
and  chills  may  recur  at  intervals  for  years  without  suppuration  in  the 
ducts.  The  distinctive  features  of  this  condition  arc  paroxysms  of  fever 
with  rigors  and  sweats — which  may  occur  with  great  regularity,  but  wliiili 
more  often  are  separated  by  long  intervals — the  deepening  of  the  jaundice 
after  the  paroxysms,  the  entire  apyrexia  in  the  intervals,  and  the  mainte- 
nance of  the  general  initrition.  The  time  element  also  is  important,  as  in 
some  of  these  cases  the  disease  has  lasted  for  several  years.  Finally,  it  is 
to  be  remembered  that  abscess  of  the  liver,  in  temperate  climates  at  least, 
is  invariably  secondary,  and  the  primary  source  must  be  carefully  sou-rht 
for,  either  in  dysentery,  slight  ulceration  of  the  rectum,  suppurating 


NEW  GROWTHS  IN  THE  LI  VEIL 


451 


luKmorrhoiils,  ulcer  of  the  stomach,  or  in  suppurative  diseases  ol  other 
uiirts  of  tlic  body,  particuhirly  iu  the  skull  or  n;  the  bones. 

Ill  suspected  cases,  Avhethor  the  liver  is  enlarged  or  not,  exploratory 
a5;i)iration  nuiy  be  performed  without  risk.  'J'he  noodle  may  bo  entered  in 
the  anterior  axillary  lino  in  che  lowest  interspace,  or  in  the  seventh  inter- 
space in  the  mid-axillary  line,  Ox-  over  the  centre  of  the  area  of  dulness 
bohiud.  The  patient  should  bo  placed  under  ether,  for  it  may  be  neces- 
sary to  make  several  deop  punctures.  It  is  not  well  to  use  too  small  an 
a^spirator.  No  ill  effects  follow  this  procedure,  even  though  blood  may 
leak  into  the  peritoneal  cavity.  Extensive  supi)uration  may  exist,  and  yet 
he  missed  in  the  aspiration,  particularly  when  the  branches  of  the  portal 
vein  are  distended  with  pus. 

Treatment. — Pya3mic  abscesses  and  suppurative  pylephlebitis  arc  in- 
variably fatal.  Surgical  measures  are  not  justified  iu  these  cases,  unless  an 
abscess  shows  signs  of  pointing  As  the  abscesses  associated  with  dysentery 
are  often  single,  they  afford  a  reasonable  hope  for  operation.  If,  however, 
the  patient  is  expectorating  the  pus,  if  the  general  condition  is  good  and 
tlie  hectic  fever  not  marked,  it  is  best  to  defer  operation,  as  many  of  these 
instances  recover  spontaneously.  The  large  single  abscesses  olfer  the  best 
eliaucc  for  operation. 

The  general  medical  treatment  of  the  cases  is  that  of  ordinary  septi- 
caemia.* 


VI.  NEW  GROWTHS   IN  THE  LIVER. 

These  may  be  cancer,  either  primary  or  secondary,  sarcoma,  or  an- 
gioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequency  of  in- 
ternal cancer.  It  is  rarely  primary,  usually  secondary  to  cancer  in  other 
organs.  It  is  a  disease  of  late  adult  life.  According  to  Leichtonstern, 
over  fifty  })er  cent  of  the  cases  occur  between  the  fortieth  and  the  sixtieth 
years.  It  occasionally'  occurs  in  children.  Women  are  attacked  less  fre- 
quently than  men.  It  is  stated  by  some  authors  that  secondary  cancer  is 
more  conimon  in  women,  owing  to  the  frequency  of  cancer  of  the  uterus. 
Heredity  is  believed  to  have  an  influence  in  from  fifteen  to  twenty  per 
cent, 

In  many  cases  trauma  is  an  antecedent,  and  cancer  of  the  bile-passages 
IS  associated  iu  many  cases  with  gall-stones.  Cancer  is  stated  to  be  less 
common  in  the  tropics.  Its  relative  proportion  to  other  diseases  may  be 
judged  from  the  fact  that  among  the  first  three  thousand  patients  admit- 
t-(l  to  the  wards  of  the  Johns  Hopkins  Hosspital  there  were  seven  cases  of 
I'uncer  of  the  liver. 


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*  For  general  rules  and  the  modern  surgical  treiitment  of  the  condition,  the  reader 
is  reforrod  to  Uodlee's  lectures,  British  Medical  Journal,  vol.  i,  18D0. 


:m 


■  t?'    <■ 


452 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


Morbid  Anatomy. — Tlie  following  forms  of  new  growths  occur  in 
the  liver  and  have  a  clinical  importance  : 

Cancer. — (1)  Primary  cancer,  of  which  throe  forms  may  he  recog- 
nized.* 

(rt)  The  massive  cancer,  which  causes  great  enlargement  and  on  section 
shows  a  uniform  mass  of  new  growth,  which  occupies  a  large  portion  <  f 
the  organ.  It  is  grayish  white,  usually  not  softened,  and  is  abruptly  out- 
lined from  the  contiguous  liver  substance. 

{b)  Nodular  cancer,  in  whicjh  the  liver  is  occupied  by  nodular  nnissesi, 
some  large,  some  small,  irregularly  scattered  throughout  the  organ.  Usu- 
ally in  one  region  there  if  a  larger,  perhaps  firmer,  older-looking  mass, 
wliich  indicates  the  primary  seat,  and  the  numerous  nodules  ar>..  sccondarv 
to  it.  This  form  is  much  like  the  secondary  cancerous  involvement,  ex- 
cept that  it  seldom  reaches  a  large  size. 

(c)  The  third  is  the  renuirkable  and  rare  variety,  cancer  with  cirrhosis, 
which  forms  an  anatomical  picture  perfectly  imique  and  at  first  verv 
puzzling.  The  liver  is  not  much  enlarged,  rarely  weighing  more  than  two 
and  a  half  or  three  kilogrammes.  The  surface  is  grayish  yellow,  studded 
over  with  nodular  yellowish  masses,  resembling  the  projections  in  an  ordi- 
nary cirrhotic  liver.  On  section  the  cancerous  nodules  are  seen  scattered 
throughout  the  entire  organ,  varying  in  diameter  from  three  to  ten  or 
more  millimetres  and  surrounded  with  fibrous  tissue. 

Histologically,  the  primary  cancers  are  epitheliomata — alveolar  and 
trabecular.  The  character  of  the  cells  varies  greatly.  Some  varieties  are 
polymorphous ;  others  small  polyhedral ;  and  others  again  contain  giant 
cells.  In  rare  instances,  as  in  one  described  by  Greenfield,  the  cells  arc 
cylindrical.  The  trabeiular  form  of  epithelioma  is  also  known  as  adenoma 
or  adeno-carcinoma. 

(2)  Secondary  Cancer. — The  organ  is  usually  enormously  enlarged, 
and  may  weigh  twenty  pounds  or  more.  The  cancerous  nodules  project 
beneath  the  capsule,  and  can  be  felt  during  life  or  even  seen  through  tlie 
thin  abdominal  walls.  They  are  usually  disseminated  equally,  though  in 
rare  instances  they  may  be  confined  to  one  lobe.  The  consistence  of  the 
nodules  varies ;  in  some  cases  they  are  firm  and  hard  and  those  on  the 
surface  show  a  distinct  umbilication,  due  to  the  shrinking  of  the  fibrous 
tissue  in  the  centre.  These  superficial  cancerous  masses  are  still  s^oine- 
times  spoken  of  as  "  Farre's  tubercles."  More  frequently  the  masses  uru 
on  section  grayish  white  in  color,  or  hsemorrhagic.  Rupture  of  blood- 
vessels is  not  uncommon  in  these  cases.  In  one  specimen  there  wa.-  an 
enormous  clot  beneath  the  capsule  of  the  liver,  together  with  hoemorrhage 
into  the  gall-bladder  and  into  the  peritonteum.  The  secondary  cancer 
shows  the  same  structure  as  the  initial  lesion,  and  is  usually  either  an  alve- 
olar or  cylindrical  carcinoma.     Degeneration  is  common  in  these  sccond- 

*  Ilanot  and  Gilbert,  fitudes  sur  les  Maladies  du  Foie,  Paris,  1888. 


NEW  GROWTHS  IN  TIIK   LIVER. 


453 


arv  i^rowths ;  tlius  tlic  hyalino  transformation  may  convert  largo  areas  into 
!i  ilcnso,  dry,  grayish-yellow  mass.  Extensive  ureas  of  fatty  degeneration 
r.Kiy  occur,  sclerosis  ia  not  uncommon,  and  luvmorrluigos  are  frequent. 
Supjniration  sometimes  follows. 

(3)  Cancer  of  the  Bile-PuHsagfix. — Much  attention  has  1)een  given  to 
tliis  of  late,  and  both  Zenker  and  Zinsser  luivo  recently  published  ex- 
liuustivo  puperr-:  on  the  subject.  In  100  cases  collected  by  Musser  tho 
largo  proportion  (3  to  1)  were  in  females.  Jaundice  was  present  in  sixty- 
nine  per  cent,  and  in  al)out  the  same  percentage  there  was  a  tumor  in  tho 
rci^'ioii  of  t)  i  gall-bladder.  Courvoisier  has  collected  100  cases,  of  which 
80  wore  in  men  and  17  in  women.  'J'ho  association  of  cancer  of  the  bile- 
passages  with  calculi  has  long  been  recognized,  and  they  are  present  in  at 
least  seven  eighths  of  all  oases.  The  fundus  of  the  gall-bladder  is  usually 
involved  first.  The  pi  .cess  may  extend  to  the  common  or  hepatic  ducts, 
and  invasion  of  the  contiguous  structures  is  common.  The  ducts  may  be 
alTe(;ted  prinuirily. 

Sarcoma. — Of  primary  sarcoma  of  tho  liver  vei'y  few  cases  have  been 
reported.  Secondary  sarcoma  is  more  frequent,  and  many  examples  of 
Ivnipho-sarcoma  and  myxo-sarconui  are  on  record,  less  frequently  glio- 
sarcDina  or  tho  smooth  or  strij)od  myoma. 

The  most  important  form  is  the  melano-sarcoma.  which  develops  in 
the  liver  secondarily  to  sarcoma  of  the  eye  or  of  tho  skin.  Very  rarely 
melano-sarcoma  develops  primarily  in  the  liver.  Of  the  reported  cases 
llanot  excludes  all  but  one.  In  this  form  the  liver  is  greatly  enlarged,  is 
oitlier  uniformly  infiltrated  with  the  cancer,  which  gives  the  cut  surface 
tho  appearance  of  dark  granjte,  or  there  are  large  nodular  masses  of  a 
deep  black  or  marbled  color.  There  are  usually  extensive  metastases,  and 
in  some  instances  every  organ  of  the  body  is  involved.  Nodules  of  melano- 
sarcoma  of  the  skin  may  give  a  clew  to  the  diagnosis. 

Other  Forms  of  Liver  Tumor. — One  of  the  commonest  tumors  in  the 
liver  is  the  angioma,  which  occurs  as  a  small,  reddish  body  the  size  of  a 
walnut,  and  consists  simply  of  a  series  of  dilated  vessels.  Occasionally  in 
ehildron  angiomata  have  developed  and  produced  large  tumors. 

Cysts  are  occasionally  found  in  the  liver,  either  single,  which  are  not 
very  uncommon,  or  multiple,  when  they  usually  coexist  with  congenital 
lystic  kidneys. 

Symptoms. — It  is  often  impossible  to  differentiate  primary  and  sec- 
ondary cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evident, 
as  in  the  case  of  scirrhus  of  the  breast,  or  cancer  of  tho  rectum,  or  of  a 
tumor  in  the  stomach,  \,hich  can  be  felt.  As  a  rule,  cancer  of  the  liver  is 
assooiatod  with  progressive  enlargement ;  but  there  are  cases  of  primary 
nodnlar  cancer,  and  in  the  cancer  with  cirrhosis  the  organ  may  not  bo 
enlarged.  Gastric  disturbance,  loss  of  appetite,  nausea,  and  vomiting  are 
frequent.  Progressive  loss  of  flesh  and  strength  may  be  the  first  symp- 
toms.   Pain  or  a  sensation  of  uneasiness  in  tho  right  hypochondriac  region 


imr' 


Jit 


454 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


may  bo  present,  but  enormous  (enlargement  of  the  liver  may  occur  wiihoui 
the  slightest  pain.  Juurulico,  which  is  i)rcsent  in  at  least  one  half  of  the 
(;ases,  is  usually  of  moderate  extent,  unless  the  common  duct  is  oechuicd. 
Ascites  is  rare,  except  in  the  form  of  cancer  Avith  v-irrhosis,  in  Avhich  the 
clinical  ])icture  is  that  of  the  atro])hic  form.  I'ressure  by  nixlules  on  the 
portal  vein  or  extension  of  the  cancer  to  the  peritoneum  may  also  induce 
ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the 
upper  zone.  In  late  stages  of  the  disease,  when  enuiciation  is  marked, 
the  cancerous  nodules  can  be  plainly  seen  beneath  the  skin,  and  in  rare 
instances  oven  the  umbilications.  The  superficial  veins  are  enlarged.  Ou 
palpation  the  liver  is  felt,  a  hand's-breadth  or  more  below  the  costal  margin, 
descending  with  each  iiisi)iration.  The  surface  is  usually  irregular,  and 
may  present  large  masses  or  smaller  nodular  bodies,  either  rounded  or 
with  central  depressions.  In  instances  of  diffuse  infiltration  the  liver  mav 
be  greatly  eidarged  and  present  a  perfectly  smooth  surface.  The  growth 
is  progressive,  and  the  edge  of  the  liver  may  ultimately  extend  below  tlio 
level  of  the  navel.  Although  generally  uniform  and  producing  enlarge- 
ment of  the  whole  organ,  occasionally,  when  the  tumor  develops  from  the 
left  lobe,  it  may  form  a  solid  mass,  which  occupies  the  epigastric  region. 
By  percussion  the  outliiue  can  be  accurately  limited  and  the  iirogressivc 
growth  of  tumor  estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is 
present  in  many  cases,  usually  a  continuous  fever,  ranging  from  100''  to 
103° ;  it  may  be  intermittent  Avith  rigors.  This  may  be  associated  with 
the  cancer  alone,  or,  as  in  one  of  my  eases,  Avith  suppuration.  (Edema  of 
the  feet,  from  anaemia,  usually  supervenes.  Cancer  of  the  liver  kills  in 
from  three  to  fifteen  months. 

Diagnosis. — The  diagnosis  is  easy  Avlien  the  liver  is  greatly  enlarged 
and  the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may 
at  first  bo  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  jaun- 
dice, the  rapid  enlargement,  aiul  the  more  marked  cachexia  will  usually 
suffice  to  differentiate  it.  Perhaps  the  most  puzzling  conditions  occur 
in  the  rare  cases  of  enlarged  amyloid  liver  Avith  irregular  gummata.  The 
large  echinococcus  liver  may  present  a  striking  similarity  to  carcinoma, 
but  the  [yrojecting  nodides  are  usually  softer,  the  disease  lasts  much  longer, 
and  the  cachexia  is  not  marked. 

Hypertrophic  cirrhosis  may  at  first  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large ;  but  the  absence  of  a 
marked  cachexia  and  wasting,  and  the  paiidess,  smooth  character  of  the 
eidargcment  are  points  against  cancer.  When  in  doubt  in  these  case;^. 
as})iratiou  may  bo  safely  performed,  and  positive  indication  may  be  gained 
from  the  materials  so  obtained.  In  large,  rapidly  groAving  secondary 
cancers  the  superficial  rounded  masses  may  almost  fluctuate  and  those 
soft  tumor-like  projections  may  contain  blood.  The  form  of  cancer  with 
cirrhosis  can  scarcely  be  separated  from  atrophic  cirrhosis  itself.     Perluijis 


FATTY  LIVER. 


455 


tlio  wasting  is  more  extreme  uiul  more  rapid,  l)ut  the  jaundice  and  the 
asfito3  are  identical.  Melano-sarcoma  causes  great  enlargoment  of  the 
or^jaii.  There  are  frequently  sym])t()ms  of  involvement  of  other  viscera, 
11.-;  tlio  lungs,  kidneys,  or  S2)leen.  Secondary  tumors  may  develop  on  the 
r,kiii.  A  very  important  symptom,  not  })re.scnt  in  all  cases,  is  melanuria, 
the  passage  of  a  very  dark-colored  urine,  whicli  nuiy,  however,  when  lirst 
voiikul,  be  quite  normal  in  color.  IMu;  existence  of  a  melano-sarcoma  of 
the  eye,  or  the  history  of  blindness  in  one  eye,  with  subsequent  extirpa- 
tion, may  iiulicate  at  once  the  true  nature  of  the  hepatic;  enlargement. 
The  secondary  tumors  may  develop  some  time  after  the  extirpation  of  the 
eye,  as  in  a  case  under  the  care  of  J.  C.  Wilson,  at  the  Pliila(leli)hia  Hos- 
pital, or,  as  in  a  case  under  Tyson  at  the  same  institution,  the  patient 
iiiiiv  have  a  sarcoma  of  the  choroid  which  had  never  caused  any  symp- 
toms. Primary  cancer  of  the  gall-bhuldcr  can  rarely  be  diagnosed.  It 
iiiiiy  be  greatly  dilated  and  readily  2)alj)able.  Occasionally  tumors  of  the 
kidney  or  a  tumor  of  the  transverse  colon  may  be  confounded  with  it. 

The  treatment  must  be  entirely  symj)tomatic — allaying  the  pain,  re- 
lieving the  gastric  distarbance,  and  meeting  other  symi)toms  as  they  arise. 


VII.  FATTY  LIVER. 

Two  different  forms  of  this  condition  are  recognized — the  fatty  inlil- 
tnition  and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since 
the  cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the 
protoplasm  of  the  liver-cells  is  destroyed  and  the  fat  takes  its  })lace,  as 
seen  in  cases  of  malignant  jaundice  and  in  phosphorus  poisoning. 

Fatty  liver  occurs  iindei  the  following  conditions :  {a)  In  association 
with  general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the 
store-houses  of  the  excessive  fat.  {b)  In  conditions  in  which  the  oxida- 
tion processes  are  interfered  with,  as  in  cachexia,  profound  ana;mia,  aiul  in 
phthisis.  The  fatty  infiltration  of  the  liver  in  heavy  drinkers  is  to  be 
iittiibutod  to  the  excessive  demand  made  by  the  alcohol  upon  the  oxj'gen. 
('•)  Certain  poisons,  of  wliich  })hosphorus  is  the  most  characteristic,  pro- 
•laco  an  intense  fatty  degeneration  with  necrosis  of  the  liver-cells.  The 
jioisoii  of  acute  yellow  atrophy,  whatever  its  nature,  acts  in  the  same  way. 

The  fatty  liver  is  uniformly  increased  in  size.  The  edge  may  reach 
hjlow  the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless ;  on 
siH'tion  it  is  dry,  and  renders  the  surface  of  the  knife  greasy.  The  organ 
may  weigh  many  pounds,  and  yet  the  specific  gravity  is  so  low  that  the 
entire  organ  floats  in  water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  pres- 
ent ;  the  stools  may  be  light-colored,  but  even  in  the  most  advanced  grades 


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456 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


tho  bilo  i3  still  formed.  Si;,'us  of  jiortal  obHtruotion  arc  raro.  ITa'inor- 
rhoids  arc  not  very  infrequent.  Altogether,  tho  symptoms  are  ill-delliicd, 
and  chiefly  those  of  tho  (Msease  with  which  the  degeneration  is  associated. 
In  cases  of  great  ohesitv,  the  physical  examination  is  un(;ertain ;  but  in 
])hthisis  and  cachectic  conditions,  the  organ  can  1)0  felt,  greatly  enlarged, 
smooth,  and  painless.  Fatty  livers  are  among  the  largest  met  with  at  the 
bedside. 


VIII.  AMYLOID  LIVER. 

The  waxy,  lardaccous,  or  amyloid  liver  occurs  as  part  of  a  general 
degeneration,  associated  with  cachexias,  particularly  when  the  result  of 
long-standing  su})puration. 

In  practice,  it  is  found  oftenest  in  tho  prolonged  suppuration  of  tuber- 
culous disease,  either  of  the  lungs  or  of  the  bones.  Next  in  order  of  fre- 
quency are  the  cases  associated  with  syphilis.  Here  there  may  be  ulcera- 
tion of  the  rectum,  with  which  it  is  often  connected,  or  chronic  disease  of 
the  bone,  or  it  may  be  present  when  there  are  no  supj)urative  changes.  It 
is  found  occasionally  in  rickets,  in  prolonged  convalescence  from  the  infec- 
tious fevers,  and  in  the  cachexia  of  cancer. 

The  amyloid  organ  is  large,  and  may  attain  dimensions  equalled  only 
by  that  of  the  cancei'ous  organ.  "Wilks  speaks  of  a  liver  Aveighing  four- 
teen pounds.  It  is  solid,  firm,  resistant,  on  section  anaemic,  and  has  a 
semitranslucent,  infiltrated  appearance.  Stained  with  a  dilute  solution  of 
iodine,  the  areas  infiltrated  with  the  amyloid  matter  assume  a  rich  mahog- 
any-brown color.  The  precise  nature  .of  this  change  is  still  in  question. 
It  first  attacks  the  capillaries,  usually  of  the  median  zone  of  the  lobules, 
and  subsequently  the  interlobular  vessels  and  the  connective  tissue.  The 
cells  are  but  little  if  at  all  affected. 

There  are  no  characteristic  ftymptoms  of  this  condition.  Jaundice 
does  not  occur;  the  stools  may  be  light-colored,  but  tho  secretion  of  bile 
persists.  The  physical  examination  shows  the  organ  to  be  uniformly  en- 
larged and  painless,  the  surface  smooth,  the  edges  rounded,  and  the  con- 
sistence greatly  increased.  Sometimes  the  edge,  even  in  very  great  enlurge- 
nicnt,  is  sharp  and  hard.  Tiie  spleen  also  may  be  involved,  but  there  are 
no  evidences  of  portal  obstruction. 

The  diagnosis  of  the  condition  is,  as  a  rule,  easy.  Progressive  and 
great  enlargement  in  connection  with  suppuration  of  long  standing  or 
with  syphilis,  is  almost  always  of  this  nature.  In  rare  instances,  however, 
the  amyloid  liver  is  reduced  in  size. 

In  IcitJcamia  the  liver  may  attain  considerable  size  and  be  smooth  and 
uniform,  resembling,  on  physical  examination,  the  fatty  organ.  The  blood 
condition  at  once  indicates  the  true  nature  of  the  case. 


ILEMOIIKIIAUK.  457 


IX.  DISEASES   OF   THE   PANCllEAS. 
I.   HiCMORRHAGE. 

Of  late  VPJirs  inuch  attention  1ms  been  })ai(l  to  this  condition,  vvhi(!li 
niiiy  prove  nipidly  fatu!  and  lias  important  jnedieo-legal  l)earin<,'s.  F.  W. 
Draper*  has  re})orted  five  eases,  in  all  of  which  death  occurred  cither  sud- 
denly or  after  a  very  short  illness.  Ihe  symptoms  are  thus  briefly  sum- 
marized by  Prince : 

"The  patient,  who  has  previously  been  perfectly  well,  is  suddenly  taken 
with  the  illness  which  terminates  his  life.  .  .  .  When  the  Im-morrhagc 
oL'curs  the  patient  may  be  quietly  restin}?  or  pursuing  his  usual  occupa- 
tion. The  pain  whicli  ushers  in  the  attack  is  usually  very  severe,  and  lo- 
cated in  the  upper  part  of  the  abdomen.  It  steadily  increases  in  severity, 
is  sliurp  or  perhaps  colicky  in  character.  It  is. almost  from  the  first  ac- 
(•(inipiinied  by  nausea  and  vomiting;  the  latter  becomes  frequent  and  ob- 
stinate, but  gives  no  relief.  The  patient  soon  becomes  anxious,  restless, 
and  depressed  ;  he  tosses  about,  and  only  with  difiiculty  can  be  restrained 
in  1)(m1.  The  surface  is  cold,  and  the  forehead  is  covered  w^ith  a  cold  sweat. 
The  pidse  is  weak,  raj)id,  and  sooner  or  later  impercei)tible.  The  abdo- 
iiuMi  l)ccomes  tender,  the  tenderness  being  located  in  the  upper  jiiirt  of  the 
alxlimieii  or  epigastrium.  Tympanites  is  sometimes  marked.  The  tem- 
perature in  most  cases  is  either  normal  or  below  normal.  The  bowels  are 
apt  to  be  constipated.  These  symptoms  continue  without  relief ;  those 
wiiicii  arc  most  striking  being  the  pain,  vomiting,  anxiousness,  restless- 
ness, and  the  state  of  colla])se  into  which  the  patient  soon  falls." 

Post  mortem,  the  pancreas  is  found  uniforudy  infiltrated  with  blood. 
Death,  as  Zenker  suggests,  is  probably  due  to  shock  through  the  solar 
|)lexus. 

Tlu're  are  cases  in  which  extensive  hemorrhage  occurs  into  the  mesen- 
tery, n'troperiton«um,  or  mesocolon.  In  a  patient  of  Bruen's,  at  the 
Pliihulelphia  Hospital,  who  had  for  some  days  obscure  abdominal  symp- 
toms, I  found  the  entire  mesentery  and  retroperitona>um  infiltrated  with 
blood-clots.  There  was  no  disease  of  the  aorta  or  of  the  cudiac  branches 
or  of  the  mesenteric  vessels.  Isambard  Owen  has  reported  a  case  of  sud- 
(li'n  death  in  a  woman  aged  sixty-seven  from  haemorrhage  into  the  trans- 
verse mesocolon. 

*  Transactions  of  the  Association  of  American  Physicians,  vol.  i. 


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458 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


II.  ACUTE   PANCREATITIS. 


(a)  Acute  Haemorrhagic  Pancreatitis.— The  iKlininihlc  studios  of  Fitz* 

liiiv(!  crvstiilli/od  our  kiiowlcdf^u  on  this  Kuhjcct,  and  broiij^lit  tlio  all'cctioii 
within  tli(!  scopo  of  tlK;  diii/^fiiosticiaii.  A  niajority  of  the  ciusoa  occur  in 
]U'rsons  over  thirty.  Many  of  the  paticiitH  had  been  achlictcd  to  alcolidl. 
and  many  liad  sutrcrcd  from  atta(;ks  of  indigestion,  occasionally  with  .sc\cri 
pains  and  voniitin<^. 

Morbid  Amitoiini. — Tlic  pancreas  is  I'ouiul  enlar<,'ed,  and  the  intcrlnhii- 
lar  tissue  iidiltrated  with  l)loo(l,and  perhai)s  witli  clots.  In  some  instances 
the  eonti<,Mious  tissues  nuiy  also  be  ha'morrhaf,dc,  and  the  whole  may  form 
a  larj^'e,  iirm  mass,  situated  at  the  u[)per  and  back  [>art  of  the  al)domiiiiil 
cavity.  'i'iie  root  of  the  mesentery,  tlu^  mesocolon,  and  the  onicntinii 
may  also  show  Inemorrhages ;  the  other  or<^ans  may  be  ))ractically  nortiml. 
In  some  instances  there  can  bo  seen  about  the  lobules  areas  of  opaf|iic 
white  tisane,  and  upon  the  omentum  and  mesentery  similar  opafpu',  wiiitc 
specks,  which  will  be  referred  to  subserpu'iitly  as  the  fatty  necrosis  of 
lialser.  In  sjjots  the  ffland-cells  may  also  be  found  necrotic,  while  there 
may  be  cases  showin<i;  a  marked  increase  in  the  fibrous  tissue. 

The  !<i/»ipf()7n,s  of  this  condition  are  remarkable.  The  attack  sets  in 
with  violent  pain  in  the  abdomen,  usually  in  the  upi)er  zone,  but  in  some 
instances  it  is  <reneral.  Nausea  and  vomitin<i;  are  present,  and  usually  con- 
stij)ation.  Tynii)anitic  distention  of  the  abdomen  is  of  frequent  occurrence. 
Fever  may  be  present,  but  is  an  inconstant  symptom.  There  may  be  early 
d-  a.    CoUapao  sym[)toms  supervene,  and  death  occurs  us\uilly  from  the 

?/  to  the  fourth  day,  or  even  earlier.     The  swellins^  and  inliltratioii  in 

the  rejrion  of  the  pancreas  necessarily  involve,  the  cceliac  plexus,  and  tlic 
stretching  of  the  nerves  may  account  for  the  agonizing  pain  and  the  sud- 
den colla[)se.  In  a  case  which  I  have  reported  the  semilunar  ganirliii 
were  swollen,  the  nerve-cells  indistinct,  aiul  there  was  an  interstitial  iiilil- 
tration  of  round  cells.  The  Pacinian  cori)Uscles  in  the  neighborhood  nf 
the  pancreas  were  enormously  swollen  and  (jodennitous. 

A  (/i(f(/nosis  of  intestinal  obstruction  or  of  acute  perforative  jieritoiiitis 
is  usually  made.  A  correct  diagnosis  was  made  in  one  case  by  Fitz,  and 
the  possibility  of  the  presence  of  this  condition  must  he  considered  in  all 
abdominal  cases  which  come  on  suddenly  with  intense  pain  in  the  epi- 
gastric region,  vomiting,  and  distention  of  the  abdomen.  Perforation  cf 
a  peptic  ulcer  or  perforation  from  gall-stones  might  produce  simihir 
symptoms,  but  the  previous  history  would  give  important  indications.  In 
the  case  in  which  the  diagnosis  was  made  by  Fitz,  the  patient  was  snd- 
denly  seized  with  severe  pain  in  the  ejjigastrium,  followed  by  vomiting 
and  prostration.  The  abdomen  was  distended,  temperature  slightly  clf- 
vated,  and  the  bowels  were  constipated.     The  diagnosis  lay  between  cb- 

*  Middleton-Qoldsmitli  Lecture.     New  York  Medical  Record,  vol.  i,  1889. 


Ji  i      >'-,        !       i,; 


..if 


.^rnvf" 


ACUTE   I'ANCUKATITIS. 


459 


struction,  iicrlonitivi!  [U'ritonitis,  ntid  acute  luiiicrciititis.  Liiparotomy  was 
liiiloriiird,  but  no  obstructiou  found.  The  auto|».sy  showuil  ucutu  lunuior- 
r\r.v/u-  pancreutitis. 

Tlie  casoa  uro  Htahd  to  bo  unifonnly  fatal,  but  recovery  may  occur,  as 
sliowii  bv  H  oarto  which  was  admitted  to  tiie  .lohns  llopkius  Hospital. 
Sviiiptoms  of  obstruction  (tf  tiie  bowels  had  |  ersisted  for  three  or  four 
(iiivs  tho  abdomen  was  distended,  tender,  and  very  painful.  I  saw  the 
iiiiiicnt  on  ailmissioii,  cfoncurred  in  the  (lia<;ii(isis  of  probable  obstruction, 
and  as  the  (iondition  was  serious,  ordered  him  t(t  be  transferred  at  once  to 
thr  (i|)eratin<f-rooin.  The  c(jils  were  distended  and  injected,  and  the  peri- 
loiical  cavity  contained  a  small  amount  of  bloody  serum.  No  <»bstructioii 
was  found,  but  in  tho  re;,non  of  tho  ])ancrea.s  and  at  tho  root  of  tho  mesen- 
tery there  was  a  dense,  thick,  indurated  nniss  and  there  wore  areas  of  fat- 
iKvpisis  in  both  mesc^itery  and  omentum      The  patient  recovere(I. 

The  literature  of  the  past  few  years  shows  that  this  all'e(;tion  is  much 
Miiirt'  fre(|iuMit  than  lias  boon  sui)[)osed.  It  has  a  very  imj)ortaut  clinioul 
ami  iiu'dico-lof^al  bearing. 

A  poiut  of  interest  is  the  relation  of  tho  f((t-ui'nrosis  to  paiu'reatic 
disease.  The  areas  are  found  in  the  interlobidar  paiuM-eatic-  tissue,  in  the 
nu'seiitery,  in  the  omentum,  and  in  the  alxlomimd  fatty  tissue  generally. 
In  the  pancreas  tho  lobules  are  seen  to  be  separated  by  a  dead-wliite 
necrotic  tissue,  which  gives  a  remarkable  apjiearanco  to  the  section.  In 
the  abdominal  fat  tho  areas  are  usually  not  larger  than  a  pin's  head  ;  they 
at  once  attract  attention,  and  may  bo  mistaken,  on  superficial  examina- 
tiiiii,  for  miliary  tubercles  or  neoplasms.  They  nuiy  be  larger;  instances 
have  been  reported  in  which  they  were  the  size  of  a  hen's  egg.  On  section 
tliey  have  a  soft,  tallowy  consistence.  Langerhans  has  sliown  that  this 
substance  is  a  combination  of  lime  with  certain  fatty  acids.  They  may  l)e 
cnistcd  with  lime,  and  in  a  man,  aged  eighty,  who  died  of  liright's  disease, 
I  found  tho  lobules  of  tho  pancreas  entirely  isolated  by  areas  of  fatty  ne- 
crosis with  extensive  deposition  of  lime  salts.  There  is  no  necessary  etiolog- 
ii'al  relation  between  disease  of  tho  ])aneroas  and  disseminated  fatty  necro- 
sis (if  the  alxlomen.  (-'asos  have  been  found  accidentally  in  la[)arotomy  for 
ovarian  tumor  and  in  instances  in  which  the  pancreas  has  been  normal. 
They  may  be  found  in  thin  ])ersons.  The  hnderium  coll  commune  was 
present  in  two  cases,  with  diphtheritic  colitis,  examined  by  Wehdi. 

(/')  Suppurative  Pancreatitis. — Of  twenty-two  cases  analyzed  by  Fitz, 
the  majority  occurred  in  adults  under  forty  years  of  age;  seventeen  were 
Males.  Anatomically,  there  may  be  a  diffuse  suppuration  throughout  tho 
orj,'an,  which  la  studded  with  small  abscesses.  In  other  instances  the 
iihseess  cavity  is  large  and  the  pancreas  is  converted  into  an  irregular 
cyst  idled  with  creamy  pus.  In  more  chronic  cases  the  abscess  may  be 
circumscribed  and  the  contents  chc  :'sy.  Communications  sometimes  oc- 
cur with  the  duodenum,  or  the  abscess  may  burst  into  the  peritonajum. 
Although  the  disease  is  usually  chronic,  it  begins  with  epigastric  pain. 


K'    < 


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ii&i-- 


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1 


460 


DISKASKS  OF   'J'lIK   DKf KS'l'lVK  SVSTKM. 


vomit iii^',  iiiirl  S()?iu!tiirum  proHtrutioii.  Tlicrc  is  iiri';,Miliir  fever,  uiid  duiitli 
iiiiiy  occur  ill  tlireo  or  four  weeks.  lu  more  eiironic  eii«eH  there  i»  very 
riii^'iit  fever  or  only  occiisioiuil  [niroxysms.  'I'lie  disetise  may  persist  fnr 
weei\s,  months,  or  even  for  ti  year. 

The  Hymptoms  are  indelinite  and  the  condition  could  scunieiy  lie  made 
out  (hirinj,'  life.  Tenderness  exists  in  the  epi-^'astrium,  or  uuiy  at  times 
(ixtciul  to  the  l(d't  and  he  (|uiti'  sluiridy  htcali/ed  over  the  position  of  the 
pancreas,  hut  a  eircumserihed  tinnor  is  rari".  Fat-necrosis  is  not  often 
I'ouiul  post  mortem  in  these  ca^es. 

(/•)  Gangrenous  Pancreatitis.— Fitz  has  collected  lifteen  eases.  The 
paiu'reas  may  he  converted  into  a  dark,  slate-ciolored,  stinkinj;  mass,  or  it. 
may  lie  nearly  free;  in  the  omental  cavity,  att^iched  oidy  hy  a  few  shreds  of 
lihrous  tissue.  (Jomi)lete  se(|uestration  of  the  or<,'an  is  not  uncoiniaon. 
It  imiy  he  (lis(!har<,'ed  as  a  hiouf^h  from  the  bowels,  and  in  two  eases 
in  which  this  hai)pened  recovery  took  place.  As  a  rule,  acutv  pcrild- 
nitis  follows.  IIii'inorrha^i(!  pancreatitis  may  pHMuule  or  he  iusocialiMl 
with  it.  j)eath  o(!(!urs  with  symptoms  of  collapse,  commonly  in  from  ten 
to  twenty  days.     Disseminated  fat-necrosis  is  usually  present. 


III.  CHRCIMIC  PANCREATITIS. 

The  or<?an  is  lirmer  than  7U)rmal,  the  interstitial  connective  tissue  is 
increased,  and  tiiere  is  more  ox  less  change  in  the  sec.'retinf;  stru(!turcs.  A 
8j)ecial  inter'  st  has  been  aroused  lately  in  this  alTeetion,  as  it  has  been  fre- 
quently fouiul  in  diabetes.  Tiiere  may  be  marked  pi<j^nieiit;iry  (tlians^cs; 
a  similar  condition  has  been  found  in  the  liver.  J)e<fen(iration  of  the 
l^landular  elen-.nits  is  present  in  these  cases.  The  sclerosis  may  be  associ- 
ated with  calculi  in  the  ducts. 


IV.  PANCREATIC  CYSTS. 

These  commonly  result  from  the  impaction  of  calculi ;  either  biliary, 
lodffing  at  the  orifice  of  the  (common  duct,  (u*  pancreati(t,  within  tiic  duet 
of  Wirsung.  The  pancreatic  concretions  consist  xisiuilly  of  carboniilc  ef 
lime.  George  Johnston  has  collected  35  cases  from  the  literature.  Ob- 
literation of  the  duct  may  also  result  from  cicatricial  contraction  and 
occasionally  from  displacement.  Eighteen  cases  of  cysts  of  the  j)aiicivas 
have  been  collected  by  Senn.  The  chief  symptoms  are  tumor  in  the  epi- 
gastric region,  usually  median,  or  sometimes  to  one  side.  When  lartre  it 
has  occupied  the  whole  abdominal  cavity,  and  in  such  instances  the  iliuif- 
nosis  of  ovarian  tumor  has  usually  been  made.  The  tumor  may  develop 
rapidly,  or  may  be  chronic  and  last  for  many  years.  In  some  iiistiiiiccs 
the  tumor  attained  a  large  size  within  a  few  weeks.     Pain  is  not  ucceb 


tl 


ill '  v^^^ 

Hi 


CANCER. 


401 


wirilv  proHcnt.     Fiitty  diiirrlui'ii  did  not  exist  in  any  of  the  cusim.     TIuj 
Ktouls  iiiiiy  bo  ('Iiiy-<'olor('d,  copious,  and  putrosccnL 

'I'lu!  dia;,'iiosi'  of  tiic  couditioii  must  he  rxtrcnu-Iy  ditlicult,  yet  it 
scH'iiw  to  liav((  lii'fu  made  in  T  nf  tiic  IH  cases.  Aspiration  sluailil  l)c  made 
todi'lcnniiu!  tlic  Tuiturc  of  tiic  tliiid.  Tliis  lias  varied  considcraltiy,  but 
most  fri'(|uciitly  bas  lu'cn  l>rovviiisii  or  ciiocolatc-coiorc(l.  In  only  <»  of  tho 
n  cases  in  wliich  tbo  nature  is  montioned  -.vas  tlic  lluid  of  ii  clear  serous 
eluiraeler. 

V.  CANCER. 

This  is  usually  scirrbus,  and  may  be  primary  or  secondary.  It  is  not 
coninion,  as  may  bo  jud;i;ed  by  tla^  analysis  by  Sej^rc,  who  found  in  11,4!I2 
iiuto|isies  oidy  Vi'Z  tumors  of  tiu'  pancreas,  1^7  of  wbicb  were  carcinonuitu, 
2  siu'coMiata,  2  cysts,  and  1  sy}»biloma.  in  only  I'i  of  the  (uiscs  of  carcino- 
ma was  the  disease  limited  to  the  ^land.  Tlu'  head  is  (lonimonly  alTected, 
and  the  disease  may  bo  limited  to  this  part  or  cxund  to  it  from  the  stom- 
iu'li  or  intestines. 

Tile  symptoms  are  variable,  and  a  dia<,Mios;.  is  not  often  possible. 
There  may  bo  stoarrha'a,  thoujfh  it  is  to  be  nMnembered  that  fatty  diar- 
rhu'a  is  not  invariably  associated  with  disease  of  the  pancreas.  Clay-col- 
ored.'ii'fasy,  and  loose  stools  maybe  i)resent,  with  undigested  food,  as 
noted  by  T.  J.  Walker  as  a  symptom  of  obstruction  of  the  pancreatic 
duel.  Diabetes  may  coexist.  Although  the  head  of  the  i)ancreas  can  be 
felt  ill  very  thin  persons,  the  tumor  masses  can  rarely  bo  paljmted.  In 
the  analysis  of  137  cases  by  Da  Costa,  in  only  13  was  the  tumor  recognized 
liy  palpation.  The  general  symptoms  are  those  of  internal  carcinoma. 
I'ldirressive  emaciation,  loss  of  strength,  and  dyspepsia  are  present.  There 
ii^  pain  in  the  epigastrium,  sometimes  ])aroxysmal.  When  the  head  of  the 
pancreas  is  involved  jaundice  is  almost  invariably  present. 

Tiie  disease  can  ^y^arcely  ever  be  distinguished  from  cancer  in  the 
pyloric  zone  with  involv'ement  of  the  glands  in  the  hilus  of  the  liver.  The 
niovalile  charaf^ter  of  the  j)3'loric  tumor  and  the  absence  of  the  hydro- 
cliloric  acid  in  the  vomit  are  valualile  points.  Tumor  of  the  transverse 
colon  is  more  superficial  and  movable,  is  often  associated  with  temporary 
olist ruction,  and  there  may  be  hiemorrhago  from  the  bowels.  In  a  case 
with  progressive  emaciation,  epigastric  pain,  and  deop-soated,  immobile 
tumor,  with  the  ])rosenee  of  fatty  and  grea.sy  stools  and  the  gradual  devel- 
opment of  jaundice,  the  diagnosis  of  cancer  of  the  pancreas  is  probable. 

As  the  wasting  proceeds  the  aortic  pulsation  is  transmitted  with  great 
force  tlirongh  the  ])ancrei.s  and  transverse  colon,  and  when  a  tumor  is 
lircscnt  the  diagnosis  of  aneurism  may  be  nnide ;  ])ut  in  the  latter  the 
sue  liiis  not  an  up-and-down  jerking  pulsation,  but  is  distensile.  In  doubt- 
ful tumors  in  this  region  the  examination  should  also  be  made  in  the  knee- 
flbow  ])osition. 


^1 


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ff 


462 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


Of  othei"  new  growtlis  in  the  jjancreus,  tubercle  may  be  mentioned  us 
a  rare  ofcurrence;  a  few  cases  of  syphiloma  liave  been  described. 

The  treatment  of  new  growths  in  the  pancreas  is  entirely  symptomatic. 


X.  DISEASES   OF  THE  PERITONEUM. 

I.  ACUTE  GENERAL  PERITONITIS. 

Definition. — Acute  inflammation  of  the  peritonanim. 

Etiology. — 'I'he  condition  may  be  i)rimary  or  secondary. 

(a)  Primary,  Idiopathic  Peritonitis.— Considering  liow  frequently  the 
pleura  and  ijcricardium  are  })rimarily  inflamed  the  rarity  of  idioputliic 
inflammation  of  the  jjeritona'um  is  somewhat  remarkable.  It  may  follnw 
cold  or  exposure  and  is  then  known  as  rheumatic  peritonitis.  No  instance 
of  the  kind  has  come  under  my  notice.  Occasionally  in  Bright's  disease 
acute  {jcritonitis  develops  as  a  terminal  event. 

{/')  Secondary  Peritonitis  is  due  to  extension  of  inflammation  from,  or 
perforation  of  one  of  the  organs  covered  by  the  peritonasum.  Peritonitis 
from  extension  may  follow  inflammation  of  the  stomach  or  intestiiies, 
extensive  ulceration  in  these  parts,  cancer,  acute  suppurative  inflammations 
of  the  s])leen,  liver,  pancreas,  retroperitoneal  tissues,  and  the  pelvic  viscera. 

Perforative  peritonitis  is  the  nu)st  common,  following  external  wounds, 
pei'foration  of  ulcer  of  the  stomach  or  bowels,  perforation  of  the  gall- 
bladder, abscess  of  the  liver,  spleen,  or  kidneys.  Two  important  causes 
are  appendicitis  and  suppurating  inflammation  about  the  Fallopian  tubes 
and  ovaries.  There  are  instances  in  which  iieritonitis  luis  followed  vu[)turo 
of  ail  apparently  normal  CJraafian  follicle. 

The  peritonitis  of  sei)tica3mia  and  pyaemia  is  almost  invariably  the  re- 
sult of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  may  1)(! 
caused  by  the  development  of  tubercles  on  the  membrane. 

Morbid  Anatomy.— In  recent  cases,  on  opening  the  abdomen  tlie 
intestinal  coils  are  distended  and  glued  together  by  lymph,  and  the  ])eri- 
touivum  presents  a  pati'hy,  sometimes  a  uniform  injection.  The  exuda- 
tion may  be :  (a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets 
of  clear  serum  between  the  coils,  (h)  Sero-flbi'inous.  1'he  coils  arc  cov- 
ered with  lym])h,  and  there  is  in  addition  a  large  amount  of  a  yellinvisli, 
scro-fil)rinous  fluid.  In  instances  in  which  the  stomach  or  intestine  is 
perforated  this  may  be  mixed  with  food  or  fa3ces.  (c)  Purulent,  in  ^\\^u^h 
the  exudate  is  either  thin  and  greenish  yellow  in  color,  or  o2)a([nc  wliito 
and  creamy.  {(/)  Putrid.  Occasionally  in  jiuerperal  and  ])erforative  peri- 
tonitis, i)articularly  when  the  latter  has  been  caused  by  caiuicr,  tlie  exudate 
is  thin,  grayish  green  in  color,  and  has  a  gangrenous  odor.  {<')  llainor- 
rbagic.    This  is  sometimes  found  as  an  admixture  in  cases  of  acute  I'li'i- 


ACUTE  GENERAL  PERITONITIS. 


4G3 


toiiitis  following  wounds,  and  occurs  in  the  cancerous  and  tuberculous 

I'liniis. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  twenty  or  thirty 
litres.  There  are  probably  essential  differences  between  the  various  kinds 
of  iioritonitis,  and  biicteriology  is  beginning  to  give  us  valuable  hifornui- 
tioii  on  this  point.  Of  the  species  of  micro-organisms  which  have  been 
Idiinil  in  peritoneal  exudates,  the  pyogenic  micrococci  and  tho  bacterium 
(vli  rovinmne  are  the  most  common,  sometimes  one  species,  often  several 
s|)(Hios  be'ng  found  in  the  same  case.  The  streptococcus  pyor/eiies  is  by 
far  tlio  most  frequent  cause  of  puerperal  peritonitis.  This  spec.'ies,  and 
vstill  oftener  the  staphylococcus  pyogenes  aureus,  or  atOus,  are  found  in 
peritonitis  consecutive  to  laparotomy.  The  bacterium  coli  commttne,  us,i>- 
ally  combined  with  other  bacteria,  is  met  with  esiMjcially  in  i>erit(mitis 
socoiulary  to  intestinal  perforation.  Tlie  diplocorcus  pneuinoniw  has  been 
foiiiid  several  times  in  peritoneal  exudates.  The  amoeba  coli  occurred  in 
lumilxM-s  in  the  tiiin  librinous  effusion  in  one  of  our  cases  of  umasbie 
dysentery. 

Symptoms. — In  the  perforative  and  septic  cases  the  onset  is  marked 
l)y  chilly  feelings  or  an  actual  rigor  with  intense  pain  in  the  abdomen.  la 
tvplidid  fever,  when  tlie  sensorium  is  benumbed,  the  onset  may  not  be 
noticed.  The  pain  is  general  and  is  usually  intense  and  aggravated  by 
movement-'  and  })ressure.  A  position  is  taken  which  reliev  .is  the  tension 
of  the  abdominal  muscles,  so  that  the  patient  lies  on  the  back  with  tho 
thij^dis  drawn  up  and  the  shoidders  elevated.  The  greate;-it  pain  is  usually 
hchiw  the  umbilicus,  but  in  peritonitis  from  perforation  of  the  stomach 
pain  may  be  referred  to  the  back,  the  chest,  or  the  shoulder.  T'he  respira- 
tion is  superficial — costal  in  type — as  it  is  painful  to  usj  the  diai)hragm. 
For  the  same  reason  the  action  of  coughing  is  restrained,  and  even  tho 
movements  necessary  for  talking  are  limited.  In  this  early  stage  the  sensi- 
tiveness may  be  great  and  the  abdominal  muscles  are  often  rigidly  con- 
tracted. If  the  patient  is  at  perfect  rest  the  pain  may  be  very  slight,  and 
there  are  instances  in  which  it  is  not  at  all  marked,  ami  may,  indeed,  be 
ah.sent. 

The  abdomen  gradually  becomes  distended  and  tense  and  is  tympanitic 
on  percussion.  The  pulse  is  rapid,  sinall,  and  ^^  "d,  and  often  has  a  jjeeuliar 
wiry  <|nality.  It  ranges  from  110  to  150.  Tiie  temperature  may  rise  rap- 
idly after  the  (diill  and  reach  104°  or  105°,  but  the  subsequent  elevation  i.'. 
moderate.  I'he  tongue  at  first  is  white  and  moist,  but  hubse(|uently  be- 
comes dry  and  often  red  and  fissured.  Vomiting  is  an  early  and  promi- 
nent feature  and  causes  great  })ain.  The  contents  of  the  stonuudi  are  first 
ejected,  ihon  yellowish  and  bile-stained  fiuid,  and  fimdly  a  greenish  and, 
in  rare  instances,  a  brownish-black  Jicpiid  with  slight  fa'cal  odor.  The 
bowels  may  be  loose  at  the  onset  and  then  constipation  folh/vvs.  Frequent 
mictnrition  may  be  present,  less  often  retention.  The  urine  is  usually 
scanty  and  high-colored,  and  contains  a  large  quantity  of  indicau. 


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464 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


The  appearance  of  the  patient  when  these  symptoms  have  fully  devel- 
oped is  very  chanieteristic.  The  face  is  pniehed,  the  eyes  are  sunken,  and 
the  expressicm  is  very  anxious.  The  constant  vomiting  of  fluids  causes  a 
wasted  appearance,  and  the  hands  sometimes  present  the  washer-woman's 
skin.  Except  in  cluilera,  we  see  the  Ilippocratic  facies  more  frecjueiiUv 
in  this  than  in  any  other  disease — "f/  sharp  nose,  hollow  ri/rs,  colhipKpd 
temples;  the  ears  cold,  coutracteit,  and  their  lobes  ttirned  out;  the  sl-iii 
about  the  forehead  being  roiKjh,  distended,  and  parched  ;  the  color  of  //ir 
whole  face  being  brown,  black,  livid,  or  lead-colored.''''  There  are  one  or 
two  additional  points  about  the  abdomen.  The  tympany  is  usually  ex- 
cessive, owing  to  the  great  relaxation  of  the  walls  of  the  intestines  l)v  in- 
flammation and  exudation.  The  splenic  dulness  may  be  obliterated,  the 
diaphragm  pushed  u]),  and  the  apex  beat  of  the  heart  dislocated  to  tiio 
fourth  interspace.  The  liver  dulness  may  be  greatly  reduced,  or  may,  in 
the  mamnmry  line,  be  obliterated.  It  has  been  claimed  that  this  is  a  dis- 
tinctive feature  of  perforative  peritonitis,  but  on  several  occasions  [  luivc 
been  able  to  demonstrate  that  the  liver  dulness  in  the  middle  and  iiiain- 
mary  line  was  obliterated  by  tympanites  alone.  In  the  axillary  line,  on 
the  other  hand,  the  liver  dulness,  though  diminished,  may  persist.  I'luninio- 
peritomtHim  following  perforation  more  certainly  obliterates  the  he])atic 
dulness.  In  such  cases  the  fluid  effused  produces  a  dulness  in  the  lateral 
region ;  but  with  gas  in  the  peritonanim,  if  the  patient  is  turned  on  the 
left  side,  a  clear  note  is  heard  beneath  the  seventh  and  eighth  ribs  in  the 
axillary  line. 

Effusion  of  fluid — ascites — is  usually  present  except  in  some  afutc, 
rapidly  fatal  eases.  The  flanks  are  dull  on  percussion.  The  dulness  may 
be  movable,  though  this  depends  altogether  upon  the  degree  of  adiiesions. 
There  nuiy  be  considerable  effusion  without  either  movable  dulness  or 
fluctuation.  A  friction-rub  may  be  present,  as  first  pointed  out  by  Bright, 
but  it  is  not  nearly  so  common  in  acute  as  in  certain  forms  of  chronic 
peritonitis. 

Course. — The  acute  diffuse  peritonitis  usually  terminates  in  death. 
The  most  intense  forms  may  kill  Avithin  thirty-six  or  forty-eight  hours; 
more  commonly  death  results  in  four  or  five  days,  or  the  attack  may  he 
prolonged  to  eight  or  ten  days.  The  pulse  becomes  more  rapid,  all  the 
symptoms  iire  aggravated,  the  vomiting  persists  and  the  patient  usually 
dies  in  eolla])se  with  a  falling  temperature.  Occasionally  death  occurs 
with  great  suddenness,  owing,  possibl}'^,  to  paralysis  of  the  heart. 

Diagnosis. — In  typical  cases  the  severe  pain  at  onset,  the  distontion 
of  the  abdomen,  the  tenderness,  the  fever,  the  gradual  development  of 
effusion,  colla])se  symptoms,  and  the  vomiting  give  a  characteristic  picture. 
Careful  inquiries  should  at  once  be  made  concerning  the  previous  ((mdi- 
tion,  from  which  a  clew  can  often  be  luid  as  to  the  starting-i)oint  of  the 
tremble.  In  young  adults  a  considerable  proportion  of  all  cases  depciuls 
upon  perforating  appendicitis,  and  there  may  be  an  account  of  previous 


ACUTE  GENERAL  PERITONITIS. 


465 


attiioks  of  pain  in  the  iliac  rcffion,  or  of  constipation  alternatinfif  with  diar- 
rluca.  In  women  the  most  frequent  causes  are  suppurative  processes  in 
the  jielvic  viscera,  either  associated  with  salpingitis,  ahscesses  in  the  broad 
lifiunonts,  or  acute  puerperal  infection.  Perforation  of  jjastric  ulcer  is 
iiK.re  common  also  in  women.  It  is  not  always  easy  to  determine  the 
ciiiisc.  Many  casts  come  under  observation  for  the  first  time  with  the 
iiliijonien  distended  and  tender,  and  it  is  impossible  to  make  a  satisfactory 
I'Xiimination.  In  such  instances  the  pelvic  organs  should  be  exanuned 
with  the  greatest  care.  In  tyi)hoid  fever,  if  the  patient  is  conscious,  the 
sudilen  onset  of  ])ain,  the  development  of  great  meteorism,  and  the  aggra- 
vati()ii  of  the  general  symptoms  indicate  clearly  Avhat  has  happened. 
Wliou  the  ))atient  is  in  deep  coma,  on  tiie  other  hand,  the  perforation  may 
be  overlooked.  The  following  conditions  are  most  apt  to  be  mistaken,  for 
acute  iieritonitis : 

{(i)  Acute  Entero-cnlitiH. — Here  the  pain  and  distention  and  the  sen- 
sitiveness on  pressure  nuiy  be  marked.  The  pain  is  more  colicky  m  char- 
acter, the  diarrhoea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(b)  The  So-caUed  Hysterical  Peritonitis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  collapse,  may 
be  simulated.  The  onset  may  be  sudden,  with  severe  pain  in  the  abdomen, 
teiHleriiess,  vomiting,  diarrhoea,  difficulty  in  micturition,  and  the  charac- 
teristic decubitus.  Even  the  temperature  may  be  elevated.  There  mr.y  be 
recurrence  of  the  attack.  A  case  has  been  reported  by  Bristowe  in  \'liich 
four  attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical 
syniptums  developed  that  the  true  nature  of  the  trouble  was  suspected. 

{(')  Obstruction  of  the  bowel,  as  already  mentioned,  may  simulate  peri- 
tonitii*,  both  having  pain,  vomiting,  tympanites,  and  constipation  in  com- 
mon. It  may  for  a  couple  of  days  really  be  impossible  to  make  a  diagnosis 
in  the  absence  of  a  satisfactory  history. 

{(I)  Rupture  of  an.  abdominal  aneurism  or  embolism,  of  the  superior 
vmeutcric  artery  may  cause  symjjtoms  which  simulate  peritonitis.  In  the 
lattiT,  sudden  onset  with  severe  pain,  the  collapse  symptoms,  frequent 
vomiting,  and  great  distention  of  the  abdomen  may  be  present. 

{r)  I  have  already  referred  to  the  fact  that  acute  ha^morrhagic  pan- 
creatitis may  bo  mistaken  for  peritonitis.  Lastly,  a  ruptured  tubal  ])reg- 
iianey  may  resemble  acute  peritonitis,  A  patient  was  admitted  to  my 
wards  in  an  enfeebled  condition,  with  a  thready  pulse,  distended  and  ten- 
der alxlonicn,  and  signs  of  Huid.  The  attack  had  come  on  suddenly  four 
(lays  before,  when  she  had  been  in  perfect  health.  She  looked  ])ale,  the 
blood  count  was  takeji  aiul  found  below  three  millions  per  cubic  centi- 
iiu'tre,  with  leucocytosis,  a  condition  rather  indicating  an:vmia  from  ha^m- 
orrhuirc.  The  abdomen  was  tapped  with  a  fine  aspirator  needle  and  a 
Woody  thiid  withdrawn.  The  diagnosis  of  ])robable  ru])tured  tubal  preg- 
nancy was  made  and  the  ])atient  was  transferred  to  the  gyna>cological  de- 
partment, where  laparotomy  was  performed  and  the  ruptured  tube  removed. 


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466 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


II.  PERITONITIS  IN   INFANTS. 


Peritonitis  may  occur  in  the  fotus  as  a  consequonco  of  sypliilis,  and 
may  lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of  the  abdomen,  sliglit  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  an  uncommon  event,  and 
existed  in  only  four  of  fifty-one  infants  dying  of  inflammation  of  the  cord 
and  sejjticaunia  (Runge). 

During  childhood  j)eritonitis  develops  from  causes  similar  to  those  af- 
fecting the  adult.  Perforative  appendicitis  is  common.  Peritonitis  fol- 
lowing blows  or  ki(^ks  on  the  abdomen  occurs  more  frequently  at  this 
period.  In  boys  injury  while  playing  foot-ball  may  be  followed  by  dill'iise 
peritonitis.  A  rare  cause  in  children  is  extension  through  the  diajjhratrni 
from  an  empyema.  There  are  on  record  itistances  of  jieritonitis  occurrinif 
in  several  children  at  the  same  school,  and  it  has  been  attributed  to  sewer- 
gas  poisoning.  It  Avas  in  investigating  an  epidemic  of  this  kind  at  the 
Wandworth  school,  in  London,  that  Anstie  received  the  post-mortem 
wound  of  which  he  died. 


III.  LOCALIZED   PERITONIT5S. 

The  inflammation  may  be  confined  to  the  lesser  periton;x^um,  particu- 
larly in  cases  of  perforation  of  the  stonuich.  A  large  air-containing  abscess 
may  form  beneath  the  diaphragm,  inducing  the  condition  known  as  pyo- 
pneumothorax subphrenicus.  More  frequent  is  the  circumscribed  perito- 
nitis due  to  inflammation  of  the  appendix.  If  the  vermiform  jirocess  is 
free,  adhesions  take  place  which  circumscribe  the  process.  The  most 
common  situation  is  a  localized  abscess  upon  the  psoas  muscle,  bounded 
by  the  caecum  on  the  right  and  the  terminal  portion  of  the  ileum  and  its 
mesentery  in  front  and  on  the  left.  The  limitation  may  be  complete,  and 
post-mortem  observation  shows  that  healing  follows  in  a  large  immbor  of 
such  cases.  In  other  instances  the  localized  peritonitis  is  more  extensive 
and  a  large  abscess  cavity  is  gradually  formed  in  the  right  iliac  fossa, 
which  may  still  be  intraperitoneal,  though  shut  off  from  the  general  sac 
A  more  frequent  cause  of  local  peritonitis  is  inflammation  about  the  uterus 
and  Fallopian  tubes,  and  here  the  ]irimary  disease  is  usually  i)nerperal  or 
gonorrluetil,  less  frequently  tuberculous.  The  fimbria?  become  adheirnt 
and  closely  matted  to  the  ovary,  and  there  is  gradually  produced  a  condi- 
tion of  thickening  and  matting  of  the  parts  in  which  the  individual  oriians 
.e  scarcely  recognizable.  An  acute  process  extending  from  this  nia\  in- 
volve oidy  the  pelvic  membranes,  being  shut  off  from  the  genei  al  pori- 
tonajum  by  adhesions  of  the  coils  of  the  intestines. 


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CnilONIC   PERITONITIS. 


IV.  CHRONIC  PERITONITIS. 


467 


The  following  varietios  may  bo  rocognizod  :  (ii)  Local  adhesive  perito- 
nitis, a  very  common  condition,  which  occurs  particularly  about  the  spleen, 
|(irmin<''a<lhesi(ms  l)etween  tiio  capsule  and  ♦^he  diapliragm,  about  the  liver, 
less,  frequently  about  the  intestines  and  mesentery.  I'oints  of  thickening 
or  iiuckering  on  the  peritomviuni  occur  sometimes  with  union  of  the  coils 
or  til)r()us  bands,  in  a  majority  of  such  cases  the  condition  is  met  acci- 
(Kiitallv  post  mortem.  Two  sets  of  symptoms  may,  however,  be  caused 
1)V  tliese  adhesions.  AVhen  a  fibrous  band  is  attached  in  such  a  way  as 
to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  1'hus, 
of  the  2db  cases  of  intestinal  obstruction  analyzed  by  Fitz,  <j;}  were  due  to 
this  cause.  The  second  group  is  less  serious  and  comprises  cases  with 
persistent  abdominal  pain  of  a  colicky  character,  sometimes  rendering  life 
misi'ral)le.  Instances  of  this  kind  have  been  successfully  operated  ujjon 
by  llomans  and  II.  A.  Kelly. 

{/j)  Diffuse  Adhesive  Peritonitis.— This  is  a  consequence  of  an  acute 
intlanimation,  either  simple  or  tuberculous.  The  peritonteum  is  obliter- 
ated. On  cutting  through  the  abdominal  wall,  the  coils  of  intestines  are 
uniformly  matted  together  and  can  neitlier  1)0  separated  from  each  other 
nor  can  the  visceral  and  parietal  layers  be  distinguished.  There  may  bo 
thickening  of  the  layers,  and  the  liver  and  sjileen  are  usually  involved  in 
the  adiiesions. 

{(•)  Proliferative  Peritonitis. — Apart  from  cancer  and  tul)ercle,  which 
l)ro(liice  typical  lesions  of  chronic  peritonitis,  the  most  characteristic 
form  is  that  which  may  be  described  under  this  heading.  The  essential 
iiiuvtomical  feature  is  great  thickening  of  the  peritoneal  layers,  usually 
without  nuich  adhesion.  The  cases  are  sometimes  founu  \\'ith  cirrhosis  of 
the  stomach.  In  one  instance  I  found  it  in  connection  with  a  cirrhotic 
conditiou  of  the  civcum  and  the  first  part  of  the  colon.  In  the  inspection 
of  a  case  of  this  kind  there  is  usually  moderate  effusion,  more  rarely  exten- 
sive ascites.  The  peritonaium  is  opaque-white  in  color,  and  everywhere 
thickenod,  often  in  patches.  The  omentum  is  usuidly  rolled  and  forms  a 
thirkened  mass  transversely  jdaced  between  the  stotnach  and  the  colon. 
The  ])eriton{«um  over  the  stonuich,  intestiiuis,  and  mesentery  is  sometimes 
greatly  thickened.  The  liver  and  spleen  may  simply  be  adherent,  or  there 
is  a  condition  of  chronic  perihepatitis  or  perisplenitis,  so  that  a  layer  of 
lu'iii,  almost  gristly  connective  tissue  of  from  one  fourth  to  half  an  inch 
in  liiickness  encircles  these  organs,  rsiudly  the  volume  of  the  liver  is  in 
•'onse(iuenee  greatly  reduced.  The  gastro-hepatic  omentum  may  be  con- 
stricted by  this  new  growth  tnd  the  calibre  of  the  portal  vein  much  nar- 
I'owcd.  A  serous  effusion  may  be  present.  On  ac(!ount  of  the  adhesions 
which  form,  the  peritonsBum  may  be  divitk'd  into  three  or  four  different 
sacs,  as  is  more  fully  described  under  the  tuberculous  peritonitis.  In  these 
cases  the  iivtestines  are  usually  free,  though  the  mesentery  is  greatly 


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468 


DISEASES  OP   THE   DIGESTIVE  SYSTEM. 


shortened.  There  are  instances  of  dironic  peritonitis  iji  wliich  tlie  mes- 
entery is  so  sliortened  by  this  proliferative  eliange  that  tlie  intestines  form 
a  ball  not  largctr  than  a  eocoa-nut  sitnateil  in  the  middle  line,  and  after  re- 
moval of  the  exudation  can  be  felt  as  a  solid  tumor.  The  intestinal  wall 
is  greatly  tlii(!kened  and  the  mucous  membrane  of  the  ileum  is  thrown 
into  folds  like  the  valvular  conniventes.  This  proliferative  peritonitis  is 
found  frequently  in  the  subjects  of  chronic  alcoliolism. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  tlic 
upper  zone  of  the  abdomen. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  numer- 
ous nodular  thickenings,  Avhich  may  be  mistaken  for  tubercles.  Tlu^v 
may  be  scattered  in  numbers  on  the  membranes,  and  it  may  be  extremely 
difficult,  without  the  most  careful  microscopical  examination,  to  deter- 
mine their  nature.  J.  F.  Payne  has  described  a  case  of  this  sort  associ- 
ated with  disseminating  growths  throughout  the  liver  which  were  not 
cancerous.  It  has  been  suggested  that  some  of  the  cases  of  tuberculous 
peritonitis  cured  by  operation  liave  been  of  this  nature,  but  histological 
examination  would,  as  a  rule,  readily  determine  between  the  conditions. 
Miura,  in  Japan,  has  reported  a  case  in  which  these  nodules  contained  the 
ova  of  a  parasite. 

{(/)  Chronic  HaBmorrhagic  Peritonitis.— Blood-stained  effusions  in  tlie 
peritonajum  occur  particularly  in  cancerous  and  tuberculous  disease.  There 
is  a  form  of  chronic  inflammation  analogous  to  the  hnemorrhagic  paehyineii- 
ingitis  of  the  brain.  It  was  described  first  by  Virchow,  and  is  localized 
most  commonly  in  the  pelvis.  Layers  of  new  connective  tissue  form  on 
the  surface  of  the  peritoneum  with  large  wide  vessels  from  which  haemor- 
rhage occurs.  This  is  repeated  from  time  to  time  with  the  formation  of 
regular  layei's  of  Inemorrhagic  effusion.  It  is  rarely  dilfuse,  more  com- 
monly circumscribed. 


V.  NEW  GROWTHS  IN  THE  PERITON>EUM. 

(a)  Tuberculous  Peritonitis. — This  has  already  been  considered. 

(fj)  Cancer  of  the  Peritonaeum. — Although  as  a  rule  secondary  to  dis- 
ease of  the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  are 
occasionally  found.  Secondary  malignant  peritonitis  occurs  in  cotnieetioii 
with  all  forms  of  cancer.  It  is  usually  characterized  by  a  number  of 
round  tumors  scattered  over  the  entire  peritonaeum,  sometimes  small  ami 
miliary,  at  others  large  and  nodular,  with  puckered  centres.  1'he  disease 
most  commonly  starts  from  the  stomach  or  the  ovaries.  The  omentum  is 
indurated,  and,  as  in  tuberculous  peritonitis,  forms  a  mass  which  lies 
transversely  across  the  np})er  portion  of  the  abdomen.  Primary  malig- 
nant disease  of  the  peritonaeum  is  extremely  rare.  Colloid  h,as  occnrreil, 
forming  enormous  masses,  which  in  one  case  weighed  over  one  hundred 


liutmA 


.r-(% 


ASCITES. 


469 


iioiimls.  Cancer  of  this  membrane  spreads,  either  by  the  detachment  of 
small  pjirticles  whicli  are  carried  in  the  lymph  currents  and  by  tlio  move- 
iii'iits  to  distant  parts,  or  by  contact  of  opposing  surfaces.  It  occurs  more 
l'it(im'iitly  in  women  than  in  men,  and  more  commonly  at  the  later  period 
of  life. 

'i'lie  diagnosis  of  cancer  of  tlie  peritonanim  is  easy  with  a  liistory 
of  a  iocal  malignant  disease;  as  wlien  it  occurs  with  ovarian  tumor  or 
willi  cancer  of  the  pylorus.  In  cases  in  which  there  is  no  evidence  of 
u  primary  lesicm  the  diagnosis  may  be  doubtful.  The  clinical  picture  ia 
usually  that  of  chronic  ascites  with  progressive  emaciation.  There  may 
1)1!  no  fever.  If  there  is  much  elfusion  nothing  definite  can  be  felt  on  ex- 
ainiiuition.  After  tapping,  irregular  nodules  or  the  curled  omentum  may 
1)0  felt  lying  transversely  across  the  upper  portion  of  the  abdomen.  Un- 
fortuiuitely,  this  tumor  upon  which  so  much  stress  is  laid  occurs  as  fre- 
(jUtMitly  in  tuberculous  peritonitis  and  may  be  present  in  a  typi(!al  manner 
ill  chronic  proliferative  form,  so  that  in  itself  it  has  no  si)ecial  diagnostic 
value.  Multiple  nodules,  if  large,  indicate  cancer,  particularly  in  persons 
al)ovo  middle  life.  Nodular  tuberculous  peritonitis  is  most  frequent  in 
children.  The  presence  about  the  navel  of  secondary  nodules  and  indu- 
niU'il  masses  is  more  common  in  cancer.  Inflammation,  suppuration,  and 
the  discharge  of  ])us  from  the  navel  rarely  occur  except  in  tuberculous 
disease.  Considerable  enlargement  of  the  inguinal  glands  may  l)e  present 
ill  cancer.  The  nature  of  the  fluid  in  cancer  and  in  tubercle  maybe  much 
aHke.  It  maybe  hamiorrhagic  in  both;  more  often  in  the  latter.  The 
histological  examination  in  cancer  may  show  large  multinuclear  cells  or 
ijroups  of  cells — the  sprouting  cell-groups  of  Foulis — which  are  extremely 
siij;i;;estive.  The  colloid  cancer  may  p'-oduce  a  totally  d liferent  picture; 
instead  of  ascitic  fluid,  the  abdomen  is  occupied  by  the  semi-solid  gelati- 
nous substance,  and  is  firm,  not  fluctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritonantm  which 
may  simulate  cancer  very  closely.  I  have  reported  a  case  of  this  kind,  in 
which  the  enlarged  liver  atul  the  innumerable  nodular  masses  in  the  peri- 
toiiii'uiu  naturally  led  to  this  diagnosis. 


VI.  ASCITES   (Ilydro-periionmum). 

Definition. — The  accumulation  of  serous  fluid   in  the  peritoneal 

I'avity. 

Etiology.— (1)  Local  Causes. — («)  Chronic  inflammation  of  the  peri- 
toiianiiii,  either  simple,  cancerous,  or  tuberculous.  (/;)  I'ortal  obstruction 
in  the  terminal  branches  within  the  liver,  as  in  cirrhosis,  or  by  compression 
ot  tlie  vein  in  the  gastro-hepatic  omentum,  either  by  ])roliferative  perito- 
nitis, by  new  growths,  or  by  aneurism,  (c)  Tumors  of  the  abdomen.  The 
solid  growths  of  the  ovaries  may  cause  considerable  ascites,  which  may 


!y  ¥^] 


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if  iiSi^^  -;;ii: 


470 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


completely  mask  the  true  eondition.     The  eiiliirfj^ed  spleen  in  leukajniia, 
less  eotniiioiily  in  mahiriii,  niiiy  be  assoeiated  witii  reeiirriiif^  ascites. 

(2)  General  Causes.— The  ascites  is  part  of  a  general  drojjsy,  the  re- 
sult of  mechanical  eU'ects,  as  in  heart-disease,  clironict  emphysema,  mid 
cirrhosis  of  the  Innjjf.  In  cardiac  lesions  the  eifusion  is  sometimes  con- 
fined to  the  peritoiui'um,  in  which  case  it  is  due  to  secondary  changes  in 
the  liver,  or  it  has  heen  suggested  to  he  connected  with  a  failure  of  t\w 
8ucti(m  action  of  this  organ,  l)y  wiiicii  the  peritonanim  is  kept  dry.  Asiitcs 
occurs  also  in  the  dropsy  of  liright's  disease,  and  in  hydrivmic  states  of 
the  Mood. 

Symptoms. — A  gradual  uniform  enlargement  of  the  abdomen  is  tlic 
characteristic  sym[)tom  of  ascites.  The  physical  signs  are  usually  distinct- 
ive, (tf)  Insju'cliou. — According  to  the  amount  of  fluid  the  ai)d()nien  is 
jjrotuberant  and  llattened  at  the  .^sides.  AVith  large  elTusions,  the  skin  is 
ten.se  and  may  ])resent  the  linea>  al])icantes.  Frcfiuently  the  navel  itself 
and  the  parts  about  it  are  very  i)rominent.  In  many  cases  the  supertieiai 
veins  arc  eidarged  and  a  })lexus  joining  the  mammary  vessels  can  be  seen. 
Sometimes  it  can  be  determined  by  pressure  on  these  veins  that  the  cur- 
rent is  from  below  upward.  In  some  instances,  as  in  thrond)()sis  or  olilit- 
eration  of  the  portal  vein,  these  superli(;ial  abdominal  vessels  may  be  ex- 
tensively varicose.  About  the  navel  in  cases  of  cirrhosis  there  is  occa- 
siojnilly  a  large  bunch  of  distended  veins,  the  so-called  caput  Medusa?. 

{!))  Palpation. — Fluctuation  is  olitained  by  jdacing  the  fingers  of  inie 
hand  upon  one  side  of  the  abdomen  and  l)y  giving  a  sharj)  ta])  on  the  i\\\- 
positc'  side  with  the  other  hand,  Avhen  a  wave  is  felt  to  strike  as  a  definite 
shock  against  the  applied  fingers.  Even  com])aratively  small  quantities  of 
fluid  may  give  this  fluctuaticm  shock.  When  the  abdominal  walls  are 
thick  or  very  fat,  an  assistant  may  j)lace  the  edge  of  the  hand  or  a  piece 
of  card-board  in  the  front  of  the  abdomen.  A  different  ])roce(hire  is 
adopted  in  ])alpating  for  the  solid  organs  in  case  of  ascites.  Instead  of  |ila(- 
ing  the  hand  flat  upcm  the  abdomen,  as  in  the  ordinary  method,  tlie  pails 
of  the  fingers  oidy  are  jdaced  lightly  upon  the  skin,  aiul  then  by  u  sudden 
depression  of  the  fingers  the  fluid  is  dis])laced  and  the  solid  organ  or 
tumor  nuiy  be  felt.  By  this  method  of  "  dii)i)ing  "  or  disj)lacemeiit,  as  it 
is  called,  the  liver  may  bo  felt  below  the  costal  margin,  or  the  s])loen,  or 
sometinu^s  solid  tumors  of  the  omentum  or  intestine. 

(r)  PercHssion. — In  the  dorsal  position  with  a  moderate  quantity  of 
fluid  in  the  peritoniBum  the  flanks  are  dull,  while  the  umbilical  and  v\n- 
gastric  regions,  into  which  the  intestines  float,  are  tym])anitic.  This  area 
of  clear  resonance  may  have  an  oval  outline.  Having  obtained  the  lateral 
limit  of  the  dulnes.s  on  one  side,  if  the  patient  then  turns  on  the  ojipositc 
side,  the  fluid  gravitates  to  the  dependent  i)art  and  the  uppermost  flank  is 
now  tympanitic.  In  moderate  effusions  this,  movable  dulness  cliaiiirts 
greatly  in  the  different  postures.  Small  amounts  of  fluid,  probaldy  iiti<k''' 
a  litre,  would  scarcely  give  movable  dulness,  as  the  pelvis  and  the  ronal 


ASCITES. 


47t 


im 


rojrions  liold  a  ('()Tisi(leral)le  quuntity.  In  such  eases  it  is  host  to  place  the 
piiticnt  ill  tiio  IviK'c'-t'lbow  position,  wlicn  a  dull  noto  will  be  deteriniued  at 
the  most  dependent  portion.  By  careful  attention  to  these  details  niis- 
taki's  are  usually  avoided. 

'I'he  followiniT  are  among  the  coiulitions  whieh  may  be  nnstaken  for 
(h'(i|isy:  Ofuritoi  tumor,  in  which  the  sac  develops,  as  a  rule,  unilaterally, 
tli()ii;^di  when  larji^e  it  is  centrally  placed.  The  dulness  is  anterior  and  the 
resonance  is  in  the  Hanks,  into  which  the  intestines  are  pushed  by  the  cyst. 
Exiiinination  prr  rdfji/iam  nuiy  give  important  indications.  In  those  rare 
instances  in  which  gas  dcveh.ps  in  the  cyst  the  diagnosis  may  be  very  ditti- 
ciilt.  Succussion  has  been  ol)taincd  in  such  cases.  A  disfendt'd  bUuldrr 
may  reach  above  the  umbilicus.  In  such  instances  so!ne  urine  dribbles 
away,  and  suspicion  of  ascites  or  a  cyst  is  occasioiudly  entertiiined.  I  once 
saw  a  trochar  thrust  into  u  distended  bladder,  which  was  supposed  to  be 
an  (ivarian  cyst,  aiul  it  is  stilted  that  .John  Hunter  tiipi)ed  a  l)la(lder,  sup- 
[Kisiiig  it  to  be  ascites.  Such  a  mistake  should  be  avoided  by  careful 
(•atlu'ti'rization  prior  to  any  o])erative  ])rocedurea.  And  lastly,  there  are 
lav;.'!'  pancreatic  or  hydatid  cysts  in  tlu^  abdomen  which  may  simulatt* 
ascites. 

Xdfiirc  of  the  Asrilic  Fluid. — Usually  this  is  a  clear  serum,  light  yel- 
low in  the  ascites  of  ana'mia  and  liright's  disease,  often  darker  in  color  in 
tinliosis  of  the  liver.  The  specific  gravity  is  low,  seldom  more  than  1-()10 
(ir  loi,").  In  the  fluid  of  ovarian  cysts  the  specific  gravity  is  high,  l-(l2()  or 
(ivcr.  It  is  albuminous  and  sometinuis  coagulates  spontaneously.  Ihemor- 
rhairic  ctl'usion  usually  octnirs  in  cancer  and  tuberculosi  .  and  occasionally 
ill  cirrhosis.  1  have  already  referred  to  the  instances  of  luvniorrhagic  elTu- 
sii)ii  in  connection  with  ruptured  tubal  pregnancy.  A  chylous,  milky  ex- 
lulatc  is  occasionally  found.  Buaey  has  collected  thirty-three  eases  from 
tlir  literature.  There  are,  as  Quincke  has  pointtnl  out,  two  distiiuit  varie- 
ties, a  fatty  and  a  chylous,  which  may  be  distinguished  by  the  microscope, 
as  in  the  former  there  are  distinct  fat-globules.  These  cases  have  been 
sometimes  connected  with  peritoneal  or  mesenteric  cancer.  In  the  true 
cliyldus  ascites  the  fluid  is  turbid  and  milky.  In  some  of  the  cases,  as  in 
Whit  la's,  a  i)erf  oration  of  the  thoracic  duct  has  been  found.  The  condi- 
tion does  not  necessarily  follow  ol)literation  of  the  thoracic  duct.  Mild 
}ri'ii(les  uf  chylous  ascites,  which  are  occasionally  found  clinically,  may  bo 
due  to  the  fact  that  the  patient  upon  a  milk  diet  has  a  pcM'manent 
lipivniia,  such  as  is  ])resent  in  young  animals  and  in  diabetics,  in  whom 
the  li(|iu)r  sanguinis  is  always  fatty.  Tender  such  circumstances  an  exu- 
tlate  may  contain  enough  of  the  nn>lecular  base  of  the  chyle  to  prfMluce 
tin-hidity  of  the  fluid.  Some  of  the  ca.ses  have  been  associated  with 
filiuiosis. 

Treatment  of  the  Previous  Conditions.  —  (f?)  Acute  Peri- 
tonitis.—Rest  is  enjoined  u})on  the  patient  by  the  ssevere  ])ain  which  fol- 
lows the  slightest  movement,  and  he  should  be  propped  in  the  position 


f=    \ 


1  ? 


472 


DlSEASf:S  OF  TIIK   DIGESTIVK  SYSTEM. 


■,'■  Vi' 


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m 


i!;v 


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which  <,'ivos  him  j^iviiti'st  relief.  For  the  pain  morphia  slioiild  \n>.  injcctnl 
iiypoihM'miciilly  in  full  (h).s('s.  In  an  adnlt  it  is  ht'tU-r  to  ^ivo  a  thinl  dp 
half  a  ^rain  at  onnc,  and  snhHcfini'iitly  at  intervals  rcpi-at  it  in  sniailir 
(loses,  as  are  necessary.  The  action  of  the  dru^  sliould  he  carefully 
watclied  and  tluf  patient  should  not  lie  allowed  to  j>ass  into  snch  a  deiricc 
of  uiie,ons(.'iousness  tiiat  he  cannot  h(>  aroused.  The  respiration  and  I  he 
condition  of  the  pupils  also  ^ive  vahiaith^  information.  The  amount  of 
opium  which  iuis  hecii  ^iveii  in  certain  instances  is  remarkahlc,  atid  indi- 
cates a  tolerance  of  the  dru^'.  The  doses  given  hy  the  late  Alonzo  Clark, 
of  New  York,  may  he  truly  termed  heroic.  Austin  Flint  notes  thai  a 
patient  under  the  care  of  this  ])hysician  took  "in  the  first  twenty-l'uur 
luairs,  of  opium  and  the  8nlj)hate  of  morphia,  a  quantity  e(|uivalent  to  l(f(i 
j^rains  of  ojiium  ;  in  the  second  twenty-four  honrs  she  took  4:72  grains; 
on  the  third  day,  2'M  grains;  on  the  fourth  day,  120  grains;  on  the  lirtli 
da}',  54  gnuns;  on  the  sixth  day,  22  grains;  on  the  seventh  day,  18  grains; 
after  winch  the  treatment  was  suspended."  It  is  unnecessary  to  use  tlicsc 
tMiormous  doses,  as,  oven  when  the  pain  is  most  intense,  from  a  thinl  to 
a  half  grain  of  mor])hia  every  few  hours  will  usually  keep  the  ])atieiit 
tiioroughly  under  the  inllneiice  of  the  drug.  In  a  rohust,  strong  jiaticiit, 
seen  at  the  outset,  twenty  leeches  a})plied  over  the  abdomen  will  give  gnat 
relief. 

Local  apjdications — either  hot  tur])entine  stupes  or  cloths  wrung  out 
of  ice-water — may  he  laid  upon  the  ahdomen.  The  patients  sometimes 
declare  that  they  are  greatly  relieved  hy  the  letter. 

The  (juestion  of  the  use  of  purgatives  in  jjeritonitis  has  of  late  lieen 
warndy  discussed.  Lawson  Tait  and  other  gynsKcologists  have  used  the 
saliiu>  purges  with  the  greatest  henetit  in  post-pi)eration  jjeritonitis.  Theo- 
retically it  ai)])ears  correct  to  give  salines  in  concentrated  foi'ni,  wliicli 
cause  a  rapid  and  profuse  exosniosis  of  serum  from  the  intestinal  vessels, 
relieving  the  congestion  and  reducing  the  (edenm,  Avhich  is  one  imjiortant 
factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased  peri- 
stalsis prevents  the  formation  of  adhesions.  In  reading  the  reports  ol'  these 
successful  cases,  one  is  not  always  cojivinced,  however,  that  peritonitis 
actually  existed.  Still,  in  cases  of  acute  peritonitis  due  to  extension  or 
following  operation  or  in  septic  conditions  the  judgment  of  many  careful 
men  is  decidedly  in  favor  of  the  use  of  salines.  I  cannot  speak  froi/i  [wr- 
sonal  experience  on  this  question.  The  majority  of  cases  of  peril mitis 
which  come  under  the  care  of  the  physician  follow  lesions  of  the  abduininnl 
viscera,  or  are  due  to  perforation  of  ulcer  of  the  stomach,  the  ileum,  or  the 
appendix.  In  such  cases,  particularly  in  the  large  group  of  appendix  eases, 
to  give  saline  purgatives  is,  to  say  the  least,  most  injudicious  treatiiient. 
The  safety  of  the  patient  lies  in  the  restriction  of  the  peristalsis  and  the 
localization  of  the  inflammation,  for  which  purpose  opium  alone  is  of 
service.  In  these  instances  rectal  injections  should  be  employed  to  relieve 
the  large  bowel.    No  symptom  in  acute  peritonitis  is  more  serious  tlmn 


iit4  '  11   ' 


...#, 


ASCITES. 


478 


mi 


tlio  tvinpanltos,  and  none  is  moro  diiru'iilt  to  meet.  Tho  uho  of  the  long 
tiihc  iiml  iiijwtioiis  coiituiuiiig  tiirpeiitiiu!  muy  bo  triud.  J)rugs  by  tho 
iiiuiith  ciiniiot  be  ivtuiia'd. 

For  the  voniitiiii,',  ico  and  small  quuntilies  of  sodii  water  may  be  om- 
pldved.  Tho  patient  should  bo  fed  on  milk,  but  if  the  vomiting  is  dis- 
tressing it  is  best  not  to  attempt  to  give  food  by  the  mouth,  but  to  use 
small  nutrient  enemata.  In  all  cases  of  peritonitis  it  is  best  to  have  a  sur- 
geon in  consultation  early  in  tho  disease,  as  tho  qucstifm  of  operation  may 
conie  up  at  any  moment.  I  have  already  mentioned  tho  conditions  under 
which  laparotomy  is  indicated  in  })erforative  appendicitis.  Tho  acute 
i)urp.lont  cases,  particularly  those  in  which  tho  streptococci  occur,  usually 
(lie;  but  although  tho  results  of  operative  interference  in  this  form  have 
not  as  yet  been  very  brilliant,  the  condition,  wo  must  remember,  is  almost 
hoiH'k'SS,  and  too  often  there  has  been  unnecessary  delay  in  calling  in  sur- 
"icul  aid.  In  the  acute  forms  of  tuberculous  ])critonitis  operation  appears 
to  be  more  hopeful,  but  they  are  not  always  sucicessful. 

(/>)  Chronic  Peritonitis. — For  the  oases  of  chronic  proliferative  peri- 
tonitis very  little  can  bo  done.  The  treatment  is  practically  that  of  ascites. 
In  all  Iheso  forms,  when  tho  distention  becomes  extreme,  tajjping  is  indi- 
cated. The  treatment  of  tuberculous  peritonitis  has  fallen  largely  into 
the  hands  of  the  surgeons,  and  tho  results  in  many  cases  are  very  good. 
According  to  the  statistics  of  Maurange,*  of  71  cases,  28  survived  the 
operation  for  more  than  a  year.  Of  20  additional  cases  which  I  have  col- 
lected,! 14  wore  dead  at  tho  time  of  tho  report.  "Within  two  years  and 
three  months  there  were  six  operations  performed  at  tho  Johns  Hopkins 
Hospital  in  tuberculous  peritonitis,  with  four  recoveries. 

(e)  Ascites. — The  treatment  depends  somewhat  on  the  nature  of  the 
case.  In  cirrhosis  early  and  repeated  tapping  may  give  time  for  the  estab- 
lislnnont  of  the  collateral  circulation,  and  temporary  cures  have  followed 
tills  procedure.  Permanent  drainage  with  Southey's  tube,  incision,  and 
wasliing  out  the  peritonaeum  have  also  been  practised.  In  the  ascites 
of  heart  and  renal  disease  the  cathartics  are  most  satisfactory,  particularly 
the  bitartrate  of  potash,  given  alone  or  with  jalap,  and  the  large  doses  of 
suits  given  an  hour  before  breakfast  with  as  little  water  as  possible.  These 
sometimes  cause  rapid  disappearance  of  the  effusion,  but  they  are  not  so 
successful  in  ascites  as  in  pleurisy  with  effusion.  The  stronger  cathartics 
may  sometimes  be  necessary.  The  ascites  forming  part  of  the  general 
anasarca  of  Bright's  disease  will  receive  consideration  under  another  section. 

*  P/iris  Thesis,  1889. 

t  On  Tuberculous  Peritonitis,  Johns  Hopkins  Hospital  Reports,  1800. 


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SECTION  IV. 
DISEASES   or  THE   llESPmATORY   SYSTEM. 


I.  DISEASES  OF  THE  NOSE. 
I.  ACUTE  CORYZA. 

Acute  catarrhal  inflammation  of  tlic  upper  air-passap;cs,  po])iilarly 
known  as  a  "catarrh  "or  a  "cold,"  is  usually  an  independent  al!eoti()n, 
but  may  precede  the  development  of  anotlier  disease. 

Etiology. — It  prevails  most  extensively  in  the  chanf^eable  woatlior  of 
the  spring  and  early  winter,  and  nuiy  occur  in  epidemic  form,  niiiny  cases 
developing  in  a  community  Avitliin  a  few  weelis.  These  outbreaks  an- 
very  like,  though  less  intense  than  the  epidemic  influenza,  cases  of  which 
may  begin  with  symptoms  of  ordiruiry  coryza.  The  disease  probably  de- 
pends upon  a  micro-organism.  Irritating  fumes,  such  as  those  of  iodine  or 
ammonia,  also  may  cause  an  acute  catarrh  of  the  nose. 

Symptoms. — The  patient  feels  indisposed,  perhaps  chill},  has  slight 
headache,  and  sneezes  frequently.  In  severe  cases  there  are  pains  in  the 
back  and  limbs.  There  is  usually  slight  fever,  the  temperature  ri;iiig  to 
101°.  Tlio  pulse  is  quick,  the  skin  is  dry,  and  there  are  all  the  featin-es  of 
a  feverish  attack.  At  first  the  mucous  membrane  of  the  nose  is  swollen, 
"  stuffed  up,"  and  the  patient  has  to  breathe  through  the  mouth.  A  thin, 
clear,  irritating  secretion  flows,  and  makes  the  edges  of  the  nostrils  sore. 
The  mucous  membrane  of  the  tear-ducts  is  swollen,  so  that  the  eyes  weep 
and  the  conjunctiva?  are  injected.  AVith  the  nasal  catarrh  there  is  slight 
soreness  of  the  throat  and  stiffness  of  the  neck ;  the  pharynx  looks  red 
and  swollen,  and  sometimes  the  act  of  swallowing  is  painful.  The  larynx 
also  may  bo  involved,  and  the  voice  bycomes  husky  or  is  even  lost.  If  the 
inflammation  extends  to  the  Eustachian  tubes  there  may  be  impairment 
of  the  hearing.  Owing  to  the  swelling  of  the  nasal  mucosa,  the  sense  of 
smell  and,  in  part,  the  sense  of  taste  are  lost.  In  more  severe  cases  there 
are  bronchial  irritation  and  cough.  Occasionally  there  is  an  outbreak  of 
labial  or  nasal  herpes.  Usually  within  thirty-six  hours  the  nasal  secretion 
becomes  turbid  and  more  profuse,  the  swelling  of  the  mucosa  subsides,  the 
patient  gradually  becomes  able  to  breathe  through  the  nostrils,  and  within 


CHRONIC   NASAIi  CATAIlim. 


476 


four  or  fivo  (lays  tho  Byniptoms  disiippoiir,  with  tho  oxooptlon  of  tho  in- 
croiised  discliargo  from  tho  nosi"  !it\(l  uppiT  jjhuryiix.  There  arc  rarely  any 
bad  ofTocta  from  a  Himj)lo  coryza.  When  the  attacks  are  frequently  ro- 
nculcd,  the  disease  may  hocomo  chronic. 

The  duKjnoiiis  is  always  ciiHy,  but  caution  must  he  exercised  lest  the 
iiiiliid  catarrh  of  measles  or  severe  influenza  should  bo  mistaken  for  tho 
Hiiii|ile  coryza. 

Treatment. — Many  cases  aro  so  mild  that  the  patients  arc  able  to  be 
about  and  to  attend  to  their  work.  If  there  aro  fever  and  constitutional 
disturbance,  tho  patient  should  be  kept  in  bed  and  should  take  a  simple 
fever  mixture,  and  at  night  a  drink  of  hot  lemoiuide  and  a  full  dose  of 
Dover's  powder.  Many  persons  find  great  benefit  from  the  T'urkish  bath. 
For  local  treatment,  particularly  in  the  early  stage,  when  the  mucous  mem- 
brane is  swollen  and  there  is  a  distressing  sense  of  tightness  and  pain  over 
the  frontal  sinuses,  cocaine  is  very  useful  and  sometimes  gives  immediate 
relief.  Tho  four  per  cent  solution  may  be  injected  int(»  the  nostrils,  or 
eotton-wool  soaked  in  the  solution  may  bo  inserted  into  them.  Later,  the 
snutT  recommended  by  Ferrier  is  advantageous,  composed,  as  it  is,  of 
morphia  (gr.  ij),  bismuth  (  3  iv),  acacia  ])owder  (  3  ij).  This  may  occa- 
sionidly  be  blown  or  snuffed  into  tho  nostrils.  Coryza  is  rarely  serious  in 
itself,  hut  renders  the  subject  morj  susceptible  to  other  affections.  The 
attacks  should  therefore  never  bo  slig!ii?d,  and  in  young  childreu  and  in 
the  old  especial  care  should  be  taken  during  convalescenco. 


II.  CHRONIC  NASAL  CATARRH 

(Rhinitis  simplex ;  Rhinitis  hypertrophica ;  Rhinitis  atrophica). 

In  simple  chronic  catarrh  there  is  increased  irritability  of  tho  mncoua 
membrane,  particularly  of  the  erectile  tissue  on  the  septum  and  turbinated 
bones.  There  is  a  tendency  to  frequent  stoppage  of  one  or  both  nostrils 
ami  the  patient  very  easily  catches  cold.  Tho  secretion  is  at  first  clear 
and  afterward  thick  and  tenacious.  The  sense  of  smell  is  not  specially 
disturbed  at  this  stage.  With  the  mirror  tho  mucous  membrane  looks 
congested  and  swollen  and  the  veins  may  be  distended. 

In  hypertrophic  rhinitis,  which  is  usually  a  sequel  of  the  former  con- 
dition, the  nasal  passages  are  obstructed,  chiefly  by  enlargement  of  the 
lower  turbinated  bodies  and  swelling  of  the  mucous  membrane  of  the  sep- 
tum. Very  often  there  is  liypertrophy  of  the  adenoid  ti&suo  in  the  vault 
of  the  ])harynx  and  of  the  mucous  membrane  about  tho  oriJBces  of  the 
Eustachian  tubes.  The  two  conditions  frequently  go  together  as  ex- 
pressed in  the  designation,  chronic  naso-pharyngeal  catarrh.  The  symp- 
toms of  this  hypertrophic  rhinitis  may  be  local  or  general. 

The  most  important  local  symptom  is  tho  obstruction  of  the  passage  of 
air  through  the  nostrils,  so  that  the  patients  become  mouth-breathers. 


my^^' 


476 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


During  the  day  this  may  not  bo  very  distressing,  but  at  night  the  '^nntli 
and  throat  got  extremely  dry  and  the  sleep  is  disturbed,  The  voice  be- 
comes nasal  in  quality  and  in  advanced  cases,  when  the  Eustachian  tuljos 
are  obstructed,  there  may  be  deafness.  It  should  ever  be  borne  in  mind  bv 
the  practitioner  that  a  very  large  proportion  of  all  cases  of  deafness  origi- 
nate in  chronic  naso-pharyngeal  catarrh.  The  general  symptoms  in  tliese 
cases,  particularly  in  children,  are  of  the  greatest  importance,  and  have 
been  considered  more  fully  under  chronic  pharyngeal  catarrh  and  mouth- 
breathing.  Suffice  it  here  to  say  that  there  is  produced  in  children  a  cliur- 
acteristic  facies,  associated  often  with  mental  dulness  and  changes  in  tlio 
form  of  the  thorax. 

Atrophic  rlunitis,  which  is  also  known  under  the  names  coryza  fctida 
and  ozaina,  may  be  a  sequence  of  the  hypertrophic  form.  Oza3na  is  only  a 
symptom,  and  is  met  with  in  many  ulcerative  conditions  of  the  nostrils, 
particularly  as  a  result  of  syphilis,  foreign  bodies,  caries  and  necrosis  of 
the  bones,  and  glanders.  Fortunately,  the  atrophic  form  by  no  moans 
necessarily  follows  the  hyi)ertrophic  stage.  The  cases  are  much  more  fre- 
quent in  women  than  in  men,  and  usually  occur  early  in  life.  The  mucous 
membrane  is  thin  and  covered  with  grayish  crusts  which,  when  removed, 
show  a  slightly  excoriated  surface,  but  tme  ulcers  are  rarely  seen.  The 
erectile  tissue  is  completely  atrophied  by  a  process  of  slow  connective-tissue 
growth,  or,  as  J.  N.  Mackenzie  calls  it,  a  cirrhosis.  The  mucous  mem- 
brane of  the  pharynx  is  usually  dry  and  glazed. 

The  symptoms  are  most  distinctive,  owing  to  the  horrible  odor  which 
comes  from  the  nose,  and  of  which,  fortunately,  the  patient  is  himself 
unconscious,  because  the  sense  of  smell  is  lost.  The  secretion,  wliicli  is 
puriform,  dries  and  forms  large  crusts,  which  are  dislodged  by  picking  or 
which  gradually  fall  off.  The  cause  of  the  offensive  odor  has  been  much 
discussed — whether  it  is  due  to  a  special  organism  or  to  specially  favoral)le 
conditions  for  tlie  growth  and  development  of  the  germs  of  putrefaction. 
Probably  the  latter  view  is  correct. 

The  treatment  of  Jiypertropliic  rhinitis  consists  in  the  thorough  cleans- 
ing of  the  nasal  passages,  the  removal  of  the  pharyngeal  growths,  and  the 
reduction  of  the  hypertrophied  nasal  mucosa.  Operative  procedures  are 
necessary  in  a  majority  of  the  cases,  and  the  practitioner  should  early  call 
to  his  assistance  the  specialist.  It  is  sad  to  think  of  the  misery  which  has 
been  entailed  i^^on  thousands  of  people  owing  to  neglect  of  naso-pharyngeal 
catarrh  by  pi.r«  ats  and  physicians. 

The  treati  <ent  of  atrophic  rhinitis  comes  more  properly  under  the 
special  monographs. 


m. 


AUTUMNAL  CATARRH. 


m 


III.  AUTUMNAL  CATARRH  (Hay  Fever). 

An  affection  of  tho  upper  air-passages,  often  associated  with  asthmatic 
attacks,  clue  to  the  action  of  certain  stimuli  upon  a  hypersensitive  mucous 
membrane. 

Tliis  affection  was  first  described  in  1819  by  Bostock,  who  called  it 
catarrhus  wstivus.  Morrill  Wyman,  of  C!ambridge,  Mass.,  wrote  a  mono- 
•rraph  on  the  subject,  and  described  two  forms,  the  "June  cold,"  or  "rose 
colli,"  which  comes  on  in  the  spring,  and  the  autumnal  form  which,  in 
this  country,  does  not  develop  until  August  and  September,  and  never 
persists  after  a  severe  frost.  Blakley  studied  its  connection  with  the  pol- 
len of  various  grasses  and  flowers.  The  late  George  M.  Beard  made 
iriiniy  careful  observations  on  the  disease.  Until  recently  this  form  of  ca- 
tarrh was  believed  to  result  exclusively  from  the  action  of  certain  irritants 
on  the  nuicous  membrane  of  the  nose,  particularly  the  pollen  of  plants, 
which,  as  the  experiments  of  lilakloy  showed,  play  an  important  role  in 
tho  disease.  Other  emanations  also  may  induce  an  attack,  as  in  the  case 
of  tho  late  Austin  Flint,  who  was  liable  to  coryza,  or  even  asthma,  if  he 
sk^l)t  on  a  certain  sort  of  feather  pillow.  This,  however,  is  only  one  factor 
in  tho  disease.  A  second,  most  important  one,  was  discovered  in  the  con- 
dition of  the  nasal  mucous  membrane  in  these  cases.  Voltolini,  of  Breslau, 
in  1871,  observed  the  cure  of  a  case  of  asthma  by  the  removal  of  a  nasal  poly- 
pus. Since  that  date  the  observations  of  Hack,  in  Germany,  and  particu- 
larly of  Daly,  of  Pittsburg ;  Roe,  of  Kochcstcr ;  John  X.  ^Mackenzie,  of 
Baltimore;  and  Harrison  Allen,  of  Philadelphia,  have  demonstrated  tho 
association  of  asthmatic  attacks  with  nasal  disease.  Daly  discovered  that 
in  a  large  proportion  of  the  cases  of  hay  asthma  there  was  local  disease  of 
the  nuieous  membrane  of  the  nose,  the  cure  of  which  rendered  the  pa- 
tient insusceptible  to  conditions  previously  exciting  the  attacks.  This  has 
been  abundantly  confirmed.  Still  identical  lesions  exist  in  many  people 
who  never  suffer  with  the  disease,  so  that  there  must  be  a  third  factor,  a 
neurotic  co'.istitution.  In  the  etiology  of  hay  fever,  then,  these  three  ele- 
ments prevail — a  nervous  constitution,  an  irritable  nasal  mucosa,  and  the 
stimulus. 

Tho  disease!  affects  certain  families,  particularly,  it  is  said,  those  with  a 
neurotic  taint.  'J'he  peculiarity  may  occur  through  several  generations. 
It  is  certainly  more  common  in  the  United  States  than  in  Europe,  and 
much  more  common  in  the  United  States  than  in  Canada.  The  United 
States  Ilay  Fever  Association  now  numbers  thousands  of  members. 

Dwellers  in  cities  are  more  subject  than  residents  in  the  country.  The 
structural  peculianties  of  the  nasal  mucous  membrane  are  those  of  hyper- 
trophic rhinitis.  Harrison  Alien  states  that  the  inferior  turbinated  bones 
Ho  well  above  the  floor  of  the  nostrils,  which  renders  the  mucous  mem- 
hnme  more  liable  to  irritation  from  inhaled  substances.  Deflection  of  the 
septum,  hypertrophy  of  the  soft  parts,  and  excessive  hypera^sthesia,  so  that 


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478 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


the  mere  touch  with  a  probe  may  bo  sufficient  to  iuduco  an  attack,  aio 
common  conditions. 

Symptoms. — These  are,  in  a  majority  of  the  cases,  very  like  those  of 
ordinary  coryza.  There  may,  however,  be  much  more  headache  and  dis- 
tress, and  some  patients  become  very  low-spirited.  Cough  is  a  connrioii 
symptom  and  may  be  very  distressing.  Paroxysms  of  asthma  may  devoloji, 
80  like  as  to  bo  indistinguishable  from  the  ordinary  bronchial  form.  Tlio 
two  conditions  may  indeed  alternate,  the  patient  having  at  one  time  an 
attack  of  common  hay  fever  and  at  another,  under  similar  circumstances, 
an  attack  of  bronchial  asthma.  Of  the  immediate  exciting  causes  of  tlio 
attack,  unquestionably  in  a  majority  of  the  cases  coming  on  in  the  autumn 
there  is  an  association  with  the  presence  of  pollen  in  the  atmosphere,  but 
this  is  only  one  of  a  host  of  exciting  causes.  In  certain  persons  tlie  par- 
oxysms may  develop  at  any  season  from  sudden  changes  in  the  tempcni- 
ture.  An  attack  may  even  come  on  through  association  of  ideas.  Tlu! 
well-known  experiment  of  J.  N.  Mackenzie,  of  inducing  an  attack  in  a 
susceptible  person  by  offering  her  an  artificial  rose  to  smell,  strikingly 
illustrates  the  nonrotic  element  in  ihe  disease. 

Treatm.ent. — This  may  be  comprised  under  three  heads :  First,  sinoo 
the  disease  appears  in  many  instances  to  be  a  form  of  chronic  neurosis, 
remedies  which  improve  the  stability  of  the  nervous  system  may  be  cm- 
ployed — such  as  arsenic,  phosphorus,  and  strychnia.  Second,  climatic. 
Dwellers  in  the  cities  of  the  Atlantic  sea-board  and  of  the  Central  States 
enjoy  complete  immunity  in  the  Adirondacks  and  White  Mountains.  As 
a  rule  the  disease  is  aggravated  by  residence  in  agricultural  districts.  The 
dry  mountain  air  is  unquestionably  the  best ;  there  are  cases,  however,  M'hieli 
do  well  at  the  seaside.  Third,  the  thorough  local  treatment  of  tlio  noso, 
particularly  the  destruction  of  the  vessels  and  sinuses  over  the  seusitivo 
areas. 

IV.  EPISTAXIS. 

Etiology. — Bleeding  from  the  nose  may  result  from  local  or  consti- 
tutional conditions.  Among  local  causes  may  be  mentioned  traumatism, 
picking  or  scratching  the  nose,  new  growths,  and  the  presence  of  foroigii 
bodies.  In  chronic  nasal  catarrh  bleeding  is  not  infinKpient.  The  blood 
may  come  from  one  or  both  nostrils.  The  flow  may  be  profuse  after  an 
injury,  but  is  soon  checked  and  is  veiy  rarely  fatal.  Occasionally  profuse 
and  fatal  hemorrhage  occurs  as  a  result  of  injury  to  the  skull.  In  a  re- 
markable case  of  this  kind,  coming  on  some  weeks  after  the  receipt  of  the 
injury,  I  found  that  there  had  been  a  fracture  across  the  sphenoid  bone 
and  an  erosion  had  taken  place  into  the  carotid  artery,  just  where  it  mns 
closest  to  the  sphenoidal  sinuses.  Tlie  young  man  had  completely  recov- 
ered from  the  effects  of  the  injury,  and  the  fatal  hemorrhage  took  place  as 
he  was  stooping  over  to  wash  his  face. 


...r 


EPISTAXIS. 


4TO 


Among  general  conditions  with  which  nose-bleeding  is  associated,  tho 
fdUowing  are  tho  most  important :  It  occurs  with  great  frequency  in  grow- 
in"'  children,  particularly  about  the  age  of  puberty ;  more  frequently  in 
tln'  ili'lieate  than  in  the  strong  and  vigorous. 

Enistaxis  is  a  very  common  event  in  persons  of  so-called  plethoric 
liabit.s.  It  is  stated  sometimes  to  precede,  or  to  indicate  a  liability  to, 
apoplexy,  but  this  is  very  doubtful. 

In  venous  engorgement,  due  to  heart  or  jnilmonary  disease,  epistaxis  is 
not  common  and  there  may  be  a  most  extreme  grade  of  cyanosis  without 
its  occurrence.  In  balloon  and  mountain  ascensions,  in  the  very  rarelied 
atmospher",  haemorrhage  from  tlie  noso  is  a  common  event.  In  haemo- 
philia  the  noso  ranks  first  of  the  mucous  membranes  from  which  bleeding 
arises.  It  occurs  in  all  forms  of  chronic  antijmias.  It  precedes  the  onset 
of  certain  fevers,  more  particularly  typhoid,  witli  whicli  it  seems  associated 
in  a  special  manner.  Vicarious  epistaxis  has  been  described  in  cases  of 
supp'^ession  of  the  menses.  Lastly,  it  is  said  to  be  brought  on  by  certain 
psychical  impressions,  but  the  obser^■ation3  on  this  point  are  not  trust- 
worthy. The  blood  in  epistaxis  results  from  capillary  oozing  or  diapedesis. 
Tile  mucous  membrane  is  deeply  congested  and  there  may  be  snudl  ecchy- 
moses.  The  bleeding  area  is  usually  in  the  respiratory  portion  of  one  nos- 
tril and  upon  the  cartilaginous  septum. 

Symptoms. — Slight  lucmorrhage  is  not  associated,  with  any  special 
fi'iitiuvs.  When  tlie  bleeding  is  protracted  the  patients  have  the  more 
soi'ious  manifestations  of  loss  of  blood.  In  tlie  slow  dripping  which  takes 
l>laeo  in  some  instances  of  luemophilia,  tliere  may  be  formed  a  remarkable 
blood  tumor  projecting  from  one  nostril  and  extending  even  below  the 
mouth. 

Death  from  ordinary  epistaxis  is  very  rare.  Tlio  more  blood  is  lost, 
tho  greater  is  the  tendency  to  clotting  with  spontaneous  cessation  of  the 
bleeding. 

The  diagnosis  is  usually  easy.  One  point  only  need  be  mentioned ; 
nanu'ly,  that  bleeding  from  the  posterior  nares  occasionally  occurs  during 
slw'P  and  the  blood  trickles  into  tlie  pharynx  and  msiy  be  swallowed.  If 
voniitod,  it  may  be  confounded  with  luvmatemesis ;  or,  if  coughed  up,  with 
luvuioptysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself. 
Various  sinijile  measures  may  bo  employed,  such  as  holding  the  arms 
above  the  head,  the  application  of  ice  to  the  nose,  or  the  injection  of  cold 
or  hot  water  into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin, 
may  bo  used ;  and  tho  old-fashioned  and  sometimes  successful  remedy,  a 
eobwi'l),  may  be  introduced  into  the  nostrils.  If  the  bleeding  comes  from 
iui  ulcerated  surface,  an  attempt  should  be  mad(>  to  apply  chromic  acid  or 
to  cauterize.  If  the  bleeding  is  at  all  severe  and  obstinate,  the  posterior 
uares  sliould  bo  plugged.  Ergot  may  be  given  internally  or  hypodermi- 
callv. 


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480  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


II.  DISEASES   OF  THE  LARYNX. 

I.  ACUTE  CATARRHAL  LARYNGITIS. 

This  may  come  on  as  an  indeponclent  affection  or  in  association  witli 
general  catarrh  of  the  upper  respiratory  passaj,^cs. 

Etiology. — Many  cases  arc  duo  to  catching  cold  or  to  overuse  of  the 
voice  ;  others  develop  in  consequence  of  the  inhalation  of  irritating  gases. 
It  may  occur  in  the  general  catarrh  associated  with  influenza  and  measles. 
Very  severe  laryngitis  is  excited  by  traumatism,  either  injuries  from  with- 
out or  the  lodgment  of  foreign  bodies.  It  may  bo  caused  by  the  action  of 
very  liot  liquids  or  corrosive  poisons. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  larynx; 
the  cold  air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous 
membrane,  the  act  of  inspiration  may  bo  painful.  There  is  a  dry  cough, 
and  the  voice  is  altored.  At  first  it  is  simply  husky,  but  soon  phonation 
becomes  painful,  and  finally  the  voice  may  be  completely  lost.  In  adults 
the  respirations  are  not  increased  in  frequency,  but  in  children  dys])nfjoa 
is  not  uncommon  and  may  occur  in  spasmodic  attacks.  If  much  axloma 
accompanies  the  inflammatory  swelling,  there  may  be  urgent  dyspnoja. 

The  laryngoscope  shows  a  swollen  and  tumefied  mucous  membrane  of 
the  larynx,  particularly  the  ary-epiglottidean  folds.  The  vocal  cords 
have  lost  their  smooth  and  shining  ap])earance  and  are  reddened  and 
swollen.  Their  mobility  also  is  greatly  impaired,  owing  to  the  infiltration 
of  the  adjoining  mucous  membrane  and  of  the  muscles.  A  slight  mucoid 
exudation  covers  the  parts.  The  constitutional  symptoms  are  not  severe. 
There  is  rarely  much  fever,  and  in  many  cases  the  patient  is  not  seriously 
ill.  Occasionally  cases  come  on  with  greater  intensitj',  the  cough  is  very 
distressing,  deglutition  is  painful,  and  there  may  be  urgent  dyspnoea. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  nature 
of  a  case  if  a  satisfactory  1j.  ryngoscopic  examination  can  be  made.  The 
severer  forms  may  simulate  jedema  of  the  glottis.  When  the  loss  of  voice 
is  marked,  the  case  may  ?.e  mistaken  for  one  of  nervous  aphonia,  but  the 
laryngoscope  would  decide  the  qiiestion  at  once.  Much  more  difficult  is 
the  diagnosis  of  acute  laryngitis  in  children,  particularly  in  the  very 
young,  in  whom  it  is  so  hard  to  make  a  proper  examination.  From  ordi- 
nary laryngismus  it  is  to  be  distinguished  by  the  presence  of  fever,  tlio 
mode  of  onset,  and  particularly  the  coryza  and  the  previous  symptoms  of 
hoarseness  or  loss  of  voice.  Membranous  laryngitis  may  at  first  be  quite 
impossible  to  differentiate,  but  in  a  majority  of  cases  of  this  affection  tlicre 
are  patches  on  the  pharynx  and  early  swelling  of  the  cervical  glands.  The 
symj)toms,  too,  are  much  more  severe. 

Treatment. — Rest  of  the  larynx  should  bo  enjoined,  so  far  as  i)li()- 
nation  is  concerned.     In  cases  of  any  severity  the  patient  should  be  kept 


..ilr 


tEDEMATOUS  LARYNGITIS. 


481 


ill  bed.  The  room  should  be  at  an  even  temperature  and  the  air  satu- 
rated with  moisture.  Early  in  the  disease,  if  there  is  much  fever,  aconite 
and  (titrate  of  jiotash  can  be  given,  and  for  the  irritating  painful  cough  a 
full  dose  of  Dover's  powder  at  night.  An  ice-bag  externally  often  gives 
great  relief. 

II.  CHRONIC  LARYNGITIS. 


Etiolog^y. — The  cases  usually  follow  repeated  acute  attacks.  The 
most  common  causes  are  overuse  of  the  voice,  particularly  in  persons 
whoso  occupation  necessitates  shouting  in  the  open  air.  The  con- 
stant inhalation  of  irritating  substances,  as  tobacco-smoke,  may  also 
cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe 
cases  may  be  almost  lost.  There  is  usually  very  little  pain ;  only  the  un- 
pleasant sense  of  tickling  in  the  larynx,  which  causes  a  frequent  desire  to 
cough.  With  the  largyngoscope  the  mucous  membrane  looks  swollen,  but 
much  less  red  than  in  the  acute  condition.  In  association  with  the  granu- 
lar pharyngitis,  the  mucous  glands  of  the  epiglottis  and  of  the  ventricles 
may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in 
some  instances  chronic  laryngitis  is  associated  with  and  even  dependent 
upon  obstruction  to  the  free  passage  of  air  through  the  nose.  Local  appli- 
cation must  be  made  directly  to  the  larynx,  either  with  a  brush  or  by 
means  of  a  spray.  Among  the  remedies  most  recommended  are  the  solu- 
tions of  nitrate  of  silver,  chlorate  of  potash,  perchloride  of  zinc,  and  tannic 
acid.    Insufflations  of  bismuth  are  sometimes  useful. 

Among  directions  to  be  given  are  the  avoidance  of  heated  rooms  and 
loud  speaking,  and  abstinence  from  tobacco  and  alcohol.  The  throat 
should  not  be  too  much  muffled,  and  morning  and  evening  the  neck  should 
be  sponged  with  cold  water. 


#• 


M 


n 

!    I- 


III.  CEDEMATOUS  LARYNGITIS. 

Etiology.  — CEdema  of  the  glottis,  or,  more  correctly,  of  the  struct- 
ures which  form  the  glottis,  is  a  very  serious  affection  which  is  met  with 
[a)  us  !i  rare  sequence  of  ordinary  acute  laryngitis,  whether  due  to  cold  or 
to  the  a]iplication  of  irritants,  (ft)  In  chronic  diseases  of  the  larynx,  as 
syidiilis  or  tubercle,  {c)  In  severe  inflammatory  diseases  like  diphtheria, 
in  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis,  (r/)  Occa- 
sionally in  the  acute  infectious  diseases — scarlet  fever,  typhus,  or  typhoid. 
In  Bright's  disease,  either  acute  or  chronic,  there  may  be  a  rapidly  devel- 
oping; (I'dema.  The  connection  with  Bright\s  disease  has  been  disputed 
and  is  certainly  rare.     I  have  met  with  two  instances,  one  in  scarlatinal 


^  m 


■':i  L-^  4^ 


5t, 


( ''7  ■ 

Hi 


im  Vm 


ItH—:- 


H   ":  •     1 


482 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


nepliritis  and  tlio  other  in  chronic  interstitial  nephritis.  Botli  cases 
proved  fatal  in  a  short  time. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  with- 
in an  lionr  or  two  the  condition  becomes  very  serious.  There  is  sometimes 
marked  stridor  in  respiration.  Tlio  voice  becomes  luisky  and  disappears. 
The  laryngoscope  sliows  enormous  swelling  of  the  epiglottis,  whicli  can 
sometimes  be  felt  with  the  finger  or  even  seen  when  the  tongue  is  strong] v 
depressed  with  a  spatula.  The  ary-epiglottidean  folds  ar{>  the  scat  of  the 
chief  swelling  aiul  may  almost  meet  in  the  middle  line.  Occasionally  the 
codema  is  below  the  true  cords. 

The  diagnosis  is  rarely  diHicult,  inasmucli  as  even  without  the  laryn- 
goscope the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The 
disease  is  very  fatal. 

Treatment. — An  ice-bag  shoidd  be  placed  on  the  larynx  and  the 
patient  given  ice  to  suck.  If  the  symptoms  arc  urgent,  the  throat  should 
be  sprayed  with  a  strong  solution  of  cocaine,  and  the  swollen  epiglottis 
scarified.  If  relief  does  not  follow,  tracheotomy  should  immediately  be 
performed.  The  high  rate  of  mortality  is  due  to  the  fact  that  this  opera- 
tion is  as  a  rule  too  long  delayed. 


IV.  MEMBRANOUS  LARYNGITIS  (Croup). 

Inflammation  of  the  larynx,  witli  membranous  exudation  occurs:  (1) 
As  a  simple,  non-specific,  non-contagious  aft'ection,  local  in  its  nature,  and 
not  occurring  in  epidemics.  It  is  unquestionably  a  rare  disease.  (2)  As 
an  effect  of  diphtheria,  in  which  the  disease  may  be  limited  to  the  larynx, 
but  most  commonly  is  associated  with  exudation  on  the  pharynx  or 
tonsils. 

Etiology. — ^Membranous  croup  is  now  regarded  by  many  authorities 
as  always  diphtheritic,  and  while  it  nmst  be  acknowledged  that  this  is  so 
in  the  great  majority  of  instances,  there  arc  cases,  few  in  immber,  it  is 
true,  in  which  it  is  not  possible  to  assign  this  origin.  The  question  may 
be  settled  by  the  presence  or  absence  of  Loeffler's  bacillus,  which  is  a 
definite  criterion  of  diphtheritic  pseudo-membrane.  At  the  Montreal 
General  Hospital,  which  received  annually  an  cxcei)tionally  large  number 
of  cases  of  diphtheria,  we  were  in  the  habit  of  regarding  all  the  laryngeal 
cases  as  true  diphtheria,  even  when  no  patches  could  be  seen  on  the  ton- 
sils. On  several  occasions,  in  cases  of  this  kind,  I  have  been  able  to  de- 
monstrate post  mortem  that  the  exudation  had  extended  at  the  back  of 
the  tonsils  or  on  the  posterior  pillars  of  tlic  fauces.  On  the  other  hand, 
twice  at  the  Infant's  Home  I  saw  cases,  sporadic  in  their  nature,  com- 
ing on  suddenly  without  much  fever,  with  extensive  fibrinous  exuda- 
tion, necessitating  tracheotomy,  but  without  a  trace  of  pharyngeal  exuda- 
tion.     Although  the  conditions  were  most  favorable  for  the  spread  of 


m 


:"p\TiT''r' 


MEMBRANOUS   LARYNGITIS. 


483 


Botli  cases 

so  tliat  witli- 
is  sometimes 
d  disappears. 
is,  which  can 
no  is  strongly 
10  scat  of  the 
casionally  the 

>\it  the  laryn- 
sfmgcr.     The 

.rynx  and  the 
throat  should 
Hon  epiglottis 
nmcdiately  be 
lat  this  opcra- 


on  occurs:  (1) 

its  nature,  and 

liseasc.     (-)  As 

to  the  larynx, 

lie   i)harynx  or 

[any  authorities 
that  this  is  so 
\\  number,  it  is 
le  question  miiy 
]us,  which  is  a 
tho  Montreal 
large  number 
11  tho  laryngeal 
len  on  the  ton- 
]een  able  to  de- 
at  tho  back  of 
[ho  other  hand, 
fir  nature,  com- 
Ihrinous  cxuda- 
iryngeal  cxuda- 
tho  spread  of 


tlio  infection  in  tho  Home,  no  other  cases  occurred.  Provisionally,  at 
any  rate,  I  still  hold  that  there  is  a  separate  independent  alTection,  a  non- 
contagious membranous  croup.  Yet  I  am  willing  to  acknowledge  that 
tlie  large  majority  of  the  cases  of  fibrinous  laryngitis  are  duo  to  the  poi- 
son of  diphtheria.  It  is  particularly  desirable  that  a  bacteriological  ex- 
amination should  be  made  of  the  membrane  in  the  forjncr  clabs  of  cases. 

'I'lic  disease  affects  young  children,  particularly  between  tho  ages  of  two 
and  six.  Cases  under  two  and  over  seven  are  very  rare.  Statistics  show 
that  boys  are  more  often  attacked  than  girls  Cases  occur  occasionally 
with  scarlet  fever  and  measles. 

Morbid  Anatomy. — On  inspection  of  tho  larynx  of  a  child  dead  of 
membraneous  croup,  the  rima  is  seen  filled  with  mucus  or  with  a  sarcddy 
material  which,  when  washed  off  carefully,  leaves  the  mucosa  covered  by  a 
thin  grayish-yellow  membrane,  which  may  be  uniform  or  in  patches.  It 
covers  the  ary-epiglottic  folds  and  the  true  cords,  and  may  be  continued 
into  the  ventricles  or  even  into  the  trachea.  Above,  it  may  involve  tho 
epiglottis.  It  varies  much  in  consistency.  I  have  seen  fatal  cases  in 
which  the  exudation  was  not  actually  membranous,  but  rather  friable  and 
granular.  It  may  form  a  thick,  even  stratified  membrane,  which  fills  the 
entire  glottis.  The  exudation  may  extend  down  the  trachea  and  into  the 
bronchi,  and  may  pass  beyond  the  epiglottis  to  the  fauces.  Usually  it  can 
be  readily  stripped  off  from  the  mucous  membrane  of  the  larynx  and  leaves 
exposed  the  swollen  and  injected  mucosa.  On  examination  it  is  seen  that 
the  librinous  material  has  involved  chiefly  the  epithelial  lining  and  has  not 
greatly  intiltratod  the  subjacent  tissues. 

Symptoms. — Naturally,  the  clinical  symptoms  are  almost  identical  in 
the  non-specific  and  specific  forms  of  membranous  laryngitis. 

The  affection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  tho  child 
suddenly  becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded 
respiration.  At  first  the  difficulty  in  breathing  is  paroxysmal,  due  proba- 
bly to  more  or  less  si)asm  of  the  muscles  of  the  glottis.  Soon  the  dyspnoea 
becomes  continuous,  inspiration  and  expiration  become  difficult,  particularly 
the  latter,  and  with  the  inspiratory  movements  the  epigastrium  and  lower 
intercostal  spaces  are  retracted.  The  voice  is  husky  and  may  be  reduced 
to  a  whisjier.  The  color  gradually  changes  and  the  imperfect  aeration  of 
the  blood  is  shown  in  the  lividity  of  the  lips  and  finger-tips.  Kestlessness 
comes  on  and  the  child  tosses  from  side  to  side,  vainly  trying  to  get  breath. 
Occasionally,  in  a  severer  paroxysm,  portions  of  membrane  are  couglied  out. 
The  fever  in  non-specific  membianous  laryngitis  is  rarely  high  and  the 
condition  of  the  child  is  usually  very  good  at  the  time  of  the  onset.  The 
pulse  is  always  increased  in  frequency  and  if  cyanosis  be  present  is  small. 
In  favorable  cases  the  dyspnoea  is  not  very  urgent,  the  color  of  the  face 
remains  good,  and  after  one  or  two  paroxysms  the  child  goes  to  sleep  and 


tt 


i 


,'^    t 


■i 

t  * 

i  J 


Vifl^l^H,.'' 


;f'^"      ;, 


Iflpji^'  ;■-!'•■■!(■ -'fip 


kj:-?.-  4  j: 


UM}'''''^  Urn   • 


484 


DISEASES  OP  THE   RESPIRATORY  SYSTEM. 


wakes  in  tho  morning,  pcrliaps  without  fever  and  feeling  comfortable. 
The  attack  may  recur  the  following  night  with  greater  severity.     In  un- 
favorable cases  the  (lys])na'a  becomes  more  and  more  urgent,  the  cyanosis 
deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks  into  a  semi- 
comatose state,  and  death  finally  occurs  from  poisoning  of  the  nerve  ccutros 
by  carbon  dioxide.     In  diphtheritic  laryngitis  the  onset  is  usually  less  sud- 
den and  is  preceded  by  a  longer  period  of  indisposition.     As  a  rule,  tliiio 
are  pharyngeal  symptoms,     1'he  constitutioiuil  disturbance,  too,  is  more 
severe,  the  fever  higher,  and  there  may  be  swelling  of  the  glands  of  the 
neck.     Inspection  of  the  fauces  may  show  the  presence  of  false  membnmcs 
on  tho  pillars  or  on  the  tonsils.     This,  however,  is  held  by  some  not  to  be 
an  invariable  evidence  of  the  diphtheritic  nature  of  the  infliimmation. 
Fagge  held  that  non-contagious  membranous  croup  may  spread  upward 
from  the  larynx  just  as  diphtheritic  inflammation  is  in  the  habit  of  sprciid- 
ing  downward  from  the  fauces.     AVare,  of  Boston,  whose  essay  on  croup  is 
perhaps  tho  most  solid  contribution  to  the  subject  made  in  this  country, 
reported  the  presence  of  exudate  in  the  fauces  in  74  out  of  75  cases  of  croup. 
These  observations  were  made  i)rior  to  1840,  during  periods  in  wliich 
diphtheria  was  not  epidemic  to  any  extent  in  Boston.     In  protracted 
cases  pulmonary  symptoms  may  develop,  which  are  sometimes  due  to  tho 
diflf^lculty  in  expelling  the  muco-pus  from  the  tubes ;  in  others,  the  false 
membrane  extends  into  the  trachea  and  even  into  the  bronchial  tubes. 
During  the  paroxysm  the  vesicular  murmur  is  scarcely  audible,  but  the 
laryngeal  stridor  may  he  loudly  communicated  along  the  bronchial  tubes. 

Diagnosis. — Memljranous  laryngitis  must  be  distinguished  from 
ordinary  simple  laryngitis  and  from  certain  spasmodic  affections.  Simple 
catarrhal  laryngitis  rarely  induces  such  sevor(\symptoms,  occurs  more  sud- 
denly, nearly  always  at  night,  and  the  hoarseness  and  implication  of  tlie 
voice  are  not  nearly  so  marked.  The  presence  of  preceding  symptoms  is 
one  of  the  most  important  diagnostic  distinctions  between  the  false  and  the 
true  croup.  By  hoarseness,  dyspnoea,  and  signs  of  membrane  on  the  fauces 
or  tonsils  the  existence  of  membranous  laryngitis  may  be  definitely  deter- 
mined. Occasionally  simple  laryngitis  induces  swelling  sufficient  to  cause 
marked  dyspnoea  and  hoarseness  and  may,  indeed,  prov^  fatal.  Of  course, 
true  membranous  laryngitis  may  follow  the  catarrhal  form.  In  laryngis- 
mus the  attack  comes  on  suddenly  and  is  not  associated  with  either  cough 
or  hoarseness.  The  child  is  seized  with  a  difficulty  in  breathing ;  the  in- 
spirations are  crowing  in  character,  and  the  dyspnoea  rapidly  becomes 
urgent,  so  that  symptoms  of  suffocation  supervene,  sometimes  within  less 
than  a  minute  ;  the  spasm  then  relaxes  and  the  child  appears  to  be  in  its 
normal  condition.     It  is  most  commonly  met  with  in  rickety  children. 

The  diagnosis  between  diphtheritic  and  non-diphtheritic  membranous 
laryngitis  is  by  no  means  eas)',  and,  as  mentioned  above,  many  excellent  au- 
thorities hold  the  diseases  to  be  identical.  The  following  are  the  chief  points 
of  distinction,  Avhich  refer  to  general  rather  than  to  local  conditions :  The 


^? .;;  yv 


■..if 


MEMBRANOUS  LARYNGITIS. 


4S6 


non-specific  alTcction  generally  begins  in  tho  larynx  and  the  fauces  are  but 
sli!,'1>tly,  if  at  all,  affected.  It  is  not  infectious.  Cases  develop  in  institu- 
tions under  circumstances  most  favorable  to  tho  spread  of  tho  disease,  but 
otlior  children  are  not  attacked.  It  has  none  of  the  serious  asthenic  symp- 
toms of  diphthe/ia,  and  it  is  not  followed  by  paralysis.  It  occnirs  almost 
exclusively  in  very  young  children,  whereas  diphtheritic  laryngitis  is  not 
at  all  uncommon  in  adults. 

Prognosis. — True  croup,  whether  simple  or  diphtheritic,  with  a  mor- 
tality of  from  sixty  to  eighty  per  cent,  is  an  extremely  fatal  disease.  When 
it  attacks  healthy  children  and  is  not  secondary  to  some  febrile  affection, 
tlie  outlook  is  more  hopeful.  Even  a  very  limited  exudation  nuiy  prove 
fatal.  On  several  occasions,  in  performing  post-mortems  in  fatal  cases,  I 
have  been  astonished  to  find  such  a  slight  involvement  of  tho  larynx ;  in 
some  instances  scarcely  more  than  a  granular  exudation  covering  tho 
cords  and  folds.  A  fatal  result  is  almost  inevitable  when  tho  disease  ex- 
tends to  the  bronchi. 

Treatment. — As  the  cases  rarely  come  under  observation  until  the 
membrane  is  formed,  tho  main  medicinal  indication  is  to  favor  its  separa- 
tion. The  air  of  the  room  should  be  saturated  with  moisture  from  an 
atomizer  and  the  throat  should  be  sprayed  with  lime-water. 

Ill  young  children  topical  ai)plication  to  tho  larynx  itself  is  extremely 
difficult  and  in  many  instances  impossible.  Good  results  have  followed 
the  passage  of  a  sponge-probang  with  a  strong  solution  of  nitrate  of  silver. 
It  is  an  easy  matter  to  recommend  such  measures,  but  very  difficult  to 
cany  them  out.  The  administration  of  a  brisk  emetic  will  sometimes 
bring  away  portions  of  the  false  membrane ;  ipecacuanha  or  the  turpeth 
mineral  is  the  most  suitable.  Of  late  years  there  has  been  a  return  to  the 
mercurial  treatment  of  membranous  laryngitis,  but  I  have  not  seen  such 
results  from  its  use  as  would  Justify  a  recommendation  of  it.  Continuous 
liot  applications  to  the  throat  aro  usually  much  more  grateful  than  the 
ice-bag,  so  highly  recommended  by  some  practitioners.  With  tho  first 
indication  of  defective  aeration  of  the  blood  it  is  well  to  let  the  child  in- 
lialo  oxygen,  which  may  be  conveniently  passed  into  a  tent  made  of  sheets 
on  tlio  bed. 

In  very  many  cases  the  obstruction  reaches  such  a  grade  that  the  pro- 
priety of  intubation  or  traclicotomy  is  raised.  One  great  advantage  of 
tho  former  is  that  it  may  be  suggested  at  an  earlier  stage  with  more  like- 
hhood  of  gaining  tho  consent  of  the  parents. 

Tho  statistics  of  tracheotomy  are  not  very  satisfactory,  as  only  a  fourth 
to  a  third  of  the  cases  recover. 

Tho  general  treatment  of  these  cases  is  of  great  importance.  In  the 
first  place  the  child  should  bo  isolated,  since  it  is  often  impossible  to  say 
wlu'tlior  the  case  is  specific  or  not.  Much  of  the  success  in  the  case  de- 
pend^5  upon  careful  nursing.  There  is  no  disease  which  requires  greater 
cure,  coolness,  and  judgment  on  tho  part  of  the  attendants.     The  diet 


>:-'ff 


■i! 


t*        T 


I  IT 


'M 


t     '  I 


I  i 


fi 


V 


'     ( 


^^    '.     H         ill 


480 


DISEASES  OP  THE   RESPIRATORY  SYSTEM. 


should  consist  of  milk  and  bcof-juiccs.  "Water  Kliould  bo  given  freely  to 
the  cliild,  and  if  tlio  \tnho  shows  HigtiH  of  failing,  stimulants  should  at  once 
bo  administorcd.  The  oxtremo  rcstlcssnoss  calls  for  anodynes,  but  tlu  y 
must  bo  administered  with  groat  c^arc  ;  bromide  and  chloral  an\  to  be  [jtc- 
fcrrcd  to  opium.  In  cases  in  whitih  the  dyspnoea  comes  on  in  jiaroxysrns, 
as  if  duo  to  spasm,  I  have  seen  great  benefit  follow  the  iidialatioii  (if 
chloroform. 


V.    SPASMODIC   LARYNGITIS  (Laryngismus  airidulm) 

Spasm  of  tho  glottis  is  met  with  in  many  affections  of  the  larynx,  l)ut 
there  is  a  special  disease  in  children  which  has  received  the  above-men- 
tioned names. 

Etiology. — A  purely  nervous  affection,  without  any  inflammatory 
condition  of  the  larynx,  it  occurs  in  children  between  the  ages  of  six 
months  and  three  years,  and  is  most  commonly  seen  in  connection  with 
rickets.  It  is  also  associated  with  tetany.  Often  the  attack  comes  on 
when  the  child  has  been  crossed  or  scolded.  Mothers  sometimes  call  tho 
attacks  "  ])assion  fits  "  or  attacks  of  "  holding  the  breath."  It  "was  sup- 
posed at  one  time  that  they  were  associated  with  enlargement  of  tlio 
thymus,  and  they  therefore  received  the  name  of  thymic  asthma. 

The  actual  condition  of  the  larynx  during  a  paroxysm  is  a  spasm  of  the 
adductors,  but  the  precise  nature  of  the  influences  causing  it  is  not  yet 
known,  whether  centric  or  reflex  from  periidieral  irritation.  The  disease 
is  not  so  common  in  America  as  in  England. 

Symptoms. — The  attacks  may  come  on  cither  in  the  night  or  in  the 
day  ;  often  just  as  the  chiM  awakes.  There  is  no  cough,  no  hoarseness, 
but  the  respiration  is  arrested  and  tho  child  struggles  for  breath,  the  fuec 
gets  congested,  and  then,  with  a  sudden  relaxation  of  the  spasm,  tho  air 
is  drawn  into  the  lungs  with  a  high-pitched  crowing  sound,  which  Ims 
given  to  the  affection  the  name  of  "  child-crowing."  Convulsions  may 
occur  during  an  attack  or  there  may  be  carpo-pedal  spasms.  Death  may, 
but  rarely  does,  occur  during  the  attack.  With  the  cyanosis  the  spasm 
relaxes  and  respiration  begins.  The  attacks  may  recur  with  great  fre- 
quency throughout  tho  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  if  swol- 
len and  hot,  freely  lanced.  The  bowels  should  be  carefully  regulated 
and  as  these  children  are  usually  delicate  or  rickety  nourishing  diet  and 
cod-liver  oil  should  be  given.  By  far  th  most  satisfactory  method  of 
treatment  is  the  cohl  sponging.  In  severe  cases,  two  or  three  times  a  day 
the  child  should  be  placed  in  a  warm  bath  and  the  back  and  chest  thor- 
oughly sponged  for  a  minute  or  two  with  cold  water.  Since  learning  this 
practice  from  Ringer,  at  tho  University  Hospital,  I  have  seen  many  casoi 
in  which  it  proved  successful.     It  may  be  employed  when  tho  child  is  in 


TUBERCULOUS   LARYNGITIS. 


487 


a  paroxysm,  tliongh  if  tlio  iittiu-k  is  sovoro  and  the  lividity  U  p^roat  it  ig 
iiuK'li  k'ttor  to  (lush  cold  water  into  tho  faco.  Somotinu's  tlio  introduc- 
tion of  tho  finger  far  back  into  tho  throat  will  reliovo  the  spasm. 

Spasmodic  croup,  bcliovod  to  bo  a  functional  spasm  of  tho  muscles  of 
tho  larvnx,  i^  an  atfcction  seen  most  conimoidy  between  tho  tho  ages  of 
two  and  five  years.  According  to  Trousseau's  dcseri[)ti()n,  tho  child  goes 
to  bod  well,  and  a])out  midnight  or  in  the  early  morning  hours  awakes  with 
oppressed  breathing,  harsh,  croupy  cough,  aiul  perhaps  some  liuskiiuiss  of 
voioc.  Tho  oppression  and  distress  for  a  time  are  very  serious,  tho  faco  is 
congested,  and  there  are  signs  of  approaching  cyanosis.  The  attack  passes 
off  abruptly,  tho  child  falls  asleep  and  awakes  tlio  next  morning  fooling 
perfectly  well.  Tiieso  attac^ks  may  bo  repeated  for  several  nights  in  suc- 
cession, and  usually  cause  great  alarm  to  tho  ])arout'i.  Whether  this  is  en- 
tirely a  functional  spasm  is,  I  think,  doubtful.  Tlierc  arc  instances  in 
wiiieh  tho  child  is  somewhat  hoarse  through  the  day,  and  has  slight  ca- 
tarrhal symptoms  and  a  brazen,  croupy  cough.  There  is  probably  slight 
catarrhal  laryngitis  with  it.  Those  cases  are  not  infrorpiently  mistaken 
for  true  croup,  and  parents  are  sometimes  unnecessarily  disturbed  by  tho 
serious  view  Avhioh  the  physician  takes  of  tho  case.  I'oo  often  tho  poor 
child,  deluged  Avith  drugs,  is  longer  in  recovering  from  the  treatment  than 
ho  would  be  from  tho  disease.  To  allay  tho  spasm  a  whiff  of  chloroform 
may  bo  administered,  Avhich  will  in  a  few  moments  give  relief,  or  the  child 
may  bo  placed  in  a  hot  bath.  A  prompt  emetic,  such  as  zinc  or  wine  of 
ipecac,  will  usually  relieve  the  spasm,  and  is  specially  indicated  if  tho  child 
lias  overloaded  the  stomach  through  tho  day. 


VI.   TUBERCULOUS  LARYNGITIS. 

Etiology. — Tubercles  may  develop  primarily  in  tho  laryngeal  mucosa, 
but  in  the  great  majority  of  cases  the  aifectiou  is  secondary  to  pulmonary 
tuberculosis,  in  which  it  is  mot  with  in  a  variable  proportion  of  from 
eighteen  to  thirty  per  cent.  ^lalos  are  more  frequently  affected  than 
fomales,  possibly,  as  Bosworth  suggested,  because  they  arc  more  frequently 
subject  to  catarrhal  laryngitis,  which  is  undoubtedly  a  predisposing  cause. 
Laryngitis  may  occur  very  early  in  pulmonary  tuberculosis.  There  may 
bu  \vc  -marked  involvement  of  the  larynx  with  signs  of  very  limited  trouble 
at  one  apex.  These  are  cases  which,  in  my  ex^jorienco,  run  a  very  unfavor- 
able course. 

Morbid  Anatomy. — The  mucosa  is  at  first  swollen  and  presents 
scattered  tubercles,  which  seem  to  begin  in  tho  neighborhood  of  the  blood- 
vessels. By  their  fusion  small  tuberculous  masses  arise,  which  caseato  and 
finally  ulcerate,  leaving  shallow  irregular  losses  of  substance.  The  nlcors 
are  usually  covered  with  a  grayish  exudation,  and  there  is  a  general  thick- 
ening of  the  mucosa  about  them,  which  is  particularly  marked  upon  the 


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488 


DISEASES  OP  THE  RESPIRATOUY  SYSTEM. 


arytenoids.  Tho  ulcers  may  erode  the  true  cords  uiul  fiiudly  destroy  them, 
ii!id  ))iissiii<r  d('o[»Iy  may  cause  poriehomlrilis  with  mscrosis  uiul  oeeasionallv 
exfoliation  of  the  (!artihif,'('H.  The  disease  may  extend  hiterally  and  involve 
tlie  ])liarynx,  and  downward  over  tlie  nineons  menihrane  covering,'  the 
cricoid  eartihi;j;e  toward  tlie  (esophagus.  Ahovr,  it  may  reatdi  the  posterior 
wall  of  the  pharynx,  and  in  rare  eases  extend  to  tho  fau(!ea  and  tonsils. 
The  epiglottis  may  ho  entirely  di'stroyed.  There  are  rare  instances  in 
which  ci('atri(;ial  changes  go  on  to  such  a  degree  that  stenosis  of  the  larynx 
ia  indiicc(l,  a  remarkablo  specinu'U  of  which  I  saw  some  years  ago  with 
J.  Solis-Cohen. 

Symptoms. — The  first  indication  is  slight  luiskiness  of  the  voice, 
whiidi  linally  <lee[)ens  to  hoarseness,  and  in  advanced  stages  there  may  he 
comi)lcte  loss  of  voice.  There  is  something  very  suggestive  in  the  early 
lumrseness  of  tuberculous  laryngitis.  My  attention  has  frequently  heeu 
directed  to  the  lungs  simply  by  tho  quality  of  tho  voice. 

Tho  cough  is  in  part  due  to  involvenuMit  of  tho  larynx.  Early  in  the 
disease  it  is  not  very  troublesonu',  but  when  the  ulceration  ia  extensive  it 
becomes  husky  anil  inelTectual.  Of  the  syu'.ptoms  of  laryngeal  tubercu- 
losis, none  is  more  aggravating  than  the  dysphagia,  which  is  met  with  ])ar- 
ticularly  when  the  epiglottis  is  involved,  and  when  tho  ulceration  has 
extended  to  the  pharynx.  There  is  no  nH)re  distressing  or  i)ainful  compli- 
cation in  i)hthisis.  In  instances  in  which  the  e])iglottis  is  in  great  part 
destroyed,  with  eaidi  attempt  to  take  food  there  are  distressing  paroxysms 
of  cough,  and  even  of  sulTocation. 

With  the  laryngoscope  there  is  seen  early  in  tho  disease  a  pallor  of  the 
mucous  membrane,  which  also  looks  thic-kciu'd  and  infiltrated,  ])articularly 
that  covering  the  arytenoid  cartilages.  1'hc  tuberculous  ulcers  are  very 
characteristic.  They  are  broad  and  shallow,  with  gray  bases  and  ill-definod 
outlines.  Tho  vocal  cords  are  infiltrated  and  thickened,  and  ulceration  h 
very  common. 

The  diagnosis  of  tuberculous  laryngitis  is  rarely  diffuailt,  as  it  is  usu- 
ally associated  with  well-marked  pulmonary  disease.  In  case  of  doubt 
some  of  the  secretion  from  tho  base  of  an  ulcer  should  be  removed  and 
examined  for  bacilli. 

Treatm.eiit. — Physicians  p;'y  scarcely  sufficient  attention  to  the 
laryngeal  complications  of  coii'.umjition.  The  ulcers  should  be  sprayed 
and  kept  thoroughly  cleans(Hl.  Solutions  of  tannic  acid,  nitrate  of  silver, 
or  sulphide  of  zinc  may  be  employed.  Tho  insufflation,  two  or  three  times 
a  day,  of  a  powder  of  iodoform,  with  morphia,  after  thoroughly  cleansing 
the  ulcers  with  a  spray,  relieves  the  pain  in  a  majority  of  the  cases.  Co- 
caine (four  per  cent  solution)  applied  with  the  atomizer  Avill  often  enable 
the  patient  to  swallow  his  food  comfortably.  There  are,  however,  distress- 
ing cases  of  extensive  laryngeal  and  pharyngeal  ulceration  in  which  even 
cocaine  loses  its  good  effects.  When  tho  epiglottis  is  lost  the  difficulty  in 
swallowing  becomes  very  great.    Wolfenden  states  that  this  may  be  obvi- 


,j       ^ 


SYPHILITIC   IiARYN(,ITIS. 


489 


atcd  if  tho  j)ati(>nt  liiiti<,'s  liin  liciul  oviir  tho  side  of  tlic  bed  iiiul  sucks  milk 
tliniii-'li  a  rubber  tubing'  from  ii  mug  phu-iil  ou  lUu  lluur. 


mi 

!  mm 


VII.    SYPHILITIC   LARYNGITIS. 

Svpbilirt  attivoka  the  larynx  willi  great  frcMiucni'V.  It  may  result  from 
the  iulit'riti'd  disuaso  or  bo  a  secondary  or  tertiary  nuinife.station  of  tiio  ac- 
(|iiin'(l  form. 

Symptoms. — In  secondary  syphilis  there  is  occasionally  erythema  of 
the  larynx,  wiiich  may  go  on  to  delinito  catarrh,  but  has  notliing  charuc- 
tci'istic.  The  process  may  proceed  to  the  formation  of  suixn'tiinal  whitish 
ulcers,  usually  symmetrically  placed  on  the  cords  or  vetitricular  bands. 
Mucous  patches  and  condylomata  are  rarely  seen.  The  symptoms  aro 
]ini('tically  those  of  slight  loss  of  voice  with  laryngeal  irritation,  as  in  tho 
sinijilc  I'atarrhal  form. 

The  tertiary  laryngeal  lesions  are  numerous  and  very  serious.  Truo 
fjumnuita,  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  develop 
iu  the  subnuicous  tissue  most  oommonb  at  tho  base  of  the  e[)iglottis. 
Tli(>v  go  through  the  changes  eharacteristi*;  of  these  structures  and  may 
lithiT  break  down,  producing  e\tensive  and  dee])  ulceratioTi,  or — and  this 
is  uHirc  characteristic  of  syphilitic  laryngitis — in  their  healing  form  a 
fibrous  tissue  which  shrinks  aiul  produces  stenosis.  The  ulceration  is  apt 
tiicxti-nd  deeply  and  involve  the  cartilage,  inducing  necrosis  and  exf(jlla- 
tiou,  and  even  luemorrhage  from  erosion  of  the  arteries.  G^deuui  nuiy 
suddenly  prove  fatal.  Tho  cicatrices  which  f(dlow  the  siderosis  of  tho 
guiuinata  or  tho  healing  of  tho  ulcers  produce  great  deformity.  The  epi- 
^dottis,  for  instance,  may  be  tied  down  to  tho  pharyngeal  wall  or  to  tho 
('l)ii,d()ttic  folds,  or  oven  to  tho  tongue ;  and  eventually  a  steiu)sis  results, 
wlucli  may  necessitate  tracheotomy. 

Tliu  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  [tuborty  ;  most  commoidy  in  the  former  period.  Of  70  cases,  J.  N. 
Miiekeiizie  found  that  03  occurred  within  the  first  year.  The  gummatous 
infiltration  leads  to  ulceration,  most  commonly  of  the  epiglottis  and  in 
the  vcutricdes,  and  tho  process  may  extend  deeply  and  involve  tho  carti- 
lage.   Cicatricial  contraction  may  also  occur. 

The  diagnosis  of  syphilis  of  the  larynx  is  rarely  diilicult,  since  it 
oeeurs  most  commonly  in  connection  Avith  other  symptoms  of  tho 
disease.  For  spociid  details  tho  manuals  of  laryngology  should  be  con- 
sulted. 

Treatment. — The  administration  of  constitutional  remedies  is  the 

most  important,  and  under  mercury  and  iodide  of  potassium  the  local 

symptoms  may  rapidly  bo  relieved.     Tho  tertiary  laryngeal  manifestations 

are  always  serious  and  difRcult  to  treat.    The  deep  ulceration  is  specially 

82 


"  Vi'i'  Ins'  *  vi 


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«^''i 
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490 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


Ijiird  to  combat,  utuI  the  cioutrijcation  may  necessitate  tracheotomy,  or  ilie 
gradual  dilatation,  as  practised  by  Hchroetter. 


III.  DISEASES  OF  THE  BRONCHI. 

I.    ACUTE  BRONCHITIS. 

Acute  catarrhal  inflammation  of  the  bronchial  mucous  mcmbrauo  is  a 
yery  common  disease, rarely  serious  in  liealthy  adults,  but  very  fatal  in  (he 
old  and  in  the  young,  owing  to  associated  })ulmonary  com])lications.  It  is 
bilateral  and  alfects  either  the  larger  and  medium  sized  tubes  or  tln' 
smaller  bronchi,  in  wliich  case  it  is  known  as  cajnllary  bronchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  part  and  parcel  of 
broncho-pneumonia. 

Etiology. — Acute  bronchitis  is  a  common  sequence  of  catching  cdld, 
and  is  often  nothing  more  than  the  extension  downward  of  an  ordinary 
coryza.  It  occurs  most  frc(iuently  in  the  changeable  weatlier  of  early 
spring  and  late  autumn.  It;  association  with  cold  is  well  indicated  l)y 
the  popular  expression  "cold  on  the  chest."  It  may  prevail  as  an  epi- 
demic apart  from  influenza,  of  Avhich  it  is  an  important  feature. 

Acute  bronchitiri  is  associated  with  many  other  affections,  notal)ly 
measles.  It  is  ])y  lU)  means  rare  at  the  onset  of  typ1u)id  fever  aiul  malaria. 
It  is  present  also  in  asthma  and  whooj)ing-cough.  The  bronehiti.s  of 
Bright's  disease,  gout,  and  heart-disease  is  usually  a  chronic  form.  Jt 
attacks  ptM-sons  of  all  ages,  but  most  frequently  the  young  and  the  old. 
There  are  individuals  Avho  have  a  sjiecial  disposition  to  bronchial  catarrh, 
and  the  slightest  exposure  is  apt  to  bring  on  an  attack.  Persons  wlut  Ww 
an  out-of-door  life  are  usually  less  subject  to  the  disease  than  those  wlio 
follow  sedentary  occupations. 

The  affection  is  pl'obably  microbic,  though  we  have  us  yet  no  definite 
evidence  u])on  this  point. 

Morbid  Anatomy. — The  nuicous  membrane  of  the  trachea  and 
bronchi  is  reddened,  congested,  and  covered  with  mucus  and  muco-pus, 
which  may  be  seen  oozing  froni  the  smaller  bronchi,  some  of  wlii(di  arc 
dilated.  The  finer  changes  in  tlie  mucosa  consist  in  de.-^cuuunafion  of  ilui 
ciliated  ei)itlielium,  swelling  and  (edema  of  the  submucosa,  and  inliltratioii 
of  the  tissue  with  leucocytes.     The  mucous  glands  are  much  swollen. 

Sjrmptoms. — The  synii>tonis  of  an  ordinary  "cold"  accom])any  the 
(mset  of  an  acute  bronchitis.  The  coryza  extends  to  the  tubes  and  may 
also  affect  the  larynx,  producing  hoarstuiess,  which  in  many  cases  is  niarkt'd. 
A  chill  is  rare,  but  there  is  invariably  a  sense  of  oi)])ression,  with  heavi- 
ness and  languor  and  pains  in  the  bones  and  havk.  In  mild  cases  there  is 
scarcely  any  fever,  but  in  severer  forms  the  range  is  from  101°  to  1U3  . 


Il'^tj 


iU 


ACUTE  BRONCHITIS. 


491 


Tlie  broTiC'hiiil  symptoms  set  in  with  a  feeling  of  tightness  and  rawness 
InMicath  the  sternum  and  a  sensation  of  o])pression  in  tlie  eliest.  The 
C(jiii,di  is  rough  at  first,  cutting  and  sore,  and  often  of  a  ringing  eharaeter. 
It  comes  on  in  paroxysms  which  rack  and  distress  the  patient  extremely. 
During  the  severe  spells  the  pain  maybe  very  intense  beneath  the  sternum 
nm\  along  the  attacliments  of  the  diaphragm.  At  first  the  cough  is  dry, 
hut  in  a  few  days  the  secretion  becomes  muco-purulent  and  abundant,  and 
linally  purulent.  With  the  loosening  of  the  cough  great  relief  is  experi- 
enced. The  sputum  is  made  up  largely  of  pus-cells,  with  a  variable  number 
of  the  large  round  alveolar  cells,  many  of  which  contain  carbon  grains, 
while  others  have  undergone  the  myelin  degeneration. 

I'/n/smd  Signs. — The  respiratory  movements  are  not  greatly  increased 
in  J'rofjuency  unless  the  fever  is  high.  There  are  instances,  however,  in 
wliich  the  breatliing  is  rapid  and  when  the  smaller  tubes  are  involved 
there  is  dyspnwa.  On  palpation  the  bronchial  fremitus  may  often  be  felt. 
On  auscultation  in  the  early  stage,  piping  sibilant  rales  are  everywhere  to 
ho  heard.  They  are  very  changeable,  and  ap])ear  and  disappear  with  cough- 
iiiir.  With  the  relaxation  of  the  bronchial  membranes  and  the  greater 
iiluindance  of  the  secretion,  the  rAles  change  and  become  mucous  and  bub- 
hliiiir  in  quality. 

The  course  of  the  disease  dejiends  on  the  conditions  under  which  it 
(levclops.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and 
the  cough  loosens.  In  another  week  or  ten  days  convalescence  is  fully 
estiihlislu'd.  In  young  children  the  chief  risk  is  in  the  extension  of  the 
|ir')cc.ss  downward.  In  measles  and  whooping-cough,  the  ordinary  bron- 
chial catarrh  is  very  apt  to  descend  to  the  fiTier  tubes,  vi\\\v\\  become  di- 
lated and  ])lugged  with  muco-pus,  inducing  areas  of  collapse,  and  finally 
broncho-pneumonia.  This  extension  is  indicated  by  changes  in  the  physi- 
cal siguH.  Usually  at  the  base  the  rales  an;  subcrepitant  and  numerous 
and  there  may  be  areas  of  defective  resonance  and  of  feeble  or  distant  tu- 
l)ular  breathing.  In  the  aged  and  debilitated  there  are  similar  dangers  if 
the  process  extends  from  the  larger  to  the  smaller  tubes.  In  old  age  the 
bronchial  mucosa  is  less  capable  of  expelling  the  mucus,  which  is  more 
apt  to  sag  to  the  dependent  parts  and  induce  dilatation  f)f  the  tubes  with 
extension  of  the  inlhunmation  to  the  contiguous  air-cells. 

rhe  ili<i(jiwsis  of  acute  bronchitis  is  rarely  difficult.  Although  the 
mode  of  onset  may  be  brusque  and  })erhaps  simulate  pneumonia,  yet  the 
al)>encc  of  dulness  and  blowing  breathing,  and  the  general  character  of 
the  hroindiial  intlammation,  renders  the  diagnosis  simple.  'Hie  com|)lica- 
tion  of  iironcho-pneumonia  is  indicated  by  the  greater  severity  of  the  synif)- 
tiinis,  |iarti('ularly  the  dyspnoea,  the  defective  color,  and  the  physical  signs. 
Treatment. — In  mild  cases,  household  measures  suffice.  The  hot 
toot-lialh,  or  the  warni  bath,  a  drink  of  hot  lemonade, and  a  mustard  plas- 
ter on  the  chest  will  often  give  relief.  For  the  dry,  racking  cough,  the 
symptom  most  complained  of  by  the  patient,  Dover's  powder  is  the  best 


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492 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


remedy.  It  is  a  popula''  belief  that  quinine,  in  full  doses,  will  cheek  an 
oneoniing  cold  in  the  chest,  but  this  is  doubtful.  It  is  a  common  rustotii 
when  persons  feel  the  approach  of  a  cold  to  take  a  Turkish  bath,  uimI 
though  the  tightness  and  oppression  may  be  relieved  by  it,  there  is  in  a 
majority  of  the  cases  great  risk.  Some  of  the  severest  cases  of  bronchitis 
which  1  have  seen  have  followed  this  initial  Turkish  bath.  No  doulit,  if 
the  person  could  go  to  bed  directly  from  the  bath,  its  a(!tion  would  he 
heneJicial,  but  there  is  great  risk  of  catching  additional  "cold"  in  going 
home  from  the  bath.  Relief  is  obtained  from  the  unpleasant  sense  df 
rawness  by  keejiing  the  air  of  the  room  saturated  Avith  moisture,  and  in 
this  dry  stage  the  old-fashioned  mixture  of  the  wines  of  antimony  ami  ipe- 
cacuanha with  liquor  ammoniae  acetatis  and  nitrous  ether  is  useful.  If 
the  ])ulse  is  very  rapiil,  tiricture  of  aconite  may  be  given,  jiarticulariy  in 
the  case  of  children.  For  the  cough,  when  dry  ami  irritating,  opium 
should  be  freely  used  in  the  form  of  Dover's  jjowder.  Of  course,  in  llii> 
vei-y  young  and  the  aged  care  must  be  exercised  in  the  use  of  opium,  par- 
ticularly if  the  secretions  are  free ;  but  for  the  distressing,  irritative  cough, 
which  keejis  the  patient  awake,  no  remedy  can  take  its  place  As  the  coairii 
loosens  and  the  expectoration  is  more  abundant,  the  patient  l)ec,,n).  ui' 
(iomfortable.  In  this  stage  it  is  customary  to  ply  the  patient  witl,  |  . 
torants  of  various  sorts.  Though  useful  occasionally,  thSy  should  \w\  he 
given  as  a  matter  of  routine.  A  mixture  of  squills,  ammonia,  and  senega 
is  a  favorite  one  with  many  practitioners  at  this  stage. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  larsjr 
and  dillicult  to  expectorate,  or  if  there  is  dyspnoea  and  the  color  hogina 
to  get  dusky,  an  emetic  (a  tablospoonful  of  ipecac  wine)  should  be  given 
at  once  and  repeated  if  necessary. 


% 

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4 

II.    CHRONIC   BRONCHITIS. 

Etiology. — This  affection  may  follow  repeated  attacks  of  acute  bron- 
chitis, but  it  is  nu)st  commonly  met  with  in  chronic;  lung  affections,  heart- 
disease,  gout,  and  renal  disease.  It  is  frequent  in  the  aged;  the  vmmij 
rarely  art.i  affected.  Clinuite  and  season  have  an  im])ortaJit  influenct .  It 
is  the  winter  cough  of  the  old  man,  which  recurs  with  ugularity  as  the 
weather  gets  cold  and  changeable. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  great  variety 
of  ciningcs,  depending  sonunvhat  upon  the  disease  with  wliicli  chroiiii' 
bronchitis  is  associated.  In  some  cases  the  mucous  membrane  is  viiy 
thin,  so  that  the  longitudinal  bands  of  elastic  tissue  stand  out  )»roniiuentl\. 
The  tubes  are  dilated  and  the  mrscular  and  glandular  tissues  are  atri)|ihieil 
and  the  epitlu'lium  in  great  part  slu>d. 

In  other  instaiu;es  the  mucosa  is  thickened,  granular,  .and  infiltrated. 
There  may  be  ulceration,  particularly  of  the  muco'js  follicles.     Broneliial 


^^^^ 


CHRONIC   BRONCHITIS. 


i^ 


4J)3 


flilatiitions  are  not  uncommon  and  emphysema  is  a  constant  acoompani- 

IlU'llt. 

Symptoms. — In  the  form  met  with  in  old  men,  associated  with  em- 
iihyscina,  gout,  or  lieart-disease,  the  chief  symptoms  are  as  follows :  Short- 
iii'ss  of  hrciith,  which  may  not  be  noticeable  ex(>ci)t  on  exertion.  The 
iiatients  "  ])uif  and  blow  "  on  going  uj)  hill  or  up  a  llight  of  stairs.  This  is 
(liie  not  so  much  to  the  chronic  bronchitis  itself  as  to  associated  euiphy.sema 
or  t'vt'ii  to  cardiac  weakness.  They  com|)hi.in  of  no  pain.  Tlic  cdugh  is  varia- 
ble, cluiiigi;H5  with  the  weather  and  with  the  season.  During  the  summer 
tliev  niav  remain  tree,  but  each  succeeding  winter  the  cough  comes  on  with 
severity  and  persists,  'i'here  nuiy  be  oidy  a  spell  in  the  morning,  (ir  the 
chief  distress  is  at  night.  The  sputum  in  chronic  bronchitis  is  very  varia- 
lile.  In  cases  of  the  so-called  dry  catarrh  there  is  no  expectoration.  Tsu- 
allv,  however,  it  is  abundant,  niuco-])Ui'ulent,  or  distinctly  purulent  in 
eharacter.  There  are  instances  in  which  the  ])aticnt  cougiis  uj)  for  years 
a  tliin  tluid  sputum.  Tliere  is  rarely  fever.  The  general  health  may  be 
gooil  and  tlie  '"  '.nise  may  present  no  serious  features  apart  from  the  lia- 
bility to  ini  cini)hysema  and  bronchiectasy.  In  many  cases  it  is  an 
inenralile  al.  cion.  Patients  imiirove  aiul  the  cough  disappears  in  the 
summer  time  oidy  to  return  during  the  winter  mouths. 

Physical  Signs. — The  chest  is  usually  distende  1,  the  movements  are 
limited,  and  the  condition  is  often  that  which  we  see  in  empbysema.  'I'he 
percussion  luitc  is  clear  or  hyperresonant.  On  auscultation,  ex]urati()n  is 
prolonged  and  wheezy  ami  rlu-nchi  of  various  sorts  are  heard — sonv  high- 
]utrlie(l  and  piping,  others  deep-toned  and  snoring.  Crepitation  is  com- 
mon at  the  lyases. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary 
chronic  iinmchitis  wbicli  occun  in  connectioji  with  cm[divsi'ma  and  beart- 
tlisease  and  in  many  elderly  men.  There  are  certain  fonns  wliieh  nu'rit  spe- 
cial description  :  (a)  On  several  occasions  1  have  met  with  a  form  of  rliromr 
broiir/iilts,  ]>articularly  in  women,  which  comes  on  between  the  ages  of 
twenty  and  thirty  and  may  continue  indefinitely  wiihout  serious  impair- 
ment of  the  health.  In  one  case,  a  lady  of  fifty,  with  a  phthisical  family 
history,  began  to  cough  when  she  was  twenty-iivi',  and  since  then  has  had 
i'"re  or  less  cough  every  day  without  intermission.  It  has  not  seriously 
unpaired  her  health,  though  she  has  never  been  strong.  Once  or  twice 
she  has  had  attacks  of  eczema.  The  cough  is  chielly  in  the  morning,  is 
apt  !'■  be  brought  on  by  too  much  conversation,  and  is  (piite  indi'peiulent 
of  tlie  weather.  The  dtuly  anmunt  of  expectoration  is  not  great,  rarely 
more  than  from  four  to  six  ounces.  It  is  muco-purulcid  in  character. 
The  examination  of  the  (>hest  is  negative — no  emiihysema,  no  rales.  I 
have  met  several  such  instances  which  se(Mn  to  form  a  type  of  cbronit; 
liroiiehitis,  though  it  is  ditUcult  to  say  upon  what  the  condition  depends. 

{/))  BrovcliarrliKd. — Excessive  bronchial  secretion  is  met  with  under 
several  conditions.    It  must  not  be  mistukeu  for  the  profuse  ex|)ectoration 


•fefc^ 


-l 


-  ir 


IIBBi 


""i'SUfi 


494 


DISEx^SES   OF  THE  RESPIRATORY  SYSTEM. 


of  bronchiectasy.  The  secretion  may  bo  very  liquid  and  watery — hronchor- 
rhcea  serosa.  More  commonly,  it  is  purulent  tliou<fh  thin,  and  with  green- 
ish or  yellow-<;reen  masses.  It  may  be  thick  and  uniform.  This  ]>rofuse 
bronchial  secretion  is  usually  a  manifestation  of  chronic  bron(!hitis  and 
may  lead  to  dilatation  of  the  tubes  and  ultimately  to  fetid  bronchitis.  In 
the  young  the  condition  may  persist  for  years  without  im]iaii'ment  of 
health  atid  without  apparently  damaging  the  lungs. 

(r)  Pulrid  IJroitc/iifis. — Fetid  expectoration  is  met  with  in  conivx'tion 
with  bronchiectasis,  gangrene,  abscess,  or  with  decomposition  of  secretions 
within  i)htliisical  cavities  and  in  an  empyema  which  has  perforattul  the 
lung,  '.riiere  are  instances  in  whieh,  apart  from  any  of  these  sUites,  tlie 
expectoration  has  a  fetid  character.  The  sputa  are  abundant,  usnallv 
thin,  grayish  white  in  color,  and  they  se})arate  into  an  upjjcr  lluid  lavrr 
i;apped  with  frothy  mucus  and  a  thick  sediment  in  which  may  sonietinics 
be  found  dirty  yellow  masses  the  size  of  peas  or  beans — the  so-called  Dit- 
trich's  j)lugs.  The  aifection  is  very  rare  apart  from  the  abovc-mentidncfl 
conditions.  \<^  ^^o-ere  cases  it  leads  to  changes  in  the  bronehial  walls, 
piieumonia,  ai  '  jn  to  abscess  or  gangrene.  Metastatic  bruin  abscess 
has  followed  puu  i    bronchitis  in  a  certain  number  of  cases. 

{(I)  Dnj  Catarrh. —  Catarrhe  sec  of  Laennec  is  a  not  unconmion  form, 
characterized  by  paroxysms  of  coughing  of  great  intensity,  with  little  (ir 
no  expectorati(m.  It  is  usually  met  with  in  elderly  persons  with  enipliy- 
sema,  and  is  one  of  the  most  chronic  and  obstinate  of  all  varieties  of  biou- 
chitis. 

Treatment. — By  far  the  most  satisfactory  method  of  treating  the 
recurring  winter  bronchitis  is  change  of  climate.  Henioval  to  a  southern 
latitude  may  i)revent  the  onset.  Southern  France,  southern  California. 
and  Florida  furnish  Avinter  climates  in  which  the  subjects  of  chronic 
bronchitis  live  with  the  greatest  comfort.  All  cases  of  ])rolonged  bronchial 
irritation  are  benefited  by  change  of  air. 

The  Hrst  endca\'or  in  treating  a  case  of  chronic  broiudiitis  is  to  ascer- 
tain if  possible  whether  there  are  constitutional  or  local  all'ections  with 
which  it  is  associated.  In  many  instances  the  urine  is  found  to  be  iiiglily 
acid,  perhaps  slightly  albuminous,  and  the  arteries  are  stilf.  In  the  fi>nn 
associated  with  this  condition,  sometimes  called  gouty  bronchitis,  the  at- 
tacks seem  related  to  the  defective  renal  elimination,  and  to  this  conditiDii 
the  treatment  should  be  iirst  directed.  In  othei'  instances  there  are  heart- 
disease  and  eniphyseuKi.  In  the  form  occurring  in  old  tnen  nnuli  may  he 
done  in  the  way  of  prophylaxis.  Septuagenarians  should  read  Oliver  W  cn- 
dell  Holmes's*  "De  Senectuto"  with  reference  to  the  can^  of  the  hcaltli 
and  the  avoidance  of  catching  cold.  He  lays  stress  upon  the  inqiortaiire 
of  the  daily  study  of  the  thermometer  and  barometer.  There  is  no  (ioulit 
that  with  prudence  even  in  our  chang(udjle  winter  weather  nuu'h  may  '* 


Over  the  Tea-cups,  Boston,  1890. 


t<r"""n' 


I.     f 


BRONCHIECTASIS. 


495 


done  to  prevent  the  onset  of  chronic  bronchitis.  Woolen  undergurmerts 
slidiild  be  used  and  especial  care  should  be  taken  in  the  spring  months  not 
to  chiinge  them  for  lighter  ones  before  the  warm  weather  is  established. 

Cure  is  scddoiu  elt'ected  by  mediciiial  remedies.  There  are  iiustances  in 
which  iodide  of  potassium  acts  with  remarkable  benelit,  and  it  should 
always  be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin. 
Wiuii  the  secretion  is  excessive  the  muriate  of  anunoiua  is  perhaps  the 
most  useful.  Stimulating  exj)ectorants  are  coiitra-indicatcd.  When  the 
heart  is  feeble,  the  coml)ination  of  digitalis  and  strychnia  is  very  bene- 
licial.  Tiirpentijie,  the  old-fashioned  remedy  so  warndy  recommended  by 
the  l)u!>lin  physicians,  has  in  many  quarters  fallen  undeservedly  into  dis- 
use. Terebene  in  capsules  is  a  useful  substitute  because  it  is  more  easily 
taken.  Of  other  balsamic  remedies,  sandalwood,  the  compound  tincture 
of  Ix'nzoin,  copaiba,  balsam  of  I'eru  or  tolu  may  be  used.  Inhalations  are 
ot'teu  very  useful.  If  fetor  be  present,  carbolic;  acid  in  the  form  of  spray 
(twenty  to  tliirty  per  cent  solution)  will  lessen  the  odor,  or  thymol  (1  to 
1.0(10).  In  fidl-blootled  men,  when  venous  engorgement  exists  and  short- 
ness (if  breath,  tlie  abstraction  of  twenty  to  thirty  ounces  of  blood  will 
ulTord  prompt  relief. 


in.   BRONCHIECTASIS. 

Etiology. — Dilatation  of  the  broiu'hi  occurs  under  the  following 
coiulitioiis  :  (1)  As  a  congenital  defect  or  anomaly.  Such  cases  are  ex- 
tremely rare,  commoidy  unilateral.  Cirawitz  has  described  the  condition 
as  lirniic/iieddsis  nuirfrsalis.  Welch  has  met  an  instance  in  a  young 
srirl.  {'I)  In  connection  with  intlammation  of  the  bronchi,  ])articularly 
wiieii  this  leads  to  weakness  of  the  walls  with  the  accumulation  of  secre- 
tion. Under  this  category  come  the  dilatation  nu't  with  in  chronic  bron- 
ehitis  and  emphysenui,  the  dilated  bronchi  in  chronic  phthisis,  in  the 
catarrh:;!  jineumonias  of  children,  and  ]iarticularly  the  dilitation  which 
n'siilts  from  the  presence  of  foreign  bodiiis  in  the  air-tubes  or  from 
j)ressure,  as  of  an  aneurism  on  one  bronchus.  (3)  In  extrenu*  contraction 
of  the  lung  tissue,  M'hether  due  to  interstitial  pneumonia  or  to  compres- 
sion by  ])leural  adhesions,  bronchial  dilatation  is  a  common  though  not 
a  constant  ac(;om])animent. 

rn<|uestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probably  the  essential,  factor  in  inducing  bronchiectasy,  since  the  wall 
ih  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing 
and  in  straining.  In  sonu^  instaiu'cs  the  nu're  weight  of  the  accunudated 
set  '•etion  may  be  sufficient  to  distend  the  terminal  tubules,  as  is  seen  in 
compression  of  a  bnmchus  by  aneurism. 

Morbid  Anatomy. — Two  chief  forms  are  recognized — the  ci/Hn- 
dnnd  and  the  saccular — which  may  exist  together  in  the  same  lung.    The 


,    -Hi 


)  I 


'  'it 


i',,   .1 


mM> 


I     !., 


496 


r^ISEASES  OF  THE   RESPIRATORY   SYSTEM. 


condition  may  be  general  or  partial.  Universal  bi'onchioctasis  is  always 
unilateral.  It  occurs  in  rare  congenital  cases  and  is  occasionally  seen  as  h 
sequence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  roprc- 
sented  by  a  series  of  sacculi  opening  one  into  the  other.  Tlie  walls  mv 
smooth  and  possibly  withoiil  ulceration  or  erosion  except  in  the  dependciit 
parts.  The  lining  meml)rane  of  the  .sacculi  is  usually  smooth  and  glisten^ 
ing.  The  dilatations  nuiy  form  large  cysts  immediately  beneath  the 
pleura.  Intervening  between  the  sacculi  is  a  dense  ciri'hotic  lung  tissue, 
The  ])artial  dilatations — the  saccular  and  cylindrical — are  common  in 
chronic  jjlithisis,  particularly  at  the  apex,  in  chronic  pleurisy  at  the  biisc. 
and  in  emi)hysema.  Here  the  dilatation  is  more  commonly  cylindi-jcal, 
sometimes  fusiform.  The  broncliial  mucous  memljrane  is  much  in- 
volved and  sometimes  tlu're  is  a  narrowing  of  the  lumen.  Occasioiialh 
one  meets  Avith  a  single  saccular  bronchiectasy  in  connection  Avith  chronic 
bronchitis  or  emphysema.  Some  of  these  look  like  simple  cysts,  with 
smooth  walls,  without  fluiil  contents. 

Histologically  the  bronchi  which  are  tlie  seat  of  dilatation  show  im- 
portant changes.  In  the  large,  smooth  dilatations  the  cylindrical  is  ro- 
placrd  by  a  ])aveinent  epithelium.  The  muscular  layer  is  stretched,  atro- 
phied, and  the  fibres  separated  ;  the  elastic  tissue  is  also  nnu'h  stretched 
and  separated.  In  the  large  saccular  bronchiectasies  and  in  some  of  the 
cylindrical  forms,  due  to  retained  secretions,  the  lining  membrane  is  ulcer- 
ated. The  contents  of  some  of  the  larger  bronchiectatic  cavities  are  hor- 
ribly fetid. 

Symptoms.  —  In  the  limited  dilatations  of  phthisis,  emphysema,  and 
chronic  bronchitis,  the  sym])toms  are  in  great  i)art  those  of  the  original 
disease,  and  the  condition  often  is  not  susjiected  during  life. 

In  extensive  saccular  bronchiectasy  the  characters  of  the  cougli  and 
expectoration  rre  distinctive.  The  patient  will  i)ass  the  greater  part 
of  the  day  without  any  cough  and  then  in  a  severe  paroxysm  will  \mnji 
up  a  large  (pnmtity  of  sputum.  Sometimes  change  of  the  position  will 
bring  on  a  violent  attack,  probably  due  to  the  fact  that  some  of  the 
secretion  Hows  from  the  dilatation  to  a  normal  tube.  The  daily  spell  ef 
cougliing  is  usually  in  the  morning.  The  expectoration  is  in  many  in 
stances  very  characteristic.  It  is  grayish  or  grayish  brown  in  color,  fluid, 
purulent,  with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  conical 
glass,  it  separates  into  a  thick  granidar  la}cr  below  and  a  thin  nuKJoid  in- 
tervening layer  above,  which  is  cajiped  by  a  brownish  froth.  Microscoiii- 
cally  it  consists  of  pus-corpuscles,  often  large  crj-stals  of  fatty  acids,  which 
are  sometimes  in  enormous  numbers  over  the  field  and  arranged  in 
bunches.  1  hematoidin  crystals  are  sometimes  present.  Elastic  fibres  are 
seldom  found  except  when  there  is  ulceration  of  the  bron(diial  walls. 
Tubercle  bacilli  are  not  present.  In  some  cases  the  expectoration  is  very 
fetid  and  has  all  the  characters  of  those  described  under  fetid  bronchitis. 
Nummular  expectoration,  such  as  comes  from  phthisical  cavities,  is  tiot 


.f  il 


;r-r 


BRONCHIAL  ASTHMA. 


497 


fDniTnon.  Hfpniorrliiigo  may  occur,  but,  in  my  oxporiouce  it  lias  been  rare. 
Abscess  of  the  1)raiii  has  in  a  few  instances  followed  the  brouchiectasisi. 
Ulieumatoid  afTections  may  develop  ((Jerliardt). 

The  dia[/HOsi.s  is  not  possible  in  a  large  number  of  tlie  cases.  In  the 
oxtciisive  sacculated  forms,  unilateral  and  associated  witli  interstitial  pncMi- 
mouia  or  chronic  i)lcurisy,  the  diagnosis  is  easy,  '{'here  is  contraction  of 
the  side,  which  in  some  instances  is  not  at  all  extreme.  The  cavernous 
siinis  may  be  chiefly  at  the  base  and  may  vary  according  to  the  condition 
of  the  cavity,  whether  full  or  empty.  There  may  be  the  most  exquisitt; 
amphoric  plicnomeua  and  loud  resonant  rales.  The  condition  persists  for 
voars  and  is  not  inconsistent  with  tolerably  active  life.  The  patients  fre- 
quently show  signs  of  marked  embarrassment  of  the  pulmonary  circula- 
tion. There  is  cyanosis  on  exertion,  the  finger-tii)8  are  clubbed,  and  the 
iiiiils  incurved.  A  condition  very  dillicult  to  distinguish  from  bronchiec- 
tasv  is  a  liniiiefl  pleural  cavity  communi(;ating  with  a  bronchus. 

Treatment. — Medical  treatment  is  not  satisfactory,  since  it  is  impos- 
sible to  heal  the  cavity.  I  have  practised  the  injection  of  antiseptic  tluids 
in  some  instaiux's  witii  benefit.  In  suitable  cases  drainage  of  the  cavi'^ies 
iiiav  be  attenii)tcd,  ])articularly  if  the  patient  is  in  fairly  good  condition. 
For  the  fetid  secretion  turpentine  may  be  given  or  terebcne,  and  iidiala- 
tions  used  of  carbolic  acid  or  thymol.  In  extreme  cases  it  is  very  ditlicult 
to  get  rid  of  the  offensive  odor. 


IV.    BRONCHIAL    ASTHMA. 

Astlima  is  a  term  which  has  been  a])plied  to  various  conditions  associ- 
ated witli  (lyspna'a — hence  the  names  cardiac  and  renal  asthma — but  its 
use  should  be  limited  to  the  affection  known  as  bronchial  or  spasmodic 
asthma. 

Etiology. — All  writers  agree  that  there  is  in  a  majority  of  cases  of 
hroiiehiai  astlima  a  strong  neurotic  element.  Many  regard  it  as  a  neu- 
rosis in  which,  according  to  one  viev/,  s])asm  of  the  broiu'hial  muscles, 
aci'onliiig  to  the  other,  turgescenee  of  the  nnicosa,  results  from  disturbed 
innervation,  pneumogastric  or  vaso-motor.  Of  the  numerous  theories  the 
following  are  the  most  important: 

(1)  That  it  is  due  to  spasm  of  the  bronchial  muscles,  a  theory  which 
has  perha|)s  the  largest  number  of  adherents.  The  original  exi)erinients 
of  C.  J.  15.  Williams,  upon  which  it  is  largely  based,  have  nijt,  however, 
been  confirmed  of  late  years. 

{'i)  That  the  attacL  is  due  to  swelling  of  the  bronchial  mucous  mcm- 
lirano — fluctionary  hyperannia  (Traube),  vaso-motor  turgescer.ee  (Weber), 
Jitl'iise  hypenemic  swelling  (Chirk). 

(;5)  That  in  many  cases  it  is  a  special  form  of  iidlammation  of  the 
smaller  bronchioles — ironchiolitis  exudativa  (Curschmann).     Other  theo- 


i*fci"i 


,1  'M 


ill 


'■•*'■ 


%:., 


V'-l 


■>'.(.^- 


ft- 


498 


DISEASES  OP  TEE  RESPIRATORY   SYSTEM. 


ries  which  may  be  mentioned  ure  that  tlic  attafk  depends  on  sj)asm  of  tlio 
diaphraj^m  or  on  reflex  spasm  of  all  the  inspiratory  uiuscles. 

As  already  nieiitioTied,  the  sft-ealled  hay  fever  is  an  ad'ection  whicli  has 
many  resenihlaTices  to  broneliial  asthma,  with  which  the  attacks  may  alter- 
nate. In  the  suddenness  of  onset  and  in  many  of  their  features  these  dis- 
eases have  the  same  origin  and  dilfer  only  in  site,  as  suggested  hy  Sir 
Andrew  (Jlark  and  now  generally  acknowledged  hy  specialists.  Making 
due  allowance  for  anatomical  dill'erences,  if  the  structural  changes  occur- 
ring in  the  nasal  mucous  mend)rane  during  an  attack  of  liay  fever  were  to 
occur  also  in  various  parts  of  the  bronchial  mucosa,  their  })resence  there 
wonld  afford  a  comjjlete  and  adecjuate  ex|)lanation  of  the  facts  observed 
during  a  paroxysm  of  bronchial  asthma  (Clark).  With  this  statement  I 
fully  agree,  l)ut  the  observations  of  Curschmann  have  directed  attention 
to  a  fi'ature  in  asthma  which  lias  been  neglected ;  namely,  that  in  a  ma- 
jority of  the  cases  it  is  associated  with  an  exudation,  such  as  might  he 
sup])osed  to  come  from  a  turgescent  mucosa  and  wliich  is  of  a  very  charac- 
teristic and  pe(.'uliar  character.  The  hyperannia  and  swelling  of  the  nui- 
cosa  and  the  extremely  viscid,  tenacious  nuicus  explain  well  the  hindrance 
to  inspiration  and  ex})iration  and  also  the  quality  of  the  rales. 

Some  general  facts  with  reference  to  etiology  nniy  be  mentioned.  The 
affection  sonu'times  runs  in  families,  ])articuhirly  those  with  irritable  and 
unstable  nervous  systems.  The  attack  may  be  associated  with  neuralgia 
or,  as  Salter  mentions,  even  alternate  Avith  e])ile])sy.  ^len  are  more  fre- 
quently alfected  than  women.  The  disease  often  begins  in  cliildhood  and 
sometimes  lasts  until  old  age.  One  of  its  most  striking  })eculiarities  is  the 
bizarre  and  extraordinary  variety  of  circumstances  which  at  times  induce 
a  paroxysm.  Among  these  local  conditions  clinuite  or  atmos])liere  are 
most  ini[)ortant.  A  ])ers(m  may  be  free  in  the  city  and  invariably  sullVr 
from  an  attack  Avlien  he  goes  into  the  country,  or  into  one  special  pait  of 
the  country.  Such  cases  are  by  no  means  uncommon.  IJreathing  the  air 
of  a  particular  roOin  or  a  dusty  atmosphere  may  bring  on  an  attack. 
Odors,  particularly  of  ilowers  and  of  hay,  or  cnuuiations  from  animals,  as 
the  horse,  dog,  or  cat,  may  at  once  cause  an  outbreak.  J-'right  or  violent 
emotion  of  any  sort  may  bring  on  a  paroxysm.  Uterine  and  ovarian 
troubles  wwri}  formerly  thouglit  to  induce  attacks  and  may  do  so  in  rare 
instances.  Diet,  too,  has  an  important  influence,  and  in  persons  subject  to 
the  disease  severe  paroxysms  may  t)e  induced  by  overloading  the  stomach, 
or  by  taking  certain  arti(des  of  foo<l.  Chronic  cases,  in  wliich  the  attacks 
recur  year  after  year,  gradually  become  associated  with  emphysoma,  and 
every  fresh  "cold"  induces  a  ])aroxysm.  And  lastly,  many  cases  of  bron- 
chial asthma  are  associated  with  affections  of  the  nose,  iiarticularly  with 
liypertro])hic  rhinitis  and  nasal  polypi.  According  to  some  sjiecialist.'^  of 
large  experience,  all  cases  of  bronchial  asthma  have  some  affection  t>\'  the 
upper  air-passages,  but  I  am  convinced  from  personal  observation  that 
this  is  erroneous.     Still  physicians  must  acknowledge  the  debt  which  we 


-JH 


BllONCrilAL   ASTHMA. 


499 


owe  to  Voltoliiii,  Iliiok,  Daly,  Hoc,  and  others  who  have  shown  tlio  close 
coiiiurlioii  wliich  exists  between  all'ections  of  the  nose  and  many  eases  of 
brt»iii'l>iid  astlnna. 

IJi'ietlv  stated  then,  bronchial  asthma  is  a  neurotic  affection,  character- 
izi'd  l)V  livperaMiiia  and  tiirffesccMicie  of  the  nuu^osa  of  the  smaller  bronchial 
tiil)i'.s  and  a  ])eculiar  exudate  of  mucin.  The  attacks  may  be  due  to  direct 
irritiition  of  the  bronchial  mucosa  or  may  be  induced  reilexly,  by  irritation 
of  the  luisal  mucosa,  and  indirectly,  too,  by  rellex  inlluences,  from  stom- 
iiL'li,  intestines,  or  genital  organs. 

Symptoms. — Premonitory  sensations  i)recede  some  attacks,  such  as 
chillv  feeling,  a  sense  of  tightness  in  the  chest,  ilatulence,  passage  of  a 
large  (juantity  of  urine,  or  great  depression  of  spirits.  Nocturnal  attacks 
are  eoiiinion.  After  a  few  hours'  sleep,  the  patient  is  aroused  with  a  dis- 
tressing sense  of  want  of  breath  and  a  feeling  of  great  op])ression  in  the 
clitvst.  Soon  the  resjjiratory  efforts  become  violent,  all  the  accessory  mus- 
cles are  brought  into  ])lay,  and  in  a  few  minutes  the  patient  is  in  a  par- 
oxysm of  the  most  intense  dyspiuea.  The  face  is  ])ale,  the  expression 
anxious,  speech  is  impossible,  and  in  spite  of  the  most  strenuous  inspira- 
tory efforts  very  little  air  enters  the  lungs.  Expiration  is  prolonged  ami 
also  whet^zy.  The  number  of  respiratioivs,  however,  is  ]u)t  much  increased. 
The  asthmatic  fit  may  last  from  a  few  nunutes  to  several  hours.  When 
severe,  the  signs  of  defective  aeration  soon  ajipear,  the  face  beconies  bo- 
tleweil  with  sweat,  the  pulse  is  small  and  ((uick,  the  extremities  get  cohl, 
and  just  as  the  patient  seems  to  bo  at  his  v/orst,  the  breathing  begins  to 
iTi't  easier,  and  often  with  a  paroxysm  of  eonghiiig  relief  is  obtained  and 
lie  -inks  exhausted  to  sleep.  The  relief  may  be  but  temporary  and  a  sec- 
ond !.tla(^k  may  soon  come  on.  In  a  majority  of  the  cases  even  in  the 
intervals  between  the  asthmati<'  fits  the  respiration  is  somewhat  embar- 
nissed.  The  cough  is  at  lirst  very  tight  and  dry  and  the  expectoration  is 
expelled  with  the  greatest  difliiculty. 

le  physical  signs  during  an  attacdv  are  very  characteristic.  On  in- 
spection the  thorax  looks  eidarged,  barrel-shaped,  and  is  iixed,  the  amount 
of  exi)ansi()n  being  altogether  disproportionate  to  the  intensity  of  the  in- 
spiratory nioveiuents.  The  diaphragm  is  lowered  and  moves  but  slightly, 
nspiraiion  is  short  and  quick,  expiration  prolonged.  Percussion  may  not 
reveal  any  special  difference,  but  there  is  sometimes  marked  liyperreso- 
uiiee,  p'lrtieulni'ly  in  cases  which  have  had  repeated  attacks. 

On  auscultation,  with  ins{)iration  and  ex])iration,  there  are  innumer- 
ahle  sil)ilant  and  sonorous  rales  of  all  varieties,  i)iping  and  high-pitched, 
"'-pitched  and  grave.  Later  in  the  attack  there  are  moist  rales. 
The  spufum  in  bronchial  asthma  is  quite  distinctive,  unlike  that  which 
'•I'eui's  in  any  other  affection.  Early  in  the  attack  it  is  brought  up  with 
irreat  dillieulty  and  is  in  the  form  of  rounded  gelatinous  masses,  the  so- 
called  "jwrZcs"  of  Lacnnec.  Though  hall-like,  they  can  be  unfolded  and 
really  represent  mould.*  in  mucus  of  the  smaller  tubes.     The  entire  expoc- 


*    •;]: 


,'i,     : 


m 


f  ? 


I.  Hf. 


■*i'.!} 


500 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


tomtion  may  bo  nmdo  up  of  tlieso  somcwliat  tnuialucont-KHjkiiiLf  pcllits, 
floating  ill  a  Hniall  qiuuitity  of  thin  inuous.  Some  of  thoni  arc  opaiiiic. 
Ofton  with  till'  naked  eye  a  twisted  Hj»iral  character  can  Ite  sc^on,  iKiiliiii- 
larly  if  tlic  H])utiiin  is  spread  on  a  glass  witii  a  black  background.  .Micn,- 
8co[)ically,  many  of  these  pellets  have  a  spiral  structure,  which  renders 
them  among  the  most  remarkable  bodies  met  with  in  sputum.  It  is  tuit 
a  littlc!  curious  that  they  should  have  been  practically  overlooked  iintij 
described  a  few  years  ago  by  CunschmaTin.  Under  the  microsc(i|ic  ili,. 
spirals  an;  of  two  forms.  In  one  there  is  simply  a  twi.sted,  spirally  ;ir- 
rangtdl  nnicin,  in  which  are  entangled  cells,  derived  jirobably  from  the 
smaller  bronchi  iind  alveoli,  often  in  all  stages  of  fatty  dcgeiicriilinii. 
The  twist  may  l)e  loose  or  tight.  'I'he  second  form  is  much  more  peciilinr. 
In  the  centre  of  a  tightly  coiled  skeiii  of  mucin  fibrils  with  a  lew  scattcreil 
cells  is  a  filament  of  extraordinary  clearness  and  translucency,  pmbalilv 
composed  of  transforincd  mucin.  As  Curschnuinn  suggests,  those  sjiinils 
are  doubtless  formed  in  the  finer  broiu'hioles  and  c(mstitute  the  pniduct 
of  an  acute  bronchiolitis.  It  is  difhcult  to  explain  their  s[iiral  nature.  I 
do  not  know  of  any  observations  upon  the  course  of  the  currents  prodiict'd 
by  the  ciliated  epithelium  in  the  broiudii,  hut  it  is  quite  possible  that  their 
action  nuiy  bo  rotatory,  in  which  case,  particularly  when  conil)ine(l  wiili 
spasm  of  the  bronchial  muscles,  it  is  possible  to  conceive  that  the  iiuieus 
formed  n  the  tube  might  bo  compelled  to  assume  a  spiral  form.  Within 
two  or  ihree  days  the  sputum  changes  entirely  in  character;  it  hcconus 
muco-purulont  aiKi  C'urschrrann's  s})irals  are  no  longer  to  be  found.  Thev 
occur  in  all  instances  of  truo  bronchial  asthma  in  the  early  period  of  the 
attack.  There  are,  in  ad;liti(m,  in  many  cases,  the  pointed,  octahedral 
crystals  described  by  Ijfyden  and  sometimes  calle('  asthma  crystals.  They 
are  identical  with  the  crystals  found  in  tlie  semen  and  in  the  blond  in 
leukaemia.  At  one  time  they  were  sup])osed,  by  their  irritating  character. 
to  induce  the  pai-oxysms. 

The  rourxe  of  tlu^  diseaso  is  very  variable.  In  severe  ttacks  the  ]iar- 
oxysms  recur  for  three  or  four  nights  or  even  nu)re,  and  in  the  intervals 
and  during  the  day  there  may  be  wlieezing  and  cough.  Early  in  the  disease 
the  patient  may  be  free  in  the  morning,  without  cough  or  much  distress, 
and  the  attacks  may  appear  at  first  to  be  of  a  ])urely  nervous  character. 
In  the  long-standing  cases  emphysema  almost  invariably  develoiis.  and 
while  the  pure  asthmatic  fits  diminish  in  frequency  the  chronic  broncliilis 
and  shortness  of  breath  become  aggravated. 

Wo  have  no  knowledge  of  the  morbid  aiuitomy  of  true  asthma.  Tcatli 
during  the  attack  is  uidiuow^n.  In  long-standing  cases  the  lesions  aiv 
those  of  chronic  broncliitis  and  emphysema. 

Treatment. — The  asthmatic  attack  usually  demands  immediiitc  and 
prompt  treatment,  and  remedies  should  be  administered  which  expcricTKO 
has  shown  are  capable  of  relieving  the  condition  of  the  bronchial  imicosa. 
A  few  whiffs  of  chloroform  will  produce  prompt  though  temporary  rclaxa- 


lifia/;::;;  i 


FIBRINOUS   BRONCHITIS. 


601 


tioii.  In  a  child  witli  very  severe  attacks,  resistinj?  all  the  usual  reniedica, 
tlu  tiviituiont  by  chloroform  gave  immediate  and  final ly  pennanent  relief. 
I'l  rios  of  nitrite  of  aniyl  may  be  broken  on  the  haiulkcruhief  or  from  two 
to  livi'  drops  of  the  sohitiou  may  be  [)laced  upon  cotton-wool  ind  inhaled. 
Stroiii;  stimuhintrf  given  hot  or  a  dose  of  spirits  of  chloroform  in  hot 
whisky  will  sometimes  induce  relaxation.  More  pernument  relief  is  given 
In  the  hypodermic  injection  of  morphia  or  of  morphia  and  cocaine  cora- 
l)iii(d.  In  obstinate  and  repeatedly  recurring  attacks  tlijs  has  ))roved  a 
vcrv  satisfactory  plan.  The  sedative  antispasmodics,  such  as  belladonna, 
hciiliaiio,  stramonium,  and  lobelia,  may  bo  given  in  solution  or  used 
ill  till'  form  of  cigarettes.  Nearly  all  the  popular  remedies  I'ither  in  this 
form  or  in  pastilles  contain  some  of  the  plant  of  the  order  aolanacew,  with 
nitrate  or  chlorate  of  potash.  Excellent  cigarettes  are  now  mamifactured 
luul  asthmatics  try  various  sorts,  since  one  form  benefits  one  ])atient, 
anotiior  form  another  patient.  Nitre  pajjcr  made  with  a  strong  solution 
of  nitrate  of  potash  is  very  serviceable.  Filling  a  room  with  the  fumes 
of  this  paper  prior  to  retiring  will  sometimes  ward  off  a  nocturmil  attack. 
I  liave  known  several  patients  to  whom  tobac  smoke  inhaled  was  quite 
as  potent  as  the  prepared  cigarettes. 

'I'lie  use  of  compressed  air  in  the  pneumatic  cabinet  is  very  beneficial; 
oxy;,'!'!!  inhalations  may  be  also  tried.  In  preventing  the  recurrence  of 
till'  attacks  there  is  no  remedy  so  unCiLil  as  iodide  of  potassium,  which 
soniotinies  acts  like  a  specific.  From  ten  to  twenty  grains  three  times  a 
(lay  is  usually  sufficient. 

Particular  attention  should  be  paid  to  the  diet  of  asthmatic  patients. 
A  rule  which  experience  generally  com[)els  them  to  make  is  to  take  the 
heavy  meals  in  the  early  part  of  the  day  and  not  retire  to  bed  before  gas- 
tri(!  digestion  is  com])leted.  As  the  attacks  are  often  induced  by  flatu- 
lency, the  carbohydrates  should  not  be  allowed.  Coffee  is  a  more  suitable 
ihink  tliiui  tea.  In  respect  to  climate  it  is  very  difficult  to  lay  down  rules 
for  asthmatics.  The  patients  are  often  much  better  in  the  city  than  in 
the  eountry.  The  high  and  dry  altitudes  are  certaiidy  more  beneficial 
than  tiie  soa-shore ;  but  in  protracted  cases,  with  emphysema  as  a  secondary 
eoniplieation,  the  rarefied  air  of  high  altitudes  is  not  advantageous.  In 
yinui^  persons  I  have  known  a  residence  for  six  months  in  F'lorida  or 
southern  California  to  be  followed  by  prolonged  freedom  from  attacks. 


V.   FIBRINOUS   BRONCHITIS. 

An  acute  or  chronic  affection,  characterized  by  the  formation  in  cer- 
tain of  the  bronchial  tubes  of  fibrinous  casts,  which  are  expelled  in  parox- 
ysms of  dyspnoea  and  cough. 

In  several  diseases  fibrinous  moulds  of  the  bronchi  are  formed,  as  in 
diphtheria  and  croup  (with  extension  into  the  trachea  and  bronchi),  iu 


if;. ,  . 


ft 


m 


|j' "'  \$ 


1^.  i--i*mmm 


Ji>~UU.'  - 


'   ■!'    1 


■!itS 


502 


DFSKASES  OP  THR   RKSPIRATORY  SYSTKM. 


pneumonia,  and  orcaHlonally  in  phthisis — conditions  wliioh,  however,  linvf 
nothiii;^  to  do  with  true  iihrijious  bronehitis.  These  casts  are  imt  \i>  ]„■ 
conroiiiided  with  tlie  I)loo(I-eaHts  whicli  occur  oc<'asioiially  in  lia'inoptvsis. 

Etiology.  —  Nothiiij,'  is  i<M<)wn  of  its  causation.  It  occurs  more  I'lc- 
(lueiitly  ill  males.  It  is  met  witli  at  all  ])eriods  of  life,  hut  is  luore  cohiiikpu 
between  the  ajjfes  of  twenty  and  forty.  It  has  luten  known  to  attack  sevcrii! 
meml)ers  of  the  same  family.  Cases  have  been  described  occurrinir  to^ntlK  r 
us  if  (lu(?  to  some  endemic  inlluence  (I'iehini).  'I'he  cases  are  rare,  particu- 
larly in  hospital  jiractice.  The  .ittacks  occur  most  commonly  in  the 
spring  months.  An  association  with  tuberculosis  has  been  frecpiently  iKitdl. 
Model,  in  an  article  from  liiUimler's  clinic,  states  that  tuberculosis  w;is 
])resent  in  ten  of  twenty-one  post-mortems.  It  has  been  met  with  alsu  in 
connection  with  skin-diseases,  siu-h  as  ])emi»hif,'us,  impetifio,  and  lii'rpcs. 
The  attacks  apju-ared  to  be  related  in  some  cases  to  the  menstrual  pcrioil. 
Several  instances  have  been  described  with  lu'urt-disease,  but  it  seems 
probalile  tbat  in  all  tbesc  conditions  the  connection  was  not  causal. 

Symptoms. — Acute  cases  are  rare.  They  nuiy  set  in  Mith  liii.'li 
fevers,  riji^ors,  severe  jiaroxysms  of  cough,  and  perhaps  with  ha-moptysis. 
The  clinical  picture  resembles  acute  bronchitis,  and  only  the  expiilsidn 
of  the  meml)ranous  casts  gives  the  characteristic  ftnitures  to  the  case.  It 
is  much  more  serious  than  the  chronic  form  aiul  fatal  termination  is  iidt 
uncommon.  N.  S.  Davis  has  reported  two  fatal  cases.  In  sonu>  of  tlio 
acute  eases  there  has  been  affection  of  the  tonsils,  and  it  is  possible  that 
the  disease  may  have  been  truly  diphtheritic  in  character  and  du  i  ex- 
tension of  the  membrane  into  the  trachea  and  bronchi.  The  cas  'lesc 
cases  are  not  (mly  more  extensive,  but  they  also  do  not  present  im-  lariii- 
uuted  structure  characteristic  of  true  plastic  bronchitis. 

A  patient  may  have  a  single  attack  without  any  recurrence,  but  in  the 
chronic  form  the  attacks  come  on  at  varying  intervals  and  the  disease  may 
last  for  ten  or  even  twenty  years.  Instances  are  on  record  in  which  the 
paroxysms  have  occurred  at  definite  intervals  for  many  months.  'J'ho  at- 
tacks may  recur  weekly  or  a  period  of  a  year  or  more  may  intervene.  Tho 
onset  is  marked  by  bronchitic  symptoms,  not  necessarily  with  fever.  The 
cough  becomes  distressing  and  paroxysmal  in  cluiracter  ;  the  sputa  maybe 
blood-stained  and  the  patient  brings  up  rounded,  ball-like  masses,  which, 
wlien  disentangled,  are  found  to  be  moulds  of  bronchi ;  the  ha>mi)rrliMpe 
may  be  profuse.  In  one  of  the  two  cases  which  I  have  seen  it  invariaMy 
accompanied  the  attack,  and  the  whitish  dendritic  easts  of  the  tubes  wtn' 
always  entangled  in  the  blood  and  clots.  Urgent  dyspnoea  and  cyaiio.<is 
may  be  present  in  severe  attacks.  The  phi/sical  signs  are  those  of  a  severe 
bronchitis.  It  may  occasionally  be  possible  to  determine  the  weakened  or 
suppressed  breath  sounds  in  the  affected  territory  and  there  may  be  deficient 
expansion  or  even  retraction  of  the  chest  wall  in  a  corresponding  area,  but 
this  is  in  reality  very  difficult,  and  twice  prior  to  the  expulsion  of  the 
casts  I  failed  to  determine  by  physical  examination  the  affected  region. 


CIR(;UIiATORY  DlSTUUnAXCES  IN  THE  IiUN(}H. 


603 


As  iiu'iitioTicd,  tho  casts  iirc  iiauiilly  rolled  up  and  mixed  with  niiiciis  or 
bl(Mi(l.     Wlu'ii  uiiravi'lU'd  ii\  water  thoy  in'csciit  a  conipit'tt'  iiinuld  of  a 
gccciidury  or  tertiary  bronchuH  with  itn  rainilicatioiiH.    'I'lio  wizti  of  the  caHt 
iiiiiv  vary  with  dilTcrciit  attacks,  hut,  as  has  often  hccii  noticed,  the  form 
iimi  si/.e  may  l>e  identical  at  eacli  attack  as  if  |trccisely  the  same  lironchial 
iircii  was  involved  each  time.     'I'he  casts  are  hollow,  laminated,  th(*  size  of 
the  lumen  varyiiifj:  with  the  immhor  and  thickimss  of  the  lamina'.     Some- 
tiiaes  tht7  are  almost  solid,     'rransverse  .sections  show  a  heaiitiful  concen- 
tric arran<;ement.     'I'he   lihrin  appears   in   ]tlaces  to  retain   its   iihrillary 
rttnictiirc  ;  in  others,  as  in  diphtheritic  memhrane,  it  has  nndcr<,'one  the 
hviiliiu'  tninsfortnation.     Leucocytort  are  inihedded  in  tho.  meshes.     In  tho 
(ciitre,  particularly  in  the  smaller  easts,  it  is  nc.t  uncommon  to  see  alveolar 
epithelium  with  numerous  carhon  particles.     Lcydcn's  crystids  are  somc- 
tinits  found  and  occasionally  Curschmann's  spirals. 

The  patholo;fy  of  the  disease  is  ohseure.  Tho  memhrane  is  identical 
with  that  to  which  the  torin  croupous  is  applied,  and  tiie  ohs(!urity  relates 
not  so  nuich  to  tho  mechanism  of  the  production,  whicdi  is  prohahly  the 
saine  as  in  other  nuicons  surfaces,  as  to  the  curious  limitation  of  the  alTec- 
tioii  to  cerhiin  bronchial  territories  and  the  remarkable  recurrence  at  stated 
or  incirular  intervals  throughout  a  ])eriod  of  many  years. 

In  the  acute  cases  the  trcnfmrut  shf)ul(l  bo  that  of  ordinary  acute  bron- 
chitis. We  know  of  nothing  which  can  prevent  tho  recurren(!o  of  tho 
iitfiu'ks  in  the  chronic  form.  In  the  njicotMj'licated  eases  there  is  rarely 
any  danger  during  the  i»aroxysm,  even  though  the  symptoms  may  be  most 
distressing  and  the  dyspnom  and  cough  very  severe.  Iidialations  of  ether, 
steam,  or  atomized  lime-water  aid  in  the  separation  of  the  membranes. 
Piloearpitu^  might  be  useful,  as  in  some  instances  it  increases  the  bronchial 
secretion.  The  employment  of  emi^tics  nxay  be  necessary,  and  in  some 
cases  they  are  eileetive  iu  promoting  the  removal  of  tho  casts. 


IV.  DISEASES  OF  TIIE  LUT^GS. 

1.  CIRCULATORY  DISTURBANCES  IN  THE  LUNGS. 

Congestion. — There  are  two  forms  of  congestion  of  the  lungs — active 
and  |)iissivo. 

(1)  Active  Conf/estinn  of  the  Ltnir/fi. — Much  doubt  and  confusion  still 
exist  on  this  subject.  French  writers,  following  AVoillez,  regard  it  as  an 
independent  primary  affection  {mahidie  de  Wnillez),  and  in  their  diction- 
iiries  iuid  text-books  allot  much  space  to  it.  English  and  American 
authors  more  correctly  regard  it  as  a  symptomatic  affection.  Active  flux- 
ion to  the  lungs  occurs  with  increased  action  of  the  heart,  and  when  very 
hot  ail  or  irritating  substances  are  inhaled.     In  diseases  which  interfere 


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504 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


lociilly  with  the  circulution  the  capilhiries  in  the  luljacent  unaffected  por- 
tions ••  I'ly  be  greatly  distended.  Tlie  importance,  however,  of  tliis  collat- 
eral fluxion,  as  it  is  called,  is  probably  exaggerated.  In  a  whole  series  of 
pulmonary  affections  there  is  thi'j  associated  t-ongestion — in  i)neuiii()iiia, 
bronchitis,  ])leurisy,  and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  are  by  no  means  deli- 
nite.  'i'lie  description  given  by  Woillez  and  by  other  French  writers  is 
of  an  alTection  which  is  dillicult  to  recognize  from  anomalous  or  larval 
forms  of  pneumonia.  The  chief  symptoms  described  are  initial  chill,  pain 
in  the  side,  dyspiux^a,  moderate  cough,  and  temperature  from  101°  to  i(t;j'. 
The  ])hysical  signs  are  defective  resonance,  feeble  breathing,  someliim^s 
broiKdiial  iti  character,  and  tine  rales.  A  nuijoiity  of  clinical  j)hysiciaiis 
would  undoubtedly  class  such  cases  under  inflammation  of  the  lung,  in 
many  epidemics  the  abnormal  and  larval  forms  are  specially  prevalent. 
This  is  no  doubt  the  condition  to  which  Porcher,  of  Charlestown,  called 
attention  a  short  time  ago  as  a  "  liitherto  undescribed  art'ection  of  the 
lungs." 

The  occurrence  of  an  intense  and  rapidly  fatal  congestion  of  the  Iiuiir, 
following  extreme  heat  or  cold  or  sometimes  violent  exertion,  is  recognized 
by  some  authors,  lienforth,  the  oarsman,  is  said  to  have  died  from  ttii 
cause  during  the  race  at  Halifax.  Leaf  has  described  cases  in  which,  in 
association  with  drunkenness,  exposure,  and  cold,  death  occurred  suddetdv, 
or  within  twenty-l'onr  hours,  and  the  only  lesion  found  luis  been  an  ex- 
treme, almost  ha'morrhagic,  congesti(m  of  the  lungs.  It  is  by  no  means 
certain  that  in  these  cases  death  really  occurs  from  itulmonary  congestion 
in  the  absence  t)f  s])ecific  statcnents  with  rcfereiuie  to  the  coronary  ar- 
teries. Several  times  in  sudden  death  from  di»eal^e  of  these  vessels  1  have 
seen  great  engorgement  of  the  lungs  thoughnot  the  extreme  gratlo  men- 
tioned by  TiCuf.  I  have  no  personal  knowledge  of  cases  siudi  as  he 
describes. 

(2)  Pdssi'rr  Coiif/psfinn. — Two  forms  of  this  nuiy  be  recognized,  the 
mechanical  and  the  hypostatic. 

{(i)  Mechanical  congestion  occurs  whenever  there  is  an  obstacle!  to  the 
return  of  the  Idood  to  the  heart.  It  is  a  common  event  in  many  aflTections 
of  the  left  hear;,.  ^J'he  lungs  are  voluminous,  russet  brown  in  color,  rut- 
ting and  tearing  with  great  resistanc,'.  On  section  they  show  at  first  ii 
brownish-red  tinge,  and  then  the  cut  surface,  ex])osed  to  the  air,  bccornt'S 
n.pidly  of  a  vivid  red  color  from  oxidation  of  the  abundant  ha'moglohin. 
This  is  the  coiulition  known  as  brown  induration  of  the  lung.  Ilir^tologi- 
cally  it  is  characterized  bv  (a)  great  distention  of  the  alveolar  capillaries; 
(/8)  increase  in  the  conn, 'ctive-tissue  elements  of  the  lung;  (y)  the  jires- 
ence  in  the  alveolar  walls  of  many  cells  containing  altered  blood-]):i:.iu'nt . 
((5)  in  the  alveoli  numerous  epithelial  cells  containing  blood-pigment  in 
all  stages  of  altcratio..,  wliich  are  also  found  in  great  numbers  in  tbe 
sputum.  . ,  , 


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CIRCULATORY   DISTURBANCES  IN  THE  LUNGS, 


505 


It  occa^ijnally  happens  tliat  this  mechanical  hyperoemia  of  the  lung 
results  from  pressure  of  tumors.  So  long  as  compensation  is  maintained 
till!  mechanical  congestion  of  tlie  lung  ii  heart-disease  does  not  i)roduce 
iiiiv  symptoms,  but  \vith  enfeebled  heart  action  the  engorgeni'-  l)ecome3 
marked  and  there  are  dyspnoea,  cough,  and  expectoration,  w'.  the  char- 
acteristic alveolar  cells. 

(A)  Hypostatic  congestion.     In  fevers  and  adynamic  ,  .,atf'H  gonorally  it 
is  very  common  to  find  the  bases  of  the  lungs  deeply  congiisted,  a  condi- 
tion in(hiced  partly  by  the  effect  of  gravity,  the  patient  lying  recumbout 
in  (iiie  nosture  for  a  long  time,  but  chiefly  by  weakened  heart  action. 
That  it  is  not  an  effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy 
person  may  remain  in  bed  an  indefinite  time  without  its  ocinirrence.    The 
U'riu  hypostatic  congestion  is  applied  to  it.     The  posterior  parts  of  the 
hui"'  are  dark  in  color  and  engorged  with  blood  and  serum ;  in  some  in- 
stances to  such  a  degree  that  th.e  alveoli  no  longer  (lontain  air  and  portions 
of  Uie  lung  sink  in  water.     The  term  splenizntion  and  hypostatic  pneu- 
monia have  been  given  to  these  advanced  grades.     It  is  a  common  affec- 
tion in  ju'otracted  cases  of  typhoid  fever  and  in  long  debilitating  illnesses. 
In  ascites,  meteorism,  and  abdominal  tumors  the  bases  of  the  lungs  may 
1)0  eoinpressed  and  congested.     In  this  connection  must  be  mentioned  the 
form  of  passive  congestion  met  with  in  injury  to,  and  oiganic  disease  of, 
tlie  brain.     In  cerebral  apoplexy  the  bases  of  the  lungs  are  de('))ly  en- 
!,forf;e(l,  not  quite  airless,  but  heavy,  and  on  section  drip  with  l)lood  and 
s  ruin.     I  have  twice  seen  this  condition  in  an  extreme  grade  throughout 
(he  lungs  in  death  from  morphia  ])oisoning.     In  some  instances  the  lung 
>sue  has  a  blackish,  gelatinous,  infiltrated  appearance,  almost  like  diffuse 
pulmonary  apoplexy.    Occasionally  this  congestion  is  nmst  nnirked  in,  and 
even  confined  to,  the  hcmiplegic  side.     In  prolonged  coma  the  hypostatic 
(^onj!;estion  may  bo  associated  with  patches  of  consolidation,  due  to  the 
luspiration  of  portions  of  food  into  the  air-passages. 

The  synii)toms  of  hypostatic  congestion  are  not  at  all  cliaracteristic, 
and  tlie  condition  has  to  be  sought  for  by  carcfid  examination  of  the  bases 
of  the  Inngs,  -.vheii  slight  dulness,  feeble,  sometimes  blowing,  breathing 
and  li(|ni(l  rales  can  be  detected. 

Tlie  fi'cdfmpiif,  of  congestion  of  the  lungs  is  usually  that  of  the  condi- 
tion witii  which  it  is  associated.  In  the  ititense  pulmonary  engorgement, 
vvliieh  may  possibly  occur  primarily,  and  which  i-  met  with  in  heart-disease 
anil  em|)hyseina,  free  bleeding  .should  be  prarnsed.  From  twenty  to  thirty 
ounces  of  blood  should  be  taken  from  the  urm,  and  if  the  blood  docs  not 
How  fretdy  and  the  condition  of  the  patient  is  desperate,  asjiiration  of  the 
liu'ht  auriide  may  be  ])erformed. 

CEilema. — In  all  forms  of  intense  congestion  of  the  lungs  there  is  a 
transudation  of  scrum  from  the  engorged  capillaries  chiefly  into  the  air- 
I'clls,  hut  also  into  the  alveolar  walls.  Not  only  is  it  very  fre(|nent  in  con- 
gestion, but  also  with  inflammation,  with  new  growths,  infarcts,  and  tuber- 


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506 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


cles.  When  limited  to  the  neighborhood  of  an  affected  part,  tlie  name 
collateral  uHleiiia  is  sometimes  applied  to  it.  General  osdema  occurs  uiulor 
conditions  very  similar  to  those  met  with  in  congestion.  It  is  very  often, 
no  doubt,  a  terminal  event,  occurring  with  the  death  agony.  It  is  seen  in 
typical  form  in  the  cachexias,  in  death  from  anaiinia,  also  in  chronic 
Bright's  disease,  disease  cf  the  heart,  and  cerebral  affections. 

The  codematous  lung  is  heavy,  looks  watery,  pits  on  pressure,  and  from 
the  cut  surface  a  large  quantity  of  clear  and,  in  cases  of  congesti(m,  bloodv 
serum  flows  freely  ;  the  tissue  may  even  have  a  gelatinous,  infiltrated  iip- 
pearance.  The  condition  is  much  more  common  at  the  bases,  but  it  inuv 
exist  throughout  the  entire  lung.  The  pathology  of  pulmonary  O'denia  is 
not  always  clear.  Two  factors  usually  prevail  in  extreme  cases — increased 
tension  within  the  pulmonary  system  and  a  diluted  blood  ])la8nia.  The 
increased  tension  alone  is  not  capable  of  producing  it.  The  exj^erinicnts 
of  Welch  seem  to  indicate  that  the  essential  factor  lies  in  a  disproijortinn- 
ate  weakness  of  the  left  ventricle,  so  that  the  blood  accumulates  in  the 
lung  capillaries  until  transudation  occurs,  a  view  which  satisfactorily  ex- 
plains certain  cases,  particularly  the  terminal  cedemas. 

Tlie  si/mpfo7ns  of  oedema  of  the  lungs  are  often  only  an  aggravation  of 
those  already  existing,  and  are  due  to  the  primary  disease,  whether  (car- 
diac, renal,  or  general.  There  are  iisually  increasing  dyspnoea  and  eoii<rh, 
and  on  examination  there  may  be  defective  resonance  and  large  liquid  nilcs 
at  the  bases.  There  are  cases  in  which  the  o'dema  comes  on  with  great 
suddenness,  and  in  chronic  Bright's  disease  it  nuiy  prove  rapidly  fatal. 

In  the  cases  of  so-called  ir.riammatory  oedema  fever  is  always  ])resent, 
and  often  signs,  more  or  less  marked,  of  pneumonia. 

The  treatment  of  oedema  of  the  lung  is  practically  that  of  the  condi- 
tions with  which  it  is  associated.  In  the  acute  cases  active  catharsis,  iuul, 
if  there  is  cyanosis,  free  venesection  should  be  resorted  to. 

Pulmonary  flssmorrhage. — This  occurs  in  two  forms — hroncho-jml- 
monary  hannorrhage,  sometimes  called  bronchorrhagia,  in  Avhich  the  l)loo(l 
is  poured  out  into  the  bronchi  and  is  expectorated,  and  piibnondri/  apo- 
plexji  or  pneumorrhagia,  in  which  the  haemorrhage  takes  place  into  the 
air-cells  and  the  lung  tissue. 

1.  Bro7icho-pnhnonary  Ilmvnrrhofie ;  ILri/iop/i/sis. — Spitting  (»f  1)1ik)(1, 
to  which  the  term  ha-mojjtysis  should  be  restricted,  results  from  a  variety 
of  conditions,  among  which  the  following  are  the  most  important :  (/i)  In 
young  healthy  i)ersons  haemoptysis  may  occur  without  warning,  .  ,d  after 
continuing  for  a  few  days  disappear  and  leave  no  ill  traces.  There  may 
be  at  the  time  of  the  attack  no  physical  signs  indicating  pulmonary  disease. 
In  sucli  cases  good  health  may  be  preserved  for  years  and  no  fiiriher 
trouble  occur.  These  cases  are  not  very  uncommon.  In  Ware's  iiiipor- 
tant  contribution  to  this  subject,*  of  380  cases  of  haemoptysis  noted  in 

•  On  Ilffimcptysis  as  a  Symptom,  by  John  Ware,  31.  1>. 


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CIRCULATORY  DISTURBANCES  IN  THE  LUNGS. 


507 


private  practice  62  recovered  and  pulmonary  disease  did  not  subsequently 
develop  in  them.     I  know  three  professional  men  who  had  haemoptysis  as 
students,  and  who  now,  at  periods  of  from  fifteen  to  eighteen  years  subse- 
quently, remain  in  perfect  liealth.     (b)  Ilaimoptysis  in  pulmonary  tubercu- 
losis. So  frequently  are  these  conditions  associated  that  in  the  lay  mind  spit- 
tincof  Idood  and  consumption  are  almost  synonymous.     The  llippocratic 
apliorism, "  From  a  spitting  of  blooil  there  is  a  spitting  of  pus,"  is  repeated 
throii<;h()ut  the  literature  of  more  than  twenty  centuries.     It  occurs  either 
early  in  the  disease,  before  there  are  any  obvious  physical  signs,  or  after  tlie 
development  of  well-marked  local  lesions.    Unquestionably  in  a  majority  of 
the  cases  in  which  subsequent  to  haemoptysis  phthisis  occurs  tubercles  were 
alreadv  ])resent  in  the  lung.     The  hsemorrhage  is  bronchial  and  associated 
with  u  limited  focus  of  disease.     When  the  pulmonary  lesion  is  more  ad- 
vanced the  haemoptysis  results  either  from  erosion  of  a  branch  of  the 
pulmonary  artery  or  from  rupture  of  an  aneurismal  dilatation  of  the  same. 
(c)  In  connection  with  certain  diseases  of  the  lung,  as  pneumonia  (in  the 
initial  stage)  and  cancer,  occasionally  in  gangrene,  abscess,  and  bronchiec- 
tiisis,  liiemoptysis  occurs,     (d)  Iltenioptysis  is  met  with  in  many  heart 
affections,  particularly  mitral  lesions.     It  may  be  profuse  and  recur  at 
intervals  for  years,     (e)  In  ulcerative  affections  of  the  larynx,  trachea,  or 
bronchi.     Sometimes  the  haemorrhage   is   profuse  and  rapidly  fatal,  as 
when  an  ulcer  erodes  a  large  branch  of  the  pulmonary  artery,  an  accident 
whieli  I  have  known  to  happen  in  a  case  of  chronic  bronchitis  with  em- 
physema.    (/)  Aneurism  is  an  occasional  cause  of  haemoptysis.     It  may 
be  sudden  and  rapidly  fatal  when  the  sac  bursts  into  the  air-pjissages. 
Slight  bleeding  maycontinue  for  weeks  or  even  longer,  due  to  pressure  on 
the  mucous  membrane,  erosion  of  the  lung,  or  in  some  cases  the  sac 
"weeps"  through  the  exposed  laminae  o''  fibrin,     (g)  Vicarious  hiemor- 
rhage,  which  occurs  in  rare  instances  in  i .,  .  ~  ^f  interrupted  menstruation 
The  instances  are  well  authenticated.     Flint  in.iiticns  a  (  asc  which  lir 
had  had  under  observation  for  four  years,  and  Hip|H  .  rates  refers  to  it  in 
the  aphorism,  "  Haemoptysis  in  a  woman  is  removed  by  an  eruption  .  f  the 
menses."    Periodical  haemoptysis  has  also  been  met  with  after  the  removal 
of  both  ovaries.    Even  fatal  hannorrhage  has  occurred  from  the  lung  during 
menstruation  when  no  lesion  was  found  to  account  for  it.     {h)    I  lierc  is  a 
form  (if  recurring  haemoptysis  in  arthritic  subjects  to  which  Sii   Andrew 
Clark  has  called  special  attention  and  which  also  is  described  by  French 
writers.    The  cases  occur  in  persons  over  fifty  years  of  age  who  iisn;i[ly 
present  signs  of  the  artliritic  diathesis.     It  rarely  leads  to  fatal   i  and 

subsides  without  inducing  pulmonary  changes.  (/)  Ilannoptysis  recurs 
8onu>times  in  malignant  fevers  and  in  purpura  liaemorrhagica.  Lastly,  there 
IS  endemic  hicmoptysis,  due  to  the  presence  of  the  Di.sfoma  Ringeri  in  the 
bronehi;d  tnl)es,  an  affection  which  is  confined  to  parts  (tf  China  and  Japan- 
Symptoms. — Haemoptysis  sets  in  as  a  rule  suddenly.  Often  with- 
out warning  the  patient  experiences  a  warm,  saltish  toiste  as  the  mouth 


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508 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


fills  with  blood.  Coughing  is  usually  induced.  There  may  be  only 
an  ounce  or  so  brought  up  before  the  bleeding  stops,  or  the  bloediiifr 
may  continue  for  days,  the  patient  bringing  up  small  quantities.  In  otlior 
instances,  particularly  when  a  large  vessel  is  eroded  or  an  aneurism  l)iiist!< 
the  amount  is  large,  and  the  patient  after  a  few  attempts  at  couoIudit 
shows  signs  of  suffocation  and  death  is  produced  by  inundation  of  tlio 
bronchial  system.  Fatal  haemorrhage  may  even  occur  into  a  large  ca\ity 
ill  a  patient  debilitated  by  phthisis  without  the  production  of  haemoptysis. 
I  dissected  a  case  of  this  kind  at  the  Philadelphia  Hospital.  Tlie  hlood 
from  the  lungs  generally  has  characters  which  render  it  readily  distiii- 
guishable  from  the  blood  which  is  vomited.  It  is  alkaline  in  reaction, 
frothy,  and  mixed  with  mucus,  and  when  coagulation  occurs  air-bubbles  arc 
present  in  the  clot.  Blood-moulds  of  the  smaller  bronchi  are  soniotiiiios 
seen.  Patients  can  usually  tell  whether  the  blood  has  been  brought  up  hy 
coughing  or  by  vomiting,  and  in  a  majority  of  cases  the  history  gives  im- 
portant indications.  In  paroxysmal  hsEmoptysis  connected  with  moiistnial 
disturbances  the  practitioner  should  see  that  the  blood  is  actually  .out^flH'd 
uj),  since  deception  may  be  practised.  Naturally,  the  patient  is  at  first 
alarmed  at  the  occurrence  of  bleeding,  but,  unless  very  profuse,  Jis  when 
due  to  rupture  of  an  aortic  aneurism  in  a  pulmonary  cavity,  the  danger  is 
rarely  immediate.  The  attacks,  however,  are  apt  to  recur  for  a  few  days 
and  the  sputa  may  remain  blood-tinged  for  a  longer  period.  In  the  great 
majority  of  cases  the  haemorrhage  ceases  spontaneously.  It  should  he  re- 
membered that  some  of  the  blood  may  be  swallowed  and  produce  vount- 
ing,  n,nd,  after  a  day  or  two,  the  stools  may  be  dark  in  color.  It  is  not 
well  during  an  attack  of  hremoptysis  to  examine  the  chest.  It  was  for- 
merly thought  that  haemorrhage  exercised  a  prejudicial  effect  and  excited 
inflammation  of  the  lungs,  but  this  is  not  often  the  case. 

(2)  Pulmonary  Ajmploxy  ;  Ummorrhafiic  Infarct. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  raiely 
indeed  diffuse,  breaking  the  parenchyma  as  the  brain  tissue  is  broken  in 
cerebral  apoplexy.  Sometimes,  in  disease  of  the  brain,  in  septic  eotidi- 
tions,  and  in  the  malignant  forms  of  fevers,  the  lung  tissue  is  uniformly 
infdtrated  with  blood  and  has,  on  section,  a  black,  gelatinous  appe'!ran((!. 

As  a  rule,  the  haemorrhage  is  limited  and  results  from  the  block inj,'  of 
a  branch  of  the  pulmonary  artery  either  by  a  thrombus  or  an  ond)ohis. 
The  condition  is  most  common  in  chronic  heart-disease.  Althon,L;li  the 
pulmonary  arteries  are  terminal  ones,  blocking  is  not  always  followed  hy 
infarction;  partly  because  the  wide  capillaries  furnish  suificiont  anasto- 
mosis, and  partly  because  the  bronchial  vessels  may  keep  up  the  eirculii- 
tion.  The  infarctions  are  chiefly  at  tlio  periphery  of  the  lung,  .isually 
wedge-shaped,  with  the  base  of  the  wedge  toward  the  surface.  W  hen  re- 
cent, they  are  dark  in  color,  hard  and  firm,  and  look  on  section  like  an 
ordinary  blood-clot.  Gradual  changes  go  m,  and  the  color  becomes  a 
reddish  brown.     The  pleura  over  an  infarct  is  usually  inflamed.    A  mi- 


CIRCULATORY   DISTURBANCES  IN  THE  LUNGS. 


509 


CTOSoopical  section  shows  the  air-cells  to  bo  distended  with  red  blood-cor- 
puscles, which  may  also  be  in  the  alveolar  walls.  The  infarcts  are  usually 
nuiltii)lo  and  vary  in  size  from  a  walnut  to  an  orange.  Very  large  ones 
may  involve  the  greater  part  of  a  lobe.  In  the  artery  passing  to  the 
affected  territory  a  thrombus  or  an  embolus  is  found.  The  globular 
thrombi,  formed  in  tlic  right  auricular  appendix,  play  an  important  part 
in  tln'  production  of  hajinorrhagic  infarction.  In  many  cases  the  source 
of  th(!  embolus  cannot  bo  discovered,  and  the  infarct  may  have  resulted 
fniiii  tlirombosis  in  the  pulmoiuiry  artery,  but,  as  before  mentioneii,  it  is 
not  infrequent  to  find  total  obstruction  of  a  large  branch  of  a  pulmona^'y 
arteiv  without  h*;-  orrhage  into  the  corresponding  lung  area.  The  fur- 
ther liistory  of  an  infarction  is  variable.  It  is  possible  that  in  some  in- 
stances the  circulation  is  re-established  and  the  blood  removed.  More 
conimonly,  if  the  patient  lives,  the  usual  changes  go  on  in  the  extra vasated 
blood  iuid  ultimately  a  pigmented,  puckered,  fibroid  patch  results.  Slough- 
ing may  occur  with  the  formation  of  a  cavity.  Occasionally  gangrene 
results.  In  a  case  at  the  University  Hospital,  Philadelphia,  a  gangrenous 
infarct  ruptured  and  produced  fatal  pneumothorax. 

The  symptoms  of  pulmonary  apoplexy  are  by  no  means  definite.  The 
condition  may  be  suspected  in  chronic  heart-disease  when  ha?montysi8 
oceiirs,  particularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the 
extreme  engorgement.  When  the  infarcts  are  very  large,  and  particularly 
in  the  lower  lobe,  in  which  they  most  commonly  occur,  there  may  be  signs 
of  consolidation  with  blowing  breathing. 

Treatment  of  Pulmonary  Haemorrhage. — In  the  treatment 
of  luemoptysis  it  is  important  to  remember  the  condition  of  the  pulmo- 
nary circulation  and  the  nature  of  the  lesions  associated  with  the  haemor- 
rhage. 

The  pressure  within  the  pulmonary  artery  is  considerably  less  than  that 
in  the  aortic  system.  We  have  as  yet  very  imperfect  knowledge  of  the 
circumstances  which  influence  the  lesser  circulation  in  man.  Researches, 
particularly  those  of  Bradford,  indicate  that  the  system  is  under  vaso- 
motor control,  but  our  knowledge  of  the  mutual  relations  of  pressure  m 
the  aorta  and  in  the  pulmoiuiry  artery,  under  varying  conditions,  is  still 
very  imporfocit.  Experiments  with  drugs  seem  to  show  that  there  may  be 
an  iiiihicnce  on  systemic  blood-pressure  without  any  on  the  pulmonary, 
anil  the  pressure  in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may 
rise  and  fall  in  both  together.  In  Andrew's  Ilarveian  Oration  these  rela- 
tions are  thoroughly  described,  and  a  statement  is  made,  based  on  Brad- 
fcrij's  experiments,  as  to  the  action  on  the  pulmonary  blood-pressure  of 
many  of  the  drugs  employed  in  haemoptysis.  Thus  ergot,  the  remedy 
perhaps  most  commonly  used,  causes  a  distinct  rise  in  the  pulmonary 
blood -pressure,  while  aconite  produces  a  definite  fall. 

The  anatomical  condition  in  hiemoptysis  is  either  hyperEemia  of  the 
bronchial  mucosa  (or  of  the  lung  tissue)  or  a  perforated  artery.     In  the 


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DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


latter  case  the  patient  often  passes  rapidly  beyond  treatment,  though  thero 
are  instances  of  tlie  most  profuse  ha3niorrhage  wliich  must  have  come  from 
a  perforated  artery  or  a  ruptured  aneurism  in  wliich  recovery  has  occurred. 
Practically,  for  treatment,  we  should  seiiarate  these  cases,  as  the  reniodics 
which  would  be  applicable  in  a  case  of  congested  and  bleeding  mucosa 
would  be  as  much  out  of  place  in  a  case  of  ha-morrhago  from  ruptured 
aneurism  as  in  a  cut  radial  artery.  When  the  blood  is  brought  up  in 
quantities — in  mouthfuls  at  a  time — it  is  almost  certain  either  that  im 
aneurism  has  ruptured  or  a  vessel  has  been  eroded.  In  the  instiinccs  in 
which  the  sputa  are  blood-tinged  or  when  the  blood  is  in  smaller  quanti- 
ties, bleeding  comes  by  diapedesis  from  hyperasmic  vessels.  In  such  oases 
the  haemorrhage  may  be  beneficial  in  relieving  the  congested  blood-vessels. 

The  indications  are  to  reduce  the  frequency  of  the  heart-beats  and  to 
lower  the  blood-pressure.  By  far  the  most  importjint  measure  is  absolute 
quiet  of  body,  such  as  can  only  be  secured  by  rest  in  bed  and  seclusion. 
In  the  majority  of  cases  of  mild  liasmoptysis  this  is  sufficient.  Even 
when  the  patient  insists  upon  going  about,  the  bleeding  may  stop  s])on- 
taneously.  The  diet  should  be  light  and  unstimulating.  Alcohol  should 
not  be  used.  The  patient  may,  if  he  wishes,  have  ice  to  suck.  Small 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  blcocling 
is  protracted  styptic  and  astringent  medicines  are  not  indicated.  For 
cough,  which  is  always  present  and  disturbing,  opium  should  be  froely 
given,  and  is  of  all  medicines  most  serviceable  in  haemoptysis.  Dij,ntali3 
should  not  be  used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery. 
Aconite,  as  it  lowers  the  pressure,  may  be  used  when  there  is  much  vaseii- 
lar  excitement.  Ergot,  tannic  acid,  and  lead,  which  are  so  niucli  em- 
ployed, have,  I  believe,  little  or  no  infiuence  in  haemoptysis.  Ergot,  accord- 
ing to  Bradford,  produces  distinct  rise  in  the  pulmonary  blood-pressure. 
One  of  the  most  satisfactory  means  of  lowering  the  blood-pressure  is  purga- 
tion, and  when  the  bleeding  is  protracted  salts  may  be  freely  given,  lu 
profuse  haemoptysis,  such  as  comes  from  erosion  of  an  artery  or  tlie  rii[)t- 
ure  of  an  aneurism,  a  fatal  result  is  common,  and  yet  ixist-morUnn  evi- 
dence shows  that  thrombosis  may  occur  with  healing  in  a  rupture  of  con- 
siderable size.  The  fainting  induced  by  the  loss  of  blood  is  probably  the 
most  efficient  means  of  promoting  thrombosis,  and  it  was  on  this  prineipio 
that  formerly  patients  were  bled  from  the  arm,  or  from  both  arms,  as  in 
the  case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's  bandages,  placed 
around  the  legs  may  serve  temporarily  to  check  the  bleeding.  The  ice- 
bag  on  the  sternum  is  of  doubtful  utility.  In  a  protracted  case  Cayley  in- 
duced pneumothorax,  but  without  effect. 

Briefly,  then,  we  may  say  that  cases  of  luemorrhage  from  rupture  of 
aneurism  or  erosion  of  a  blood-vessel  usually  prove  fatal.  The  fainting 
induced  by  the  loss  of  blood  is  beneficial,  and,  if  the  patient  can  bo  kept 
alive  for  twenty-four  liours,  a  thrombus  of  sufficient  strength  to  ])r(^vent 
further  bleeding  may  form.     The  chief  danger  is  the  inundation  of  the 


PNEUMONIA. 


511 


hrdnchial  system  witli  tlie  blood,  so  that  while  the  haemorrhage  is  profuse 
till'  cough  should  be  encouraged.  Opium  should  not  then  be  used,  and 
stimiiliuitd  should  be  given  with  caution. 

Ill  the  other  group,  in  which  the  lueinorrhage  comes  from  a  congested 
iircii  and  is  limited,  tlie  patient  gets  well  if  kept  absolutely  quiet,  and 
fiitiil  liiemorrhage  probably  never  occurs  from  this  source.  Kest,  reduc- 
tion of  the  blood-pressure  by  minimum  diet,  purging,  if  necessary,  and  the 
uilininistration  of  opium  to  allay  the  cough  are  the  main  indications. 


:« 


i: 


II.  PNEUMONIA 

(Lobar,  Croupous,  or  Fibrinous  Pneumonia;  Pneumjnds;  Lung  Fever). 

Definition. — An  infectious  disease  characterized  by  inflammation  of 
tlie  liuigs  and  constitutional  disturbance  of  varying  intensity.     The  fever 
terminates  abruptly  by  crisis.     Secondary  infective  processes  are  common 
Au  organism,  the  diplococcus  pneumonmy  is  invariably  found  in  the  dis- 
cusiod  hing. 

Etiology. — Pneumonia  is  one  of  the  most  wide-spread  of  acute 
diseases.  Hospital  statistics  show  that  the  ratio  to  other  admissions  is  in 
the  proportion  of  twenty  to  thirty  per  thousand. 

It  prevails  at  all  ages  Children  are  quite  as  susceptible  to  it  as  adults, 
and  it  is  the  special  enemy  of  old  age.  Males  are  more  frequently  alfected 
than  females.  Dwellers  in  cities  and  persons  whose  occupations  are  as- 
sociated with  exposure,  hardship,  and  cold  are  most  liable  to  the  dis- 
ease. Contrary  to  the  general  rule  in  infectious  diseases,  newcomers  and 
immigrants  seem  less  susceptible  than  the  native  inhabitants.  Debilitat- 
ing causes  of  all  sorts  render  individuals  more  susceptible.  Alcoholism 
is  perhaps  the  most  potent  predisposing  factor.  Persons  weakened  by 
disease  are  especially  prone  to  it ;  thus  we  find  many  cases  in  connection 
with  chronic  Bright's  disease,  diabetes,  the  chronic  affections  of  the  nerv- 
ous system,  and  protracted  fevers.  One  important  predis})osing  cause  is  a 
jirevious  attack.  No  acute  disease  recurs  with  such  frequency.  Instances 
are  on  record  of  individuals  who  have  had  ten  or  more  attacks. 

Climate  does  not  appear  to  have  much  influence.  The  disease  pro- 
viiils  otpially  in  cold  and  in  hot  countries,  but  it  is  stated  that  on  this 
continent  it  is  more  prevalent  in  the  Southern  than  in  the  Northern  States. 
More  important  is  the  influence  of  season.  Statistics  everywhere  show 
tiiiit  more  persons  are  attacked  from  December  to  May  than  in  the  sum- 
mer and  autumn.  Seitz's  large  statistics  of  5,905  cases  in  Munich  give 
'i'i.  ])er  cent  in  winter,  30'8  per  cent  in  spring,  15-3  per  cent  in  summer, 
and  1,V7  jier  cent  in  autumn.  Bell's  statistics  of  the  Montreal  General 
Hospital  show  practically  the  same  distribution,  but  it  is  worth  noting 
that  during  January,  the  coldest  month  of  the  year,  in  which  the  mean 
temperature  for  ten  years  was  13'75°  F.,  the  percentage  was  compara- 


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512 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


tivcly  low.  Junuiiry,  liowevcr,  is  a  month  with  very  slij^ht  variations  in 
teinpcrature,  and  it  seems  that  the  sudden  clianf^es  eharaeteristic  uf 
March,  April,  and  May  are  tlie  important  climatic  factors  which  predis- 
pose to  pneumonia. 

Of  other  factors,  cold  has  been  thouglit  to  be  one  of  the  most  iiii 
portant,  and  for  years  was  regarded  as  the  efhcient  cause  of  the  (liseasc. 
Undoubtedly  the  disease  sometimes  promptly  follows  a  sudden  chilling  nr 
wetting,  but  in  a  large  majority  of  cases  no  such  history  can  be  obtiiiiied. 

Pneumonia  folU)WS  traumntism  with  great  frequency,  more  particu- 
larly iiijury  of  the  chest.  Jjitten  has  called  special  attention  to  this  so- 
called  c(»ituHions-pneumonia.  ' 

A  change  of  o])inion  has  of  late  taken  place  as  to  the  nature  of  pneu- 
monia, which  is  now  almost  universally  regarded  as  a  specific  iiifiKtious 
disease,  depending  U})on  a  micro-organism.  Among  general  circiiin- 
stances  favoring  this  view,  is  the  occurrence  of  piu'umonia  in  {'pidcun'c 
form,  a  fact  recognized  by  Laennec  and  by  Grisolle.  Many  house 
epidemics  have  been  described  within  the  past  twenty  years.  On  sfv- 
eral  occasions  I  have  known  two,  three,  and  even  four  ])ersons  admithMi 
to  hospital  from  the  same  house.  In  1887,  I  saw,  Avith  (Jrahani,  of  To- 
ronto, a  lo(!al  outbreak  in  which  three  members  of  a  family  were  consecu- 
tively attacked  with  the  most  malignant  pneumonia.  There  are  instanccH 
on  record  in  which  as  many  as  ten  residents  in  one  house  have  been  at- 
tacked. Of  late  years  many  epidemics  in  towns  luive  been  reported. 
Still  more  striking  are  the  epidemics  which  have  been  described  in  |)i'is()n.s 
and  garrisons,  of  which  one  of  the  most  remarkable  is  that  reported  by 
W.  B.  Rodman,  of  Frankfort,  Kentucky.  In  one  year  there  occurred  in 
a  prison  population  of  735^  118  cases,  with  25  deaths.  The  prison  \viu< 
much  overcrowded  at  the  time.  Similar  epidemics  have  been  described  in 
Europe.  At  the  penitentiary  at  Amberg,  from  the  1st  of  January  to  the 
1st  of  June,  there  were  161  cases  of  pneumonia  with  a  mortality  of  over 
twenty-eight  per  cent. 

The  diplococctiK  pyienmonm  of  Fraenkel  is  the  most  constant  organism 
in  lobar  pneumonia  and  is  now  believed  by  many  competent  authorities 
to  be  the  specific  agent  of  the  disease.  It  is  identical  with  the  micrococ- 
cus whi(di  Pasteur  and  Sternberg  found  in  the  saliva  of  certain  individu- 
als and  which  produces  septic.nemia  in  the  rabbit.  It  occurs  occasionally 
in  the  nose,  the  larynx,  and  the  Eustachian  tube.  According  to  Netter's  ob- 
servations, it  is  present  in  the  buccal  secretion  in  twenty  per  cent  of  healtiiy 
persons.  It  persists  for  months  or  even  years  in  the  saliva  of  j)(>rsons 
who  have  had  pneumonia.  The  researches  of  Fraenkel,  Weichselbauin, 
Gamaleia,  and  others  show  that  it  is  by  far  the  most  constant  organism  in 
pneumonia  and  that  it  occurs  in  the  secondary  processes  of  the  disease, 
such  as  pleurisy,  endocarditis,  pericarditis,  and  meningitis.  In  ten  cases 
recently  examined  at  the  pathological  laboratory  of  the  Johns  Hopkins 
Hospital  by  my  colleague  Welch,  this  organism  was  present  in  all ;  in 


PNEUMONIA. 


613 


'■•  1 


six  ns  pure  cultures  in  tlio  luup:,  in  four  topfcthor  with  pus  or/nanisms. 
Ill  tilt'  s})utiim  it  may  bo  dcinoiistratiMl  by  treating  the  ordinary  cover- 
{^lass  prci)arations  with  /glacial  acetic  a<'i<l  and  then,  witiiout  wayhinj;  olT  tlio 
lu'ui,  (Iroppinj^  on  aniline  oil  and  gentian-violet,  which  is  to  bp  poured  olT 
1111(1  renewed  two  or  three  times.  The  organism  is  seen  to  be  a  somewhat 
elliptical  lance-shaped  coccus  occurring  in  pairs,  hence  the  term  dii>lv'Ooe- 
cus.     It  is  usually  encapsulated. 

According  to  the  dominant  view,  pneumonia  is  an  iiifeetivo  disease 
caused  by  this  diploeoc(!Us,  which  has  its  seat  of  election  in  and  prmhiees 
its  chief  etTeets  on  the  lung,  and  which  can,  under  favoring  circumstances, 
iiiviidc  other  parts  (»f  the  body — the  j)leura,  meninges,  and  endocardium 
This  microbe  may  possibly  attack  these  parts  without  the  interventicm  of 
inl!aiiiiiiation  of  the  lung,  as  it  has  been  found  in  meningitis  and  pleurisy 
independent  of  pneumonia.  It  is  a  wide-spread  organism,  at  times  ])res- 
eiit,  iis  ])efore  stated,  in  the  buccal  secretions  of  healthy  jiersons.  It  is  not 
iniprnhable  that  the  various  predisposing  causes,  such  as  cold,  exhaustion, 
and  debility,  lower  the  vihility  and  render  the  individ  ;l  susceptible, 
thus  changing  the  character  of  the  tissue-soil  so  that  the  virus  can  grow 
ami  produce  its  specific  etTeets. 

Oil  this  view,  pneumonia  may  be  regarded  as  a  local  disease,  produced 
by  micro-organisms  which  induce,  as  in  other  local  diseases,  such  as  ery- 
si[)elas  and  diphtheria,  constitutional  disturbance  of  varying  degrees  of 
intensity,  or  even,  by  the  further  invasion  of  the  parasites,  secondary  in- 
fective processes  in  other  organs.* 

l{(!ceiitly  from  Leyden's  clinic  very  interesting  studies  have  been  issued 
liy  the  brothers  Klemperer  on  the  production  of  immunity  and  upon 
the  cure  of  pneumonia.  Immunity  is  readily  obtained  in  animals  cither 
by  siilnnitaneous  or  intmvenous  injections  of  large  quantities  of  the  fil- 
U'lvd  bouillon  cultures,  or  by  the  injection  of  the  glycerine  extract.  The 
iiniuiinity,  though  rarely  lasting  more  than  six  months,  was  transmitted 
to  the  ()ITsi)ring  born  within  this  period.  Still  more  interesting  are  their 
observations  upon  the  cure  of  the  exiierimentilly  produced  disease.  They 
found  tliat  the  serum  and  fluids  of  the  body  of  an  animal  which  had  been 
roiidcicd  imnnine  had  the  property  not  only  of  producing  immunity 
when  introduced  into  the  circulation  of  another  susceptil)le  animal,  but 
actually  of  curing  the  disease  after  infection  had  been  in  progress  for 
some  time.  In  infected  animals  with  a  body  tempt^niture  of  from  40"  to 
41°  ('.,  the  fever  fell  to  normal  in  twenty-four  hours  after  the  injection  of 
scruni  of  another  animal  which  possessed  immunity.  They  believe  that 
the  piKHimococcus  produces  a  poisonous  albumen  (pneumotoxin)  wdiich 
wlion  introduced  into  the  circulation  of  an  animal  causes  elevation  of 
tcmperatiu'e  and  the  subsequent  production  in  the  bcwly  of  a  substance 

*  S(>(>  on  the  ciiiestion  of  etiology  the  elaborate  essay  of  Wells,  Journal  of  the  Ameri- 
can Medical  Association,  1889. 


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614 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


(untipneumotoxin)  wliii-h  possosscs  the  power  of  noutraliziiif,'  the  poison- 
ous ulbumeii  which  is  formed  by  the  bucteria.  In  iiuiii  thoy  hold  that 
during  the  pueuniotuc  i)ro(;e88  there  is  u  constant  absor])tion  into  tin-  tir- 
culatiou  of  this  poisonous  albumen  {)rodueed  by  the  bacteria  in  the  liiii;;s. 
This  continues  until  eventually  the  same  antidotal  substance  is  jinKiiiccd 
in  the  circulation  tiiat  has  been  seen  to  occur  experimentally.  It  is  tluii 
that  the  crisis  occnirs.  The  bacteria  are  neithcir  destroyed  nor  is  their 
power  to  produce  the  poisonous  albumen  lessened,  but  the  third  factor, 
the  antitoxic  element,  now  exists  and  neutralizes  the  toxit^  sidwlanccs  as 
they  are  produced.  They  demonstrated  that  the  serum  of  the  blood  of 
patients  after  the  crisis  of  pneumoiua  contained  the  antitoxic  substanco 
and  was  capable,  in  a  fair  number  of  cases,  of  curing;  the  disease  when  in- 
jected into  infected  animals.  They  have  nuide  i)reliminary  observations 
upim  patients  with  a  view  of  inducing  tiie  crisis  by  the  injection  of  the 
blood  serum  of  persons  convalescent  from  pneumonia,  and  which  conse- 
quently contains  the  antitoxic  body.  In  six  pneumoinc  patients  the  re- 
sults were  promising.  In  all  there  was  a  decdded  fidl  of  temperatiirc  in 
from  six  to  twelve  hours  after  subcutaneous  injections  of  from  four  to  six 
c.  c.  of  the  serum.  Tlie  pulse  and  respirations  were  also  diminished  in 
frequency.  In  two  cases  the  temperature  fell  to  37°  C.  Twice  it  fell  and 
renuiined  at  normal.  In  the  other  cases  it  fell  only  temporarily.  In  two 
typhoid  cases  the  injections  were  negative.  The  serum  has  no  eifect  when 
injected  into  healthy  individuals. 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  have 
recognized  three  stages  in  the  inflamed  lung — engorgement,  red  hepatiza- 
tion, and  gray  hepatization. 

In  the  stage  of  engoryement  the  lung  tissue  is  deep  red  in  color,  fhnier 
to  the  touch,  and  more  solid,  aiul  on  section  the  surface  is  bathed  with 
blood  and  serum.  It  still  crepitates,  though  not  so  distinctly  as  healthy 
lung,  and  excised  portions  float.  The  air-cells  can  be  dilated  l)y  in- 
sufflation from  the  bronchus.  Microsco])ical  examination  shows  the 
(iapillary  vessels  to  be  greatly  distended,  the  alveolar  ei)itheliuni  swollen, 
and  the  air-cells  occupied  by  a  variable  nund)er  of  blood-cor])uscles  and 
detached  alveolar  cells.  In  t^ie  stage  of  red  hcpntizathm  the  lung  tissue 
is  solid,  firm,  and  airless.  If  the  entire  lobe  is  involved  it  looks  volnnii- 
nous,  and  shows  indentations  of  the  ribs.  On  section  the  surface  is  dry, 
reddish  brown  in  color,  and  has  lost  the  deeply  congested  ai)i;earaii(e  of 
the  first  stage.  One  of  the  most  remarkable  features  is  the  friability ;  in 
striking  contrast  to  the  healthy  lung,  which  is  torn  with  difiicnity,  a 
hepatized  organ  can  be  readily  broken  by  the  finger.  Careful  inspe(  tion 
shows  that  the  surface  is  distinctly  granular,  the  granulations  lejireseiit- 
ing  fibrinous  plugs  filling  the  air-cells.  The  distinctness  of  this  appear- 
ance varies  greatly  with  the  size  of  the  alveoli,  which  are  about  O-IO  mm.  m 
diameter  in  the  infant,  0-15  or  0-16  in  the  adult,  and  from  O-xiO  to  O-i.")  in 
old  age.     On  scraping  the  surface  with  a  knife  a  reddish  viscid  serum  is 


■    ^ 


PNEUMONIA. 


616 


rt'iiioved,  contuining  small  grumilur  inu«808.  The  smaller  broiu'hi  ofton 
coiitaiu  fibrinous  plugs.  H  the  lung  has  been  removed  before  tlio  heart, 
it  is  not  uncommon  to  find  solid  moulds  of  clot  filling  the  blood-vessids. 
Microsc.opii'idly,  the  air-cells  are  seen  to  be  occupied  by  coaguliitt'd  fibrin 
ill  till'  meshes  of  which  are  red  blood-corpuscles,  polynudeur  leucocytes, 
iiiui  alveolar  epithelium.  The  alveolar  walls  are  infiltrated  and  leucoi^ytea 
iiiv  seen  in  the  interlobular  tissues.  Cover-glass  preparations  from  the 
exiuhite,  and  thin  sections  show,  as  a  rule,  the  diplo(H)cci  already  referred 
tn,  niauv  of  which  are  contained  within  cells.  Staphylococci  and  strep- 
tdiocci  may  also  be  seen  in  some  cases.  In  the  stage  of  yraji  Itcpntiuitiun 
the  tissue  has  changed  from  a  reddish-brown  to  a  grayish-white  color. 
Tlio  surface  is  moister,  the  exudate  obtained  on  scraping  is  more  turbid, 
the  granules  in  the  acini  are  less  distinct,  and  the  lung  tissue  is  still  more 
frialile.  Histologically,  in  gray  hepatization,  it  is  seen  that  the  air-cells 
iiiT  densely  filletl  with  leucocytes,  the  fibrin  network  and  the  red  blood- 
(;f)ri)uscles  have  disappeared.  A  more  advanced  condition  of  gray  hepa- 
ti/atioii  is  that  known  n^ purulent  iiifiUration,  in  which  the  lung  tissue  is 
softer  and  bathed  with  a  purulent  fiuid. 

The  stage  of  gray  hepatization  appears  to  be  the  first  step  in  the 
])ro(esH  of  remlutioH.  The  exudate  is  softened,  the  cell  elements  are 
(lisiutegrated  and  rendered  cajjable  of  absorption.  When  the  purulent 
iiitiltration  of  the  lung  tissue  reaches  the  grade  scmietimes  st^en  post 
inortein,  it  is  probable  that  resolution  couhl  not  take  place.  Small  al)sces3 
cavities  nuiy  arise,  and  by  their  fusion  larger  ones.  Often  in  one  lung, 
or  even  in  one  lobe,  the  various  stages  of  the  process  may  be  seen,  and  the 
passagi!  of  the  engorgement  into  red  hepatization  and  of  the  latter  into 
the  gray  stage  can  be  reailily  traced. 

The  general  details  of  the  morbid  anatomy  of  pneumonia  may  be 
jjathered  from  the  following  facts,  based  on  100  autopsies,  made  by  me  at 
the  (Icneral  Ilosjiital,  Montreal :  In  51  cases  the  right  lung  was  affected ; 
in  Wl.  the  left;  in  17,  both  organs.  In  27  cases  the  entire  lung,  with  the 
exception,  perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border, 
was  (toMsolidated.  In  34  cases,  the  lower  lobe  alone  was  involved ;  in  13 
eases,  the  upper  lobe  alone.  "When  double,  the  lower  lobes  were  usually 
atfeoted  together,  but  in  three  instances  the  lower  lobe  of  one  and  the 
iipi)er  lobe  of  the  other  were  attacked.  In  three  cases  also,  both  upper 
lobes  were  affected.  Occasionally  the  disease  involves  the  greater  jiart  of 
l)otii  lungs;  thus,  in  one  instance  the  left  organ  with  the  exception  of  the 
anterior  border  was  uniformly  hepatized,  while  the  right  was  in  a  stage 
of  gray  hepatization,  except  a  still  snudler  portion  in  the  corres])onding 
region.  In  a  third  of  the  cases,  red  and  gray  hepatization  existed  together. 
In  tl  instances  there  was  gray  hepatization.  As  a  rule  the  unaffected 
portion  of  the  lung  is  usually  congested  or  codematous.  When  the  greater 
portion  of  a  lobe  is  attacked,  the  uninvolved  part  may  be  in  a  state  of  almost 
gelatinous  oedema.     The  unaffected  lung  is  usually  congested,  particularly 


'u 


V 


t\ 


1 

i 
I 

516 


DISEASRS  OP  THE  RESPIRATORY  SYSTEM. 


1! 


^1 1« 


SLlmi 


at  tho  poHtorior  jmrt.  TIiIh,  it  must  bo  ronu' tribe  red,  iimy  bo  lurgoly  duo  to 
post-mortom  siibsi(l((ii(!o.  Tho  unintlaiiicil  portiona  uro  not  alwuvH  con- 
goHtt'd  and  d'dcniatoiis.  Tho  upper  hibo  may  W.  dry  and  l)l(HHllt'«H  when 
tho  lower  lobe  is  nniforrnly  consolidated.  'JMie  avera^^e  wei^dit  (»t'  a  noriinil 
hin<?  is  about  <i(  (»  j^ratnnies,  wiiilo  that  of  an  intlanied  orjjjan  may  Ix-  l/ido, 
2,000,  or  even  ^,500  j^'rainmes. 

'I'he  bronchi  contain,  as  a  ruk;,  at  the  time  of  (U'ath  a  frotliy  senms 
fluid,  rarely  the  tenacious  nuicus  so  characteristic  of  piicunioMic  sputiiin. 
The  nnicous  membrane  is  usually  reddened,  rarely  swollen.  In  tlu-  aHV(  ted 
areas  the  snudler  bronchi  often  contain  librinous  jjIu^s,  whi<'h  may  extciKJ 
into  tb.e  lar<i;er  tubes,  forming  perfect  casts.  The  bronchial  j^lands  arc 
swollen  and  may  even  bo  soft  and  l)ulpy.  The  pleural  surface  of  llic 
inflajued  lum;  is  invarialtly  involved  uhen  the  jirocess  becomes  superli(  iul. 
Commonly,  there  is  only  a  thin  sheetinjLj  of  exudate,  jiroduciii;,'  sli;f|ii 
turbidity  of  the  membrane.  In  only  two  of  i\w  hundred  iuslanccs  the 
pleura  was  not  involved.  In  some  cases  the  fibrinous  exudate  luay  fdiin  ;i 
creamy  layer  an  inch  in  tliickness.  A  serous  exudation  of  varial)le  aiiiniiiii 
is  not  uncommon. 

Lesions  in  other  Organs.— The  lieart  is  distended  with  firm,  tenaciciis 
coagula,  which  can  be  withdrawn  from  tlio  vessels  as  dendritic^  mnuMs 
In  no  other  acute  disease  do  we  meet  with  coajjula  of  such  solitlity  iiiid 
firmiies.s.  The  distention  of  the  ri<j;lit  chambers  of  the  heart  is  partici. 
larlv  marked.  The  left  chambers  are  rarely  distended  to  the  same  drj^frcc. 
The  spleen  is  often  eidarged,  thoufifh  in  oi\ly  35  of  the  10()  eases  wiis  tlic 
weij,'ht  above  200  grammes.  The  kidneys  show  ])arenchymatous  swelliiijr. 
turbidity  of  the  cortex,  and,  in  a  very  considerable  proj)ortion  of  the  cases 
— twenty-live  per  cent — chronic  interstitial  (changes. 

Pericarditis  is  not  infrefpient,  and  occurs  more  jjarticularly  with  piicu- 
monia  of  the  left  side  and  with  double  i)neunionia.  In  5  of  the  loo  autop- 
eies  it  was  present,  and  in  4  of  them  the  lappet  of  lung  overlying  tho  peri- 
cardium with  its  pleura  was  involved.  Endocarditis  is  more  frefiueiit  uiid 
occurred  in  1(!  of  the  100  cases.  In  5  of  these  the  endocarditis  was  of  tlu' 
simple  character ;  in  11  tho  lesion.s  were  ulcerative.  Fatty  degenerutiim 
of  tho  heart  is  not  common  except  in  protracted  cases. 

]\Ieningitis  is  not  infrequently  found,  and  in  many  cases  is  associated 
with  nudignant  endocarditis.  It  was  present  in  8  of  the  100  autciisits. 
Of  twenty  cases  of  meningitis  in  ulcerative  endocarditis  fifteen  occiinod 
in  pneunn)nia.  The  meningeal  inflammati'ni  in  these  cases  is  u.-iiall\ 
corticil. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  part«.  A 
croupous  colitis,  as  pointed  out  by  BrLstowo,  is  not  very  uncommon.  It 
occurred  in  5  of  my  100  post-mortems.  It  is  usually  a  tliin,  flaky  exiula- 
tion,  most  marked  on  the  tops  of  the  folds  of  the  mucous  mombraiie.  In 
one  case  there  was  a  patch  of  croupous  gastritis,  covering  an  area  of  \'i  by 
8  cm.,  situated  to  the  left  of  the  cardiac  orifice. 


f  1-1  1*    'ii 


..if 


PNKL'MOMA. 


f)17 


The  livor  hIiows  pMrciichyiimtouH  clmngos  and  often  cxtrornc  onj^orgc- 

IllCllt   nf  tllC   lu'lKltif,   V(ailH. 

Symptoms. — Abruptly,  or  preceded  by  ii  day  or  two  of  iiulisposi- 
tidii,  the  piitient  liiis  a  sovero  clull,  liiHtiiig  from  ten  to  thirty  miniitert.  In 
no  acute  disease  is  an  initial  diill  ho  constant  or  so  severe.  The  fever 
risis  (|iii('kly.  Tliere  is  pain  in  tlic!  sidi",  often  of  an  agonizing  ciiaracter. 
A  short,  dry,  painful  eougii  soon  develops,  and  the  rt'spirations  art;  in- 
creased in  freipuniey.  When  .'L.ii  on  the  second  or  third  day  the  patient 
presents  un  appearancio  whicili  may  be  (piite  pathognomonic.  JIc^  lies  Hat 
in  lied,  often  on  the  alTected  side* ;  the  face  is  Hushed,  particularly  tho 
elieeks  ;  tiie  breathing  is  hurried;  Hie  ahe  nasi  dilate  with  each  inspira- 
tii»ii ;  tlu^  eyes  an;  bright,  tlie  I'xpression  is  anxious,  and  there  is  a  friMpieut 
short  cough  which  makes  the  jiatient  wince  ami  imid  his  side.  'IMk!  ex- 
pectoration is  blood-tinged  and  extremely  tenacious.  The  temperaturo 
rises  rapiilly  to  104°  or  10,')".  'I'lie  ])ulse  is  full  and  bounding  and  tho 
piil.>c-rcs|)iration  ratio  much  disturbed.  Kxamination  of  the  lung  shows 
the  |)hysieal  signs  of  (tonsolidation — blowing  breathing  and  line  riiles. 
After  persisting  for  from  seven  to  ten  days  the  crisis  occurs,  and  with  a 
fall  in  the  temperatures  the  patient  passes  from  a  condition  of  extreme  dis- 
tress ami  anxiety  to  one  of  comparatives  comfort. 

The  fever  of  pneumoiua  rises  abruptly  with  the  chill,  (hn'ing  which 
the  rectal  temperaturis  may  be  high.  Tn  (thildren  and  in  cases  without 
(hill  the  rise  is  more  gradual.  The  teni[)erature  reaches  lO-t"  or  lO')"  and 
is  eoiiti!uu»us,  with  a  variation  of  a  degree  to  a  degree  and  a  half.  If 
a  two-hour  record  is  kept  the  diirMial  variations  ure  seen  to  follow  tho 
iKirrual  type.  In  children  and  healthy  adults  the  fever  is  nsnally  higher 
thiin  in  old  persons  and  drunkards.  After  contimnng  for  from  fiv:  to 
nine  (lays  the  temperature  falls  alnniptly,  forming  what  is  known  e.s  (ho 
crisis,  so  characteristic  in  a  large  proportion  of  the  cases.  In  from  livo 
to  twelve  hours  the  temperature  may  fall  eight  degrees.  The  crisis  may 
(leeur  as  early  as  the  third  day  or  as  late  as  the  twelfth  or  fourteenth.  A 
psciidii-crisis  may  occur  on  tho  fd'tli  day  or  earlier.  Defervescence  may 
tiike  place  gradually  by  lysis.  In  cases  of  delayed  resolution  the  fever 
may  persist  for  weeks. 

Respiratory  Symptoms. — Pain  of  an  agoinzing  character  is  an  early 
mill  distressing  symptom.  It  is  usually  referred  to  the  niiiple  or  axillary 
regions  of  the  affected  side.  In  exceptional  cases  it  may  be  in  tho  abdo- 
men or  flank,  or  even  beneath  tho  shouhhsr-blade.  Deep  inspiration  and 
eongh  aggravate  it.  Dyspiux^a  is  a  very  pronunent  feature.  The  respira- 
tions may  he  from  forty  to  sixty  in  the  miimte  and  in  exceptional  eases 
and  in  children  may  rise  to  eighty.  To  j)roduco  this  shortness  of  breath 
many  factors  combine — the  fever,  tho  loss  of  function  in  a  consideraldo 
urea  of  lung  tissue,  and  tho  excessive  psdn  in  the  side,  which  makes  it  im- 
possihle  to  draw  a  deep  breath.  There  maybe  nervous  fa' tors  at  work, 
M  with  the  crisis  the  number  of  respirations  may  fall  nearly  to  normal, 


t!       ^ 


•J 

( 

?  t 

- 

u 

"« 

^1 

I  ,''.  *  -i'l 


tS 


i<i'  iiM 


H8 


DISKASES  OF  THE   IIESPIIIATOIIY  SYSTEM, 


while  the  eonsolidivtion  of  the  hxng  still  persists.     The  type  of  broiilhincf 
in  pneumouia  is  peculiar  aud  almost  distiuctive.    The  inspirations  iirc 


Jan.  in 


Kc&p. 


76 


70 


«S 


50 


35 


26 


20 


10 


Pnlse 
190 


180 


170 


100 


160 


140 


130 


100 


90 


CO 


50 


40 


Temp, 
109 


107 


IOC 


105 


IM 


103 


102 


100 


97 

90 
Timp. 

I'lilse 

Rt'sp. 
Rtvols 

frlne 


ilay  of 


II n /«  10 


10 


13 


13 


BLACK,    temperature;  bed,    pulse;  blue,   BtSPmATlON 

Chart  XV.— Fever,  pulse,  ami  respirations  in  lobar  pneumonia, 

short  and  superficial.     Expiration  is  often  assoeiaied  with  a  short  ^niiit. 
The  ratio  between  the  re.spirations  and  pulse  may  be  1  to  2,  or  evrii  1  to 


•1,1  ;    /'     ■   \        .  i 


PNEUMONIA. 


619 


15.  In  no  other  disease  do  ^^c  see  such  marked  disturbance  in  the  pulse- 
rorij)irati<)n  ratio,  and  this  is  sometimes  an  aid  in  <liagno.sis. 

The  cough  is  also  very  characteristic — frecjuent,  short,  restrained,  and 
assotiutod  witli  great  pain  in  the  side.  It  is  at  first  dry,  hard,  and  with- 
out expectoration.  In  old  persons  and  drunkards  and  in  those  debihtated 
by  long  illness  there  may  be  no  cough.  The  sputum  is  mucoid  at  first, 
l)nt  within  twenty-four  hours  shows  special  fesitures.  A  bi'isk  ha'moi)tysi8 
may  be  an  initial  symptom.  Pneumonic  sputum  is  viscid,  tenacious,  and 
blood-tinged.  The  gummous  viscidity,  together  with  the  red  blood-cor- 
puscles m  various  stages  of  alteration,  give  pathognomonic  cliaract'.'rs  to 
tlic  sput'i,  unknown  in  any  other  disease.  The  rusty  tinge  becomes  more 
uiiirkcd  as  the  disease  progresses,  and  so  tonacious  is  the  ex])ectoration 
that  it  has  to  be  wiped  from  the  lips  of  the  patient,  and  a  spit-cu}),  half 
full,  may  be  inverted  without  spilling.  Toward  the  close  it  becomes 
more  liijuid  ami  is  more  readily  expelled.  In  h)w  tyjws  of  tlic  disease  the 
sputum  may  be  fluid  and  dark  brown,  resembling  j)rune  juice.  The 
amount  is  very  variable.  In  children  and  old  people  there  may  be  none ; 
ordinarily,  however,  there  are  from  100  to  300  c.  c.  daily.  After  the  crisis 
tlio  (piantity  is  variable ;  abundant  in  some  cases,  absent  in  others.  3Iicro- 
ti(;opi(!ally,  the  sputum  contains  red  blood-cor{)uscles  in  all  stages  of  de- 
f^encratioi),  alveolar  epitheliu'ni,  diplococci  and  other  micro-organisms, 
ooll-moulds  of  the  alveoli,  and,  in  some  cases,  small  llbrinous  casts  of  the 
hromiiioles.     The  latter  are  sometimes  plainly  visible  to  the  naked  eye. 

Physical  Signs. — Insj)ectiu)i  may  not  at  first  show  any  diffi'rence  be- 
tween the  two  sides,  though  us"ally  if  the  lower  lobe  of  a  lung  is  involved 
the  movement  is  less  on  the  affected  side.  Later,  when  consolidation  lias 
oeeurrod,  particularly  if  it  is  massive,  this  deficient  expansion  is  very 
marked.  Mensuration  may  show  a  definite  increase  in  the  volume  of  the 
si(l(^  involved.  The  intercostal  spaces  are  not  obliterated.  Palpation  in- 
ilioatos  still  more  clearly  the  lack  of  expansion,  and  a  pleural  friction  may 
1)0  felt.  Tactile  fremitus  is  increased.  These  signs  arc  all  more  nuirkcd 
when  consolidation  is  established. 

/'(■mission. — In  the  stage  of  engorgement  the  note  is  higher  pitched 
inul  nuiy  have  a  somewhat  tympanitic  qu  ility,  the  so-called  Skoda's  reso- 
iiauee.  This  can  often  be  obtained  over  the  lung  tissue  just  above  a  con- 
soliilaletl  area.  When  the  lung  is  he])atized,  the  percussion  note  is  flat, 
the  (piali'v  of  the  f  vLness  varying  a  go  )d  deal  from  a  note  which  has  in  it 
a('(H-t:iin  tyini)anitic  ipudity  to  absolute  dulness.  There  is  not  the  wooden 
llatlu^ss  of  effusion  and  the  sense  of  resistance  is  not  so  gre;it.  During 
resolution  the  tympanitic  quality  of  th<!  percussion  note  may  return.  For 
weeks  or  months  after  convalescence  iner  may  be  a  higher-pitched  note 
oil  the  ulTeeted  side. 

Aiisridlafiim. — Quiet,  s-ppressed  breathing  in  thoalTcctod  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  \'ery  early 
there  is  heard  at  the  end  of  inspiration  the  fine  crepitant  rale,  a  scries  of 


•"i    . 


■m 
I 

':M 

.    i 

I 


■:^i 

m 

■.-ii, 

'    'J- 

1 

.».' i: 

i 

■jsi 


*^^^ 


1,  >, 


m 


'   f' 


li^ 


"11'  I 


■  s 


520 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


minute  crucklin^s  hoard  close  to  the  ear,  and  perhaps  not  audible  until  a 
full  breath  is  drawn.  Whether  this  is  a  fine  pleural  crepitus  or  is  jiro- 
duced  in  the  air-cells  and  finer  bronchi  is  still  an  o])en  (juestion.  At  this 
stage,  before  consolidation  lias  occurred,  the  breath-sounds  may  bo.  as 
before  mentioned,  much  feebler  than  in  health,  but  on  drawing  a  Ion;.' 
breath  they  may  liave  a  harsh  quality,  to  which  the  term  broTicho-vesiciilar 
has  been  applied.  In  the  stage  of  red  hepatization  and  when  duliiosn  is 
well  delined,  the  respiration  is  tubular,  similar  to  that  heard  in  health  over 
the  larger  bronchi.  With  this  blowing  breathing  there  may  be  no  nilcs. 
and  it  may  present  an  intensity  unknown  in  any  otlier  pulmonary  aiTcc 
tion.  It  is  simply  the  propagation  of  the  laryngeal  and  tracheal  souinis 
through  the  bronclii  and  the  consolidated  lung  tissue.  The  permeal)ihtv 
of  the  bronchi  is  essential  to  its  production.  Tubular  breathing  is  ahsoiit 
in  certain  cases  of  massive  pneumonia  in  •which  the  larger  bronchi  are 
completely  lilled  with  exudation.  When  resolution  begins  mucous  rales  of 
all  sizes  can  be  heard.  At  first  they  are  small  and  have  been  called  flic 
redux-crrpifns.  Tlie  voice-sounds  are  transmitted  through  the  consoli- 
dated lung  with  great  intensity.  This  broiu'hoj)hony  may  have  a  ciiriouH 
nasal  quality  to  which  the  term  a?gophony  has  been  given. 

Circulatory  Symptoms. — During  the  chill  the  pulse  is  small,  but  in 
the  succeeding  fever  it  becomes  full  and  bounding.  In  cases  of  moderate 
severity  it  ranges  from  100  to  IIG.  It  is  not  often  dicrotic.  In  stronir. 
healthy  individuals  and  in  children  there  may  be  no  sign  of  failing  pulse 
througliout  the  attack.  With  extensive  consolidation  the  left  ventricle 
may  receive  a  very  diminished  amount  of  blood  and  the  pidse  in  conse- 
quence may  be  small. 

In  the  old  and  feeble  the  pulse  may  be  small  and  rapid  from  the 
outset.  The  heart-sounds  are  usually  loud  and  clear.  During  tho  in- 
tensity of  the  fever,  particularly  in  children,  bruits  are  not  uncommon 
both  in  the  n)itral  and  in  the  pulmonary  areas.  The  second  sound  over 
the  pulmonary  artery  is  accentuated.  Attention  to  this  sign  gives  a  valu- 
able indication  as  to  the  condition  of  the  lesser  circulation.  With  di.-t'ii- 
tion  of  the  right  chambers  and  failure  of  the  right  ventricle  to  empty 
itself  completely  the  pulmonary  second  sound  becomes  much  less  distinct. 
When  the  right  heart  is  engorged  there  may  be  an  increase  in  i\\o  dulness 
to  the  right  of  tlie  sternum.  With  gradual  heart-failure  and  signs  of 
dilatation  the  long  pause  is  greatly  shortened,  the  sounds  a])i)roacli  each 
other  in  tone  and  have  a  fa>tal  character  (embryocardia). 

Blood. — The  number  of  red  corpuscles  is  reduced,  but,  in  consequence 
of  the  comparative  shortness  of  tho  attack,  we  rarely  see  the  ana>mi:i  asso- 
ciated M-ilih  other  febrile  disorders.  No  special  changes  occur  in  the  cor- 
puscles themselves.  The  colorless  corpuscles  are  increased  in  number  from 
about  (!,000  per  c.  mm.,  the  normal  number,  to  10,000,  or  even  more.  Tliis* 
leucocytosis  disappears  as  soon  as  crisis  occurs.  Its  absence  during  ♦!»' 
fastigium  is  considered  to  indicate  an  unfavorable  prognosis.     A  strikinj: 


PNEUMONIA. 


521 


featiir(^  in  the  l)loo(l-slicle  is  tlie  viohnosa  and  density  f>f  tlio  librin  net- 
work- Tins  corresponds  to  tiie  great  inorease  in  the  lihrin  elements, 
which  has  long  been  known  to  oecur  in  pneumonia,  the  proportion  rising 
fi-diii  t'liur  to  ten  parts  per  thousand,  llayem  describes  the  blood-plates 
08  iricatiy  increased.     The  diplococci  can  very  rarely  be  demonstrated  in 

the  Mood. 

'I'lie  fjaxtro-intesiinal  sijmptoms  are  those  associated  with  an  ordinary 
sthenic  fever.  Vomiting  is  not  fre,|uent  at  the  outset.  There  is  naturally 
loss  of  appetite.  The  tongue  is  'vhit^^  and  furred,  and,  in  cases  of  a  low 
tvi>c,  r;ipidly  becomes  dry.  (Constipation  is  more  common  than  diarrlura, 
wliicli  (iocs  prevail,  however,  in  some  epidemics.  The  spleen  is  usually 
ciiliirL^'d,  and  the  edge  can  be  felt  during  a  deep  inspiration.  Except  in 
cases  of  extreme  engorgement  of  the  right  heart,  the  liver  is  usually  not 
increased  in  volume. 

Among  cutaneous  symptoms  one  of  the  most  interesting  is  the  associa- 
tion nf  herpi's  with  pneumonia.  Not  excepting  malaria,  we  see  labial 
li('r])(s  more  frequently  in  this  than  in  any  other  disease,  occurring,  as  it 
ilofs.  ill  from  twelve  to  forty  per  cent  of  the  cases.  It  is  supposed  to  be 
of  fa\or!il)lc  prognosis,  and  figures  have  beei\  quoted  in  proof  of  this  asser- 
tion. It  may  also  occur  on  the  nose  or  on  the  genitals.  Its  significance 
and  relation  to  the  disease  are  unknown.  It  is  scarcely  necessary  to  men- 
tion the  theory  which  has  been  advanced,  that  it  is  an  external  expression 
of  a  neuritis  which  involves  the  pneumogastric  and  induces  the  pneumo- 
nia. At  the  height  of  the  disease  sweats  are  not  common,  but  at  the  crisis 
tlu'V  may  be  profuse.  Redn(!ss  of  one  cheek  is  a  phenomenon  long  recog- 
nized in  connection  with  pneumonia,  and  is  usually  on  the  Siime  side  as 
the  disease. 

The  urine  jiresents  the  usual  febrile  characters  of  high  color,  high  spe- 
cific gravity,  high  <lensity,  and  increased  acidity.  The  nitrogenous  ele- 
ments, urea  and  uric  acid,  are  notably  increased.  The  chlorides  are 
absent,  or  greatly  reduced,  during  the  height  of  the  fever — due,  it  is  sup- 
posed, to  the  anu)unt  exuded  in  the  hepatized  lung.  At  the  crisis  there  may 
be  marked  increase  in  the  amount  of  urine,  which  is  heavily  laden  with 
urates  und  extractives.  When  jaundice  occurs  there  is  bile-pigment.  A 
trace  of  all)umen  is  j)resent  in  a  large  proportion  of  the  cases.  It  is  rarely 
of  seriuns  siguilieance,  and  seldom  associated  with  tube-casts. 

Cerebral  Symptoms. — As  an  initial  symptom,  headache  is  common. 
Coiisf  iiiusness  is  usually  retained  throughout,  even  in  severe  cases.  In 
cliildreii  ( oiivulsions  are  common,  and  in  at  least  otie  half  the  cases  usher 
ill  the  disease.  There  may  be  violent  maniacal  symptoms  in  the  adult.  I 
once  performed  an  autopsy  in  a  case  of  this  kind  in  which  there  was  no 
snspiriiin  what(>ver  that  the  disease  was  other  than  acute  mania.  In  drunk- 
ards the  symptoms  from  the  outset  may  be  those  of  didirium  tremens,  in 
,  which  disease  it  should  be  an  invariable  rule,  even  if  fever  is  not  present, 
to  exuniitie  the  lungs.     These  patiouta  are  apt  to  wander  about,  and  must 


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522 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


be  carefully  wiitcheil.  The  preliminary  excitement  and  delirium  nuiy  f,nvo 
place  to  hebetude,  which  deepens  to  coniu.  It  is  not  possible  to  deciik'  in 
tiiese  cases  whether  meningitis  is  present  or  not,  since  it  is  usually  corticul, 
and  there  are  no  symptoms  of  pressure  on  the  nerves.  In  oidv  one  df 
eight  instances  was  there  involvement  of  the  base,  ri'udering  clear  tlic 
diagnosis  of  meningitis.  These  cases  of  so-called  cerebral  pneunioniu  are 
frequently  associated  with  very  high  fever.  In  senile  and  alcoholic  pinu- 
monia,  however,  the  temperature  may  be  low  and  yet  brain  .sviii|it()iiis 
very  pronounced.  Mental  disturbance  may  persist  during  and  after  v.tm- 
valcscence,  and  iihsanity  develops  in  a  few  cases.  It  is  currently  .stated 
that  apex  jjueumonia  is  more  often  complicated  with  severe  delirium,  but 
it  has  not  been  so  in  my  experience. 

Complications. — Many  of  these  seem  to  depend  directly  on  the  in- 
vasion of  the  biidy  by  the  diplococci. 

As  already  mentioned,  jy/ewr/'.s-y  is  an  inevitable  event  when  the  iiitlam- 
mation  reaches  the  surface  of  the  lung,  and  thus  can  scarcely  be  termed 
a  complication,  lint  there  are  cases  in  which  the  pleuritic  features  take 
the  first  place — cases  tt>  which  the  term  pleuro-pneumonia  is  applicahle. 
The  exudation  nuiy  be  sero-fibrinoua  with  copious  elfusion,  diileriiig  lidm 
that  of  an  ordinary  acute  pleurisy  in  the  greater  richness  of  the  librin, 
which  may  form  thick,  tenacious,  curdy  layers.  l*neunu)nia  on  one  side 
with  extensivi'  pleurisy  on  the  other  is  sonu'times  a  puzzling  cdMipIicatinn 
to  diagnose  and  an  aspirator  needle  may  be  recpiired  to  settle  the  mn'»- 
tion.  The  bai  U'riological  examination  of  the  fluid  has  demonstrated,  in  a 
large  nxnnber  of  cases,  the  presence  of  the  pjieumococcus.  Of  late,  special 
attention  has  been  paid  to  the  frequency  with  wliich  empyenui  ediiipli- 
cates  piu'umonia.  Effusion  may  not  have  been  suspected  during'  tlic 
height  of  the  disease,  but  after  the  temj)erature  has  been  normal  for  some 
days  a  slight  rise  occurs  and  the  irregular  lever  persists.  I) ulnesa  con- 
tinues at  the  base,  or  may  have  extended.  The  breathing  is  feeble  and 
there  are  no  rales.  Such  a  condition  may  be  closely  simulated,  of  coiuso, 
by  the  thickened  {)leural  layers  which  niv  so  commoidy  found  alter  the 
pneumonia.  The  questioji  should  be  settled  at  onc^e  by  the  iutni<liiction 
of  the  needle.  It  is  by  no  means  an  uncomnnm  complication,  and  many 
(iases  of  empyema  sujiposed  to  be  primary  are  in  reality  secondary  to  a 
slight  ])iuMimonia. 

Pcruutrdihs  is  more  common  in  the  pjunimonia  of  children,  particu- 
larly when  double,  and  it  is  said  with  the  piuMimonia  of  the  lel't  side,  it 
was  present,  as  I  stated,  in  five  of  my  one  hundred  autopsies.  'I'timigh 
usually  plastic,  there  nuty  be  much  serous  effusion.  'I'liere  is  rarely  any 
ditliceUy  in  the  diagnosiss,  but  when  the  ])neumonia  involves  the  portion 
of  lung  covering  the  pericardium,  there  may  be  dilliculty  in  deteriiiining, 
i)y  physical  signs,  ti>e  existence  of  fluid.  The  iiu^'ease  in  the  dyspnteii, 
the  greater  fc(!blenes8  of  the  pulse,  and  the  gradual  suppression  of  the 
heart-sounds  will  ijive  the  most  valuable  indications.     In  some  iusiaiices 


m  'I 


PNEUMONIA. 


523 


the  fluid  19  purulent.  Tliougli  a  very  serious  event,  it  is  surprising  how 
often  recovery  takes  plaee  even  in  the  most  desperate  cases  of  pneumonia 
coiiiplieated  witli  jjeriearditis.  I  remember  that  the  late  Dr.  ^Murehison 
.some  years  ago  commented  upon  this  feature  in  a  case  at  8t.  Thomas's 
II()S[)ital. 

Kiidocardilis  is  still  more  frequent,  and  in  niy  one  hundred  autopsies 
wu:^  present  in  sixteen.  I  called  attention  in  the  Ciulstonian  lectures  for 
IHS.")  to  the  great  frequency  of  this  complication.  Of  ;^0!)  cases  of  malig- 
nant endocarditis  collected  frojn  the  literature,  54  cases  occurred  in  this 
ilisease.  Subsequent  o])servations  have  fully  confirmed  this  statement.  It 
niav  1)0  said  that  with  no  acute  febrile  disease  is  endocarditis  so  frequently 
associiiled.  It  is  much  more  common  in  the  left  heart  than  in  the  right. 
It  i^  particularly  liable  to  attack  persons  with  old  valvular  disease.  There 
mav  bo  no  symptoms  indicative  of  this  com])lication  even  in  very  severe 
ca.sos.  It  may,  however,  be  suspected  in  cases  (1)  in  which  the  fever  is 
jirDtracted  and  irregular;  {'I)  when  signs  of  septic  mischief  arise,  such  as 
chills  and  sweats;  (3)  when  embolic  phenomena  apjjcar.  The  f recjuent 
complication  of  meningitis  with  the  endocarditis  of  pneumonia,  which  has 
already  been  mentioned,  gives  prominence  to  the  cerebral  symjitoms  in 
tiic-io  cases.  The  physical  signs  may  be  very  deceptive.  There  arc  in- 
stances in  which  no  cardiac  murmurs  have  been  heard.  In  others  the  de- 
viloiinient  under  observation  of  a  loud,  rough  murmur,  i)articularly  if 
(liastoHc,  is  extremely  suggestive. 

Changes  in  the  myocardium  are  not  uncommon,  rarely  more,  however, 
than  cloudy  swelling  of  the  fibres ;  but  in  some  instances  there  is  fatty 
cliango. 

Ante-mortem  heart-clots  are  rare  in  pneumonia,  even  in  the  extreme 
;^ra(le  of  dilatation  of  the  right  clnunbcr.  In  not  a  single  instance  of  my 
autopsies  were  there  globular  throml)i  in  the  aurii'les  or  in  apices  of  the 
ventrieles.  In  protracted  cases  throml)i  occasionally  form  in  the  veins. 
A  rare  complication  is  endjolism  of  one  of  the  larger  arteries.  I  saw  an 
instane(>  in  Montreal  of  embolism  <  f  the  femoral  artery  at  the  height  of 
pneumonia,  which  necessitated  amputation  at  the  thigh.  The  patient  ru- 
oovered. 

By  far  the  most  important  complication  is  the  imeumonic  meningitis, 
wliirh  varies  nnich  at  different  times  aiul  in  dilTcrent  places.  My  Mont- 
real experience  is  rather  cxcejitional,  as  eight  })er  cent  of  the  fatal  cases  had 
Ihi:-;  complication.  It  usually  comes  on  at  the  height  of  the  fever  and  in 
the  majority  of  the  cases  is  not  recognized  unless,  as  before  menti(»ned,  the 
base  is  involved,  which  is  not  common.  ^Ici\ingitis  may  develop  later  in 
the  disease  and  is  then  more  easily  diagnosed.  Associated  as  it  so  often 
\^  with  ulcerative  endocarditis,  there  may  be  eml)olism  of  the  cerebral 
arteries,  inducing  hemiplegia.  .Vmong  ran^  complications  may  be  men- 
tioned ;w7'//>/;^/vf/  nrnri/is,  of  which  several  instances  have  been  described. 

I  saw  Olio  well-markod  instance,  following  pueuinonia  and  influenza,  in  the 
34 


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524 


DISEASES  OF  TOE  RESPIRATORY  SYSTEM. 


■  I  ii 


r'ii: 


'-?. 


spring  of  18'JO.     There  was  neuritis  of  the  loft  arm  with  consiJeniblo 
wasting. 

Serious  f/ns/ric  complications  arc  rare.  A  croupous  gastritis  has  ah'cadv 
been  inontioueil.  Tl>o  croupous  coUlis  may  iiuhu'e  sovero  diarrlida. 
Jaundice  is  one  of  the  most  iiiterostiug  comijliratious  of  i)ni'unioriia  uml 
occurs  witii  curious  irregularity  in  dilTercnt  outbreaks  of  the  (liseasc.  ](, 
sets  in  early,  is  rarely  very  intense,  and  has  not  the  characters  of  obstruct- 
ive jaundice.  There  arc  cases  in  which  it  assumes  a  very  serious  form. 
The  mode  of  production  is  not  well  ascertained.  It  does  not  appear  U\ 
bear  any  de(initc  relation  to  the  degree  of  hej)atic  engorgement  and  it  is 
certainly  not  due  to  catarrh  of  the  ducts.  Possibly  it  may  be,  in  grout 
part,  luicmatogenous. 

Paroliiis  occasionally  occurs,  commonly  in  association  with  endocar- 
ditis. 

A  rare  complication  of  pneumonia  is  an  arthritis  resend)ling  rhciinui- 
tism,  which  may  como  on  gradually  during  the  disease  or  in  tlie  couva- 
lescence. 

BriyhCs  disease  docs  not  often  follow  pneumonia.  Peritonitis  is  ex- 
ceedingly rare. 

liclapsc  in  pneumonia  is  so  uncommon  that  some  good  observers  liavo 
doubted  its  occurrence.  I  have  never  seen  an  insUiiu-e  in  which  I  was 
certain  that  there  was  a  definite  relapse.  There  are  cases  in  wliich  fnun 
the  ninth  to  the  eleventli  day  the  fever  subsides,  and  after  the  tonipora- 
turo  has  been  normal  for  a  day  or  two,  a  rise  occurs  and  fever  may  ]H'rsi>t 
for  another  ten  days  or  even  two  weeks.  Though  tliis  niigiit  l)e  termed  ii 
relapse,  it  is  more  correct  to  regard  it  as  an  instance  of  an  anomalous 
course  of  delayed  resolution.  Wagner,  who  has  stiuiied  the  subject  ciu-c- 
fully,  says  that  in  his  large  experience  of  1,100  cases  he  met  willi  only 
3  doubtful  cases.  When  it  docs  occur,  the  attack  is  usually  abortive  ami 
mild. 

Recurrence  is  more  common  in  pneumonia  than  in  any  other  aciito 
disease,  liush  gives  an  instance  in  which  there  Avere  twenty-eigiit  attacks. 
Other  authorities  mirrato  cases  of  eight,  ten,  and  even  more  attacks. 

Formerly  it  was  much  disjiuted  Avliether  ordinary  lobar  pneumonia 
ever  terminated  in  pulmonary  piithisis.  These  arc  really  cases  of  tuhor- 
culo-pneumonic  phthisis  the  onset  of  which  may  resemble  acute  pneu- 
monia. 

Clinical  Varieties. — A  number  of  dilTerent  forms  of  pneumonia  liavo 
been  recognized,  such  as  malignant,  atlynamic,  bilious,  malarial,  rheu- 
matic, and  the  like,  but  they  scarcely  recpiire  a  full  description.  A  main- 
rial  jmeumoiiia  is  described  and  is  thought  t()  be  very  prevalent  in  some 
parts  of  this  country.  Although  I  have  seen  during  the  past  seven  years 
several  huiulred  cases  of  malaria  and  am  familiar  with  the  bronchial  trou- 
ble so  commoidy  associated  with  it,  I  have  yet  to  see  an  instance  of  i)mni- 
monia  which  seemed  in  any  way  connected  with  paludism.     The  so-callod 


PNEUMONIA. 


525 


rlu'umatio  pncnmonia  luis,  so  far  as  I  know,  no  necullaritics  ;  nor  has 
ihciiinatism,  I  think,  any  special  relation  to  the  disease.  The  term 
t\|)h()iil  pneimoniu  is  commonly  used  to  designate  cases  with  adynamic 
HViiiptonis  and  it  is  to  he  distinguished  from  those  cases  in  Avhich  typhoid 
t\'\i'r  begins  with  u  definite  i)neum()nia,  the  so-cuWvd  p7ieitvio-(i/j)huf<  of 
fiircign  writers",. 

Ki)i(lemic  pneumonia  is,  as  a  rule,  more  fatal  and  may  display  minor 
peculiarities  which  dilTer  in  dilferent  epidemics.  In  some  the  cerebral 
complications  are  marked  ;  in  others,  the  cardiac.  There  may  he  diarrlura. 
The  pneumonia  which  occurs  with  infiuenza,  and  was  so  common  in  the 
last  epidemic,  presents  no  special  features  other  than  the  peculiarities  of 
oiisi't.  Perhaps,  also,  it  was  more  severe  and  more  fatal.  In  diabetic 
patients  j)neumonia  runs  a  rapid  and  severe  course,  ending  sometiines  in 
iibscess  or  gangrene.  In  the  sul)jects  of  chronic  alcoholism  the  onset  of 
piininionia  is  insidious,  the  symptoms  may  be  masked,  the  fever  slight, 
;i!i(l  Uie  clinical  })icture  may  be  that  of  delirium  tremens.  So  latent  ia 
the  tliseaso  in  some  of  these  cases  that  the  thermometer  alone  may  indi- 
cate the  presence  of  an  acute  disease. 

At  the  extremes  of  life  jmeumonia  presents  certain  well-marked 
fi'utnres.  It  is  sometimes  seen  in  the  new-born.  In  infant.'i  it  very 
often  sets  in  with  a  convulsion.  The  summit  of  the  lung  seems  more 
frecpuMitly  involved  than  in  adults  and  the  cerebral  symptoms  are  more 
marked  throughout.  The  torpor  and  coma,  i)articularly  if  they  follow 
convulsions,  and  the  preliminary  stage  of  excitement,  may  lead  to  the 
(liiignosis  of  meningitis.  Holt  has  recently  published  figures  which  indi- 
cate that  lobar  piunimonia  is  not  uncommon  in  infants  under  two  years  of 
age.     rneumonic  sputum  is  rarely  seen  in  children. 

In  old  (if/e  pncMunonia  nuiy  be  latent,  coming  on  without  chill ;  the 
cough  and  ex{)ectoration  are  slight,  the  physical  signs  ill-defined  aiul 
cliiingcal)le,  and  the  constitutional  symptoms  out  of  all  proportion  to  the 
extent  of  the  local  lesion. 

When  pneumonia  is  prevailing  extensively,  particnilarly  in  jails  and 
^Mirisoiis,  cases  are  found  which  have  some  of  the  initial  symptoms  of  the 
(liscii<c — perhaps  a  slight  chill,  moderate  fever,  and  a  few  indefinite  local 
siirus.  This  is  the  so-called  larval  ])iieumonia.  Apex  pneumonia  is  said 
to  he  more  dften  associated  with  adynamic  features  and  with  marked 
ccrchral  symptoms.  The  expectoration  atid  cough  may  be  slight.  I  can- 
not say  that  in  my  exju^rieiu'c  the  cerebral  symptoms  in  adults  have  been 
more  marked  in  this  form,  iu)r  do  I  think  it  necessarily  graver  than  if 
situated  at  the  base. 

The  ireeping  or  mi;/rafori/  j)noumonia  successively  involves  ono  lobo 
iittiT  the  other  and  is  a  peculiar  and  well-recognized  variety. 

Ihniblr  pneumonia  presents  no  peculiarities  other  than  the  greater  dan- 
ger connected  with  it.  The  term  mafisive  pneumonia  is  applied  to  the  rare 
condition  in  which  not  alone  the  air-cells  but  the  bronchi  of  the  entire 


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520 


DTSEASKS  OP  TDK   UKSPiriATOUY  SYSTEM. 


lol)o  or  cvoii  of  tlio  luii;;  ;iro  iWhd  with  tlio  fihriiiou.s  cxudato.  The  aus- 
cultatory Ki^j^ns  aro  nl)S('nt ;  tluTo  is  iK'itiicr  fremitus  nor  tubular  broiilli- 
i:ig,  and  oji  poroussion  tlio  lung  \i  alwolutcly  ilat.  It  olosoly  roseiiililos 
pl(M)risy  witli  olTiision.  The  inoulds  of  tlio  bronclii  may  bo  oxpnctoratnl 
ill  violent  fits  of  I'oughing. 

Prognosis. — lu  a  <liHease  wbicli  earriea  ofT  one  in  every  four  or  (ivci 
of  those  attacked  the  prognosis  in  a  largo  number  of  cases  la  necessarilv 
grave.  In  children  and  in  healthy  adults  the  outlook  is  good.  In  tlu' 
debilitated,  in  drunkards,  and  in  the  aged  the  chances  are  against  recovcrv. 
So  fatal  is  it  in  the  latter  class  that  it  has  been  termed  the  natural  end  ut 
tho  old  man.  Many  circumstances,  of  course,  influence  i)rognosis,  par- 
ticularly the  extent  of  tho  disease,  tho  height  of  the  fever,  the  presence  of 
other  diseases,  and  the  occurrence  of  comjilications. 

When  a  lower  lobe  on  one  side  or  tlio  lower  and  middle  lobes  of  tlic 
right  side  are  involved  in  a  liealthy  adult,  if  there  are  no  complications, 
tho  case  usually  proceeds  to  satisfactory  resolution.  >reningitis  is  a  fatal 
complication.  Endocarditis  is  oxtrenudy  grave,  much  more  so  than  peri- 
carditis, from  which  many  cases  recover.  Early  signs  of  heart-failiiro, 
dilatation  of  tho  right  chamber,  gradual  cyanosis,  and  o'dema  of  the  lung's, 
are  symptoms  of  the  most  serious  i-haracter.  As  before  stated,  the  danger 
of  heart-clot  is  not  great  in  pneumonia.  The  risk  is  in  the  extreme  dis- 
tention of  the  right  chandler.  I  believe  the  firm  fibrinous  coagida  en- 
tangled in  the  ccdumnsw  carnea^  and  the  valves  are  invariably  ])ro(iii('i(I 
during  tho  death  agony.  When  there  are  symptoms  of  abscess  of  the  lung 
or  of  gangrene  the  jirognosis  is  extremely  ])ad  ;  yet  cases  are  on  record  of 
recovery  from  both  these  conditions.  Increasing  rapidity  of  respiration, 
with  ditHculty  in  expectorati(m,  very  li(|uid  and  dark  sputa,  a  low  nuittcr- 
ing  delirium,  dry  tongue,  and  failing  pulse,  with  a  sulfused  lividity  of  the 
face,  arc  indicative  of  apjiroaching  dissolution.  Death  rarely  occnrs 
from  direct  interferenco  with  the  function  of  respiration,  though  it  may 
happen  in  cases  of  exteiisive  double  pneumonia.  In  a  majority  of  ciisoi 
the  fatal  result  is  brought  about  by  gradual  heart-failure,  whether  induicd 
by  the  prolonged  action  of  tho  fever,  the  s])ecitic  action  of  tho  poison,  or 
paralysis  due  to  overdistension  of  the  right  ventricle.  A  collateral  anieniii 
of  the  uninvolved  portion  of  the  lung,  so  much  spoken  of,  rarely,  I  believe, 
occurs  in  pneumonia  ;  nor  is  it  likely,  if  the  observations  of  Wehdi  ujmii 
the  production  of  this  condition  are  correct,  that  in  the  course  of  jnieii- 
monia  the  left  ventricle  can  bo  disproportionately  weak  in  conipaiison 
with  the  right. 

Termination. —  Resoh((ion,  the  process  by  which  tho  lung  is  restored 
to  its  normal  state,  is  effected  partly  by  expectoration  and  partly  by  lique- 
faction and  absorption  of  the  exudate.  It  is  not  always  possi))lo  to  esti- 
mate the  share  respoctively  taken  by  these  processes.  Thoro  are  (nises  in 
which  a  rapid  resolution  of  extensive  consolidation  takes  place  witliout 
any  special  increase  in  tho  expectoration  ;  and,  on  tho  other  hand,  during 


11 


PNEUMONIA. 


527 


resolution  it  is  not  uncommon  to  find  in  the  exppotorution  tlio  little  pluj^'s 
(if  librin  and  li'ucocytos  which  have  lu'cn  loosi'iicd  front  tho  air-cells  uiul 
cxucllcd  by  c()U{,'hiii^.  In  a  majority  oi  cases  both  processes  are  probably 
at  work.  A  variable  time  is  taken  in  the  restoration  of  the  lun^'.  Sonie- 
tinies  within  a  week  or  ten  days  the  dulness  is  f,'reatly  diminished,  the 
lircalh-sounds  become  clear,  and,  so  far  as  physicial  si<rns  are  any  fTuide, 
tlu'  lull"'  seems  perfectly  restored.  It  is  to  be  remembered  that  in  any 
case  of  pneumonia  with  extensive  pleurisy  a  certain  amount  of  dulness 
will  persist  fo!  montlus,  owing  to  thickening  of  tl'.e  pleura.  Dvlaycd  rexo- 
lulioii  is  a  condition  wiiich  causes  much  anxiety  to  the  physician.  Itnuiy 
lie  postponed  until  the  fourth,  eighth,  or  even  the  tenth  week.  I'sually 
the  fever  subsides,  but  the  consolidation  of  the  lung  may  persist,  with 
{,M-eat  improvement  in  the  general  condition  of  the  patient.  In  apex 
pneumonia  the  resolution  is  more  apt  to  be  retarded.  It  has  been  stated 
tliiit  bleeding  is  one  cause  of  delayed  resolution.  A  solid  exudation  can 
persist  for  weeks  ami  yet  the  integrity  of  the  lung  may  be  idtimately  re- 
stored, (i  rissole  describes  the  lung  from  a  patient  who  died  on  the  six- 
tietli  day  in  which  the  affected  part  looked  not  unlike  the  acute  disease. 

. I //.vrcNS  may  result  from  })urulent  infiltration  of  the  lung  tissue.  It 
(lecinred  in  4  of  my  lOU  cases.  I'sually  the  lung  breaks  in  limited  areas 
iuul  the  abscesses  are  not  large,  but  they  luay  iiivolvi'  a  considerable  por- 
tion of  a  lobe.  This  most  serious  complication  is  imlicated  by  cavern- 
ous signs  and  the  expectoration  of  purulent  nuiterial  containing  elastic 
tissue.  The  constitutional  symptoms  are  usually  very  severe.  In  a  large 
majority  of  the  clinical  cases  in  which  abscess  of  the  lung  is  believed 
to  follow  an  acute  })neumoiiia,  the  process  has  in  reality  been  rapid  tuber- 
eulous  consolidation  with  breaking  of  the  lung  tissue.  There  can,  how- 
ever, be  no  reasoiuible  doubt  that  abscess  of  the  lung  does  occur  as  a  rare 
sequence  of  ordiiuiry  pneumonia. 

(uin;/rriie. — 'i'he  presence  of  this  complication  is  rendered  evident  by 
the  horribly  fetitl  odor  of  the  expectoration,  the  presence  of  lung  tissue, 
and  crystals  of  fatty  acids.     It  occurred  in  ',]  of  my  100  autopsies. 

Fihruid  Tnduration. — That  a  chronic  interstitial  pneumonia  may  fol- 
low the  ordinary  acute  disease  cannot  be  questioned,  though  it  is  jirobably 
the  rarest  of  all  terjuinations.  It  was  present  in  one  of  my  100  auitopsies. 
The  [)atient,  aged  fifty-eight,  died  on  the  thirty-second  day  after  the  initial 
ehill.  The  right  lung  was  uniforndy  solid,  grayish  in  color,  firm,  anil 
[iresented  in  places  a  translucent,  smooth,  honu)geneous  aspect.  In  these 
areas  the  alveolar  walls  were  thickened  and  the  fibrinous  l)Iugs  filling  the 
air-cells  were  undergoing  transformation  ivito  a  new  growth  of  connective 
tissue. 

Mortality. — Pneumonia  is  one  of  the  most  fatal  of  acute  disea.scs. 
Hospital  statistics  show  that  the  mortality  ranges  from  twenty  to  forty 
per  cent  Of  1,013  cases  at  the  Montreal  (ieiu'ral  Hospital,  tlic  mortality 
was  2U-4  per  cent.     It  appears  to  be  somewhat  more  fatal  in  southern 


.'.'■.;i. 


>  ^H 


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v4  ■  It 

'       ^       fin* 


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ti4lj 


528 


niSKASES  OF  TIIK  RKSPIUATORY  SYSTEM. 


n?. 


n 


'  '  V    4*1 


dinmtos.  Of  ;{,!)()!)  chs(m  treatod  at  the  Churity  Hospital,  New  OtlcaiiH, 
the  (U'lith  rate  was  28-01  per  cent.  It  lius  btTii  iir^'cd  tlmt  the  mortality 
in  tliis  disease  has  l)een  steadily  increusinir,  and  attempts  have  heen  made 
to  conneet  this  increase  with  the;  expectant  plan  of  treatment  at  presiMit 
in  vogue.  Hut  the  careful  and  thorough  analysis  hy  ('.  N'.  'I'ownseiul  and 
A.  Ooolidge,  Jr.,*  of  1,000  eases  at  the  Massachusetts  (ieneral  Hospital 
indicates  clearly  that,  when  all  circumstances  are  taken  into  consideratinii, 
this  conclusion  is  not  jiistilied.  They  found  that  when  all  fatal  cases 
over  llfty  years  of  age  were  omitted,  and  those  patients  who  were  deiicati', 
intemperate,  or  the  suhject  of  some  eomi)lication,  there  was  very  little 
variation  from  decade  to  decade,  and  that,  excluding  these  oases,  the  rate 
was  but  little  over  ten  per  cent.  In  answer  to  the  assertion  that  the 
modilied  treatment  is  in  jiart  nspfmsihle  for  the  increasetl  mortality,  these 
authors  show  clearly  that  the  risc^  in  death  rate  took  place  in  the  jM'iiud 
prior  to  18G0,  when  the  treatment  was  entirely  or  in  great  i)art  heroic. 

Acconling  to  the  recent  analysis  of  T08  cases  at  St.  Thomas's  IFcspital 
hy  TTadden,  H.  W.  (J.  McKeiizie,  and  \V.  W.  Ord,  the  mortality  ])rngress- 
ively  increases  from  the  twentieth  year,  rising  from  ',i-7  per  cent  under 
that  age  to  22  per  cent  Iti  the  third  decaile,  .'JO-8  per  cent  in  the  fourth, 
47  per  cent  in  the  fifth,  51  per  cent  in  the  sixth,  05  per  cent  in  the  sev- 
enth decade. 

Diagnosis. — No  disease  is  more  dily  recognized  in  a  large  majutity 
of  the  cases.  The  external  character;^,  the  sputa,  and  the  jjliysical  sigius 
combine  to  make  one  of  the  clearest  of  clinical  pictures.  After  a  study 
in  the  post-mortem  room  of  my  own  and  others'  mistakes,  I  thiidv  that 
the  ordinary  lobar  i)neumonia  of  adults  is  rarely  overlooked.  .luiLnnjj; 
from  my  autopsy  records,  I  should  say  that . errors  are  particularly  lialilo 
to  occur  in  the  intennirrent  jtneutncnwas,  in  those  comnlicating  clinuiie 
affections,  and  in  the  disease  as  met  with  in  children,  the  aged,  and 
drunkards.  Tul)erculo-pneumonic  jdithisis  is  frequently  confounded  with 
pneumonia.  Pleurisy  with  eflusicm  is,  I  believe,  not  often  mistaken  ex- 
ce])t  in  children. 

In  diabetes,  Hright's  disease,  chronic  lieart-disease,  pulmonary  phthisis, 
and  cancer,  an  acute  j)noumonia  often  ends  tlu!  scene,  and  is  frequently 
overlooked.  In  these  cases  the  temj)erature  is  perhaps  the  best  index, 
ami  should,  more  ])articularly  if  cough  develops,  lead  to  a  careful  exami- 
nation of  the  lungs.  The  absence,  however,  of  expectoration  and  suino- 
times  the  entire  absence  of  pulmonary  symptoms  makes  a  diagnosis  very 
dilKcuH. 

In  children  there  are  two  special  sources  of  error ;  the  disease  may  bo 
entirely  masked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one 
of  meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there 
are  of  pulmonary  trouble.     The  other  condition  is  pleurisy  with  etTusion, 

*  Boston  Medical  and  Surgical  Journal,  1889. 


PXKUMO.VIA. 


620 


whii'li  ill  <liil«ln'n  nffm  Ims  (Icccntivc  physiciil  sii^nis.  Tlic  Imnithing 
iiiiiv  1)0  intensely  tnhnlar  and  tactilo  fivniitiis  may  lie  present.  The 
('xitlijnit(trv  neetllo  is  sometimes  rer|nire<l  to  decide  the  question.  In  tho 
olil  and  deltilitattul  a  kno\vledi,M(  tliat  the  onset  of  jinennionia  is  insidious, 
nii'l  tliat  the  syniptoms  are  ill-defiiK  d  and  Iat(>nt,  Klionld  place  the  practi- 
tidMcr  on  his  ^ruard  and  nnikt^  hitn  very  earefu!  in  tin-  examination  of  the 
liintrs  in  douhtful  cjises.  In  chronic  alc'dinlism  the  cerchral  symptoms 
iii;i\  predoMiinute  and  cojupletely  nunk  the  local  disease.  As  mentioned, 
tlic  disease  may  ;i>snme  the  form  of  violent  mania,  hut  more  commotdy 
tlie  syn.;'toms  are  those  of  delirium  tremens.  In  an\  case  rapid  pulse, 
rapid  respiration,  and  fever  are  sym|)toins  which  shouhl  invariahly  excite 
suspicion  of  inflammation  of  the  lungs. 

I'neiunonia  i.s  rarely  confounded  with  ordinary  consumijtion,  hut  to 
(lilTcrciitiatc  acute  tuherculo-piu'iimonic  phtliisis  is  often  dillu'ult.  The 
case  may  .sot  in  with  a  chill.  It  may  he  impossil)le  to  deti'rmino  which 
(■(iiidition  is  present  until  softenin;:  occurs  and  <dastic  tissue  and  tuhercio 
liai  ilH  a|>pear  in  the  sputum.  A  sinular  mistake  is  sometimes  nuide  in 
cliildreii.  With  typhoid  fever,  piu-nmonia  is  not  infre(piently  confounded. 
There  are  instances  of  pneumonia  with  the  local  signs  well  nuirked  in 
which  tho  jiationt  rapidly  siidvs  into  what  is  known  us  the  typhoid  state, 
with  dry  tongue,  rapid  pulse,  and  diarrluea.  Unless  tho  ca.so  is  seen  from 
thr  outset  it  may  ho  very  dilHoult  to  determine  the  true  nature  of  the 
malady.  On  the  other  haiul,  there  are  cases  of  tvphoid  fever  whieli  sot 
in  with  symptoms  of  lohar  j)iu".inii)nia — the  so-called  pneiimo-typluus.  It 
iiuiv  lie  impossihle  to  make  a  ditl'erential  diagiiosi*  in  such  a  case  unless 
the  characteristic  eruption  develops. 

Treatment. — Pneumonia  is  a  self-limited  disease,  and  runs  its  course 
iiniiillueuced  in  any  way  hy  medicine.  It  c:in  nc'ther  he  nhorteil  nor  cut 
short  l)y  any  known  nmans  at  our  command.  E  en  under  the  most  un- 
favoral)lo  circumstances  it  will  terminate  ahruptly  and  naturally,  without  a 
dose  of  niodioine  having  heen  administered.  A  patient  was  admitted  into 
ono  of  my  wards  at  the  Philadelphia  IFospil  d  on  the  eveiung  of  the  seventh 
(lay  after  the  chill,  in  \vhi(di  he  had  heen  seen  hy  oiu'  of  my  assistatits,  who 
had  onhred  him  to  go  to  hospital,  lie  remained,  however,  in  his  house 
aloiu",  without  assistance,  taking  iu)tliing  hut  a  littlo  milk  and  bread  and 
whisky,  and  was  hrought  into  the  hospital  hy  the  p(dice  in  a  condition  of  act- 
ive delirium.  That  night  his  tempi'ratur(>  was  K).")"  and  his  pulse  ahovc  120. 
In  his  delirium  he  came  near  escai)ing  through  the  wiiulow  of  the  ward. 
The  hdlowing  morning — the  eighth  day — the  crisis  occurred,  and  at  ward 
cla:^s  his  temperature  was  below  98".  The  entire  lower  lobe  of  the  right 
side  was  found  involved,  and  he  entered  upon  a  rapid  convalescence.  So 
also,  under  the  favoring  eircumstaiu'es  of  go(jd  nursing  and  careful  diet, 
the  ex[K'rience  of  many  physicians  in  dilTerent  laiuls  has  shown  that  pnon- 
monia  runs  its  course  in  a  definite  time,  aborting  sometimes  spontaneously 
ou  the  third  or  the  fifth  day,  or  continuing  until  the  tenth  or  twelfth. 


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530 


DISEASES  OF  THE  UKSnUATOUY  SYSTEM. 


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Wo  hiivo,  tlipn,  no  Hpof-ilk-   frciitnicnt  for    pnouniotiiii.      In  cases  (jf 
niodc'iitp  Hcvcrity  a  purely  cxpoctaiit  i)liiM  jnay  bo  followed — keopiii;r  ii,,, 
bowels  open,  re^'tiliitin^  tlio  diet,  and,  if  neee8«a»*y,  j,'ivin<,'  a  Dover's  |i.p\v- 
der  at    iii;,dit  to  procure  sleep.      In   severer  cmhor  a  syuiptoniutic  plan  df 
treatment  sli(»tild  be  pursued,  niectin<,'  tbe  indications  as  they  arise.     Tli,. 
tirst  distressing,'  symptom  is  usually  the  pain   in   the  side,  which  may  he 
relieved  by  local  dei)letion — by  cuppin;;  or  leechinj; — or,  better  still,  hy  ;i 
hypodermic  injection  of  morphia.     In  imiiiy  cases  the  (piestion  coriics  up 
at  thi;  outset  as  to  the  propriety  (tf  vetu'section.     The  reproach  of  \"ari 
lleluKUit,  that  "a  bloody  Moloch  presides  in  the  chairs  (»f  medicine,"  can- 
not be  broujrht  a,crainst  tlio  present  generation  of  physicians.     During  the 
first  five  dei'ades  of  this  century  the  profession  l»led  too  much,  but  diiriufr 
the  last  decades  we  have  certainly  bled    too  little.     Pneumonia  is  one  cf 
the  diseases  in  which  a  timely  venesection  may  save  life.     To  be  of  service 
it  sliould  be  doiu*  early.     In  ii  full-bloo(l(>d,  healthy  man  with  high  fever 
and  bounding  pulse  the  abstraction  of  from  twenty  to  thirty  ounces  of 
blood  is  in  every  way  beiu'ficial,  relieving  the  pain  ami  dyspno'a,  reducing 
the  temi)eraturo,  and  allaying  the  cerebral  symptoms,  so  violent  in  some 
instances,    rnfortiinately,  in  a  majority  of  the  cases,  bleeding  is  now  uscij 
at  a  late  stage  in  the  disease,  when  the  heart  i.s  beginning  to  fail,  the  right 
cliiiiid)ers  are  dilated,  the  face  is  of  a  dusky  hue,  the  respirations  are  very 
rapid,  aiul  tlu'n^  are  signs,  perhajts,  of  (cdema  of  the  uniiivolvcd  portiims 
of  the  lungs.     Though  resorted  to  rather  us  a  forlorn  h(»pe,  it  is  a  rational 
practice,  and,  in  cases  of  emphysema  and  of  heart-(liseaso,  j)roves  satisfac- 
tory under  identical  hydraulic  indications,  but,  unfortunately,  in  a  luajor- 
ity  of  the  cases  of  pneumonia  it  proves  futile.     Time  and  again,  in  such 
oaaos,  have  I  urged  free  venesecti(»n,  but  in  twelve  hospital  patients  liicd 
uiuler  these  circumstances  only  one  recovered. 

In  the  majority  of  cases  requiring  treatnu-nt  the  indications  are  tn 
lower  the  temperature  and  to  8U])port  the  heart. 

Fever  alone  is  not,  T  think,  hurtful ;  but  if  is  dinicult  to  dilTerciitiati' 
the  effects  of  fever  and  of  the  poisons  circulating  in  il'c  blood.  It  is  not 
imj)ossible,  us  sonu'  suppose,  that  the  fever  may  be  directly  beiiedcial; 
still,  high  and  prolonged  pyrexia  is  undoubtedly  dangerous  and  sliouM  he 
combated.  Of  efficient  measures  cold  un(|uestionably  heads  the  list. 
l*erhai)s  the  most  convenient  way  is  th(>  application  of  ice-bags  to  tlio 
affected  side — a  practice  long  followeil  in  (iernumy  and  now  becdniiiii,' 
prevalent  in  England  and  America.  When  the  temperature  is  above  Hi'f 
or  lOS'S"  sponging  may  be  resorted  to.  If  the  high  fever  is  combined 
with  brain  symptoms  the  bath  at  T(i°  may  be  used  without  risk. 

The  use  of  medicinal  antipyretics  in  j)neumonia  is  of  doubtful  pro- 
priety. (Quinine  has  been  much  vaunted.  I'er.soiuilly  I  cannot  speak  cf  any 
special  advantages  which  I  have  .seen  from  its  use.  From  thirty  to  sixty 
grains  daily  will  reduce  the  temperature,  iu  a  certain  proportion  of  the 
cases,  one  or  two  degrees,  but  in  this  respect  it  is  far  below  other  antipv- 


PNEUMONIA. 


531 


rotirs.  It  id  also  not  without  ill  ('(Tcrts  in  (listurbin;;  difjoslioii  or  even 
ciuisiii^'  vdiuitin^,  atid,  ufcdnliii;^  to  some  writi'fs  — tli(>u;;li  this  I  havu 
luMi"  lutticcd — iiului'in;,'  marked  cardiac  wraktu'ss  aixl  dcjtrt'ssioii.  Aiiti- 
pyriti,  untifcbrin,  and  phoiiacctiti  have  luid  ii  thorou<{h  trial  in  pni'tiiiionia, 
iiiiil,  allln)ii;,'li  they  Htill  have  tlu'ir  advocates,  the  ^jeiieral  ojiiiiion  of  clini- 
cal phv.sician.s  seems  decidedly  a^'ainst  tlu'ir  systematic  employmi'nt. 

'I'he  jirojjressive  cardiac  weakness  is,  after  all,  the  niKsl  imiMirtant 
I'luinv  to  light  in  pneumonia  and  is  emi)hasize(l  by  tho  old  axiom,  Siiic 
jttilsit  nulla  t/ienipcin.  Doubtless  this  is  in  part  caused  by  the  fever,  but 
iiuuh  m(»re  impdrlant  is  the  t(»xic  action  of  the  puisnns  pnxluccd  in  tho 
I'diirse  of  the  disease.  'I'o  these  must  be  addi-d  the  third  factor,  over- 
(listeiilion  of  the  ri;,fht  ehandjers  of  the  heart.  We  are  still  without  an 
iiirciit  which  can  counteract  tho  grailual  inlluence  of  the  poisons  which 
develop  in  tho  course  of  acuto  fobrilo  diseases,  8Uch  as  typhoid  fever, 
|iiu'tnnonia,  and  diphtheria,  the  chief  elTect  of  which  is  exercised  upon 
liie  circulation,  inereasinj^  tho  rapidity  of  llu!  pulse  and  indncin;,'  a  pro- 
},'ri'ssive  heart-failure.  To  meet  this  indication  the  general  experieiu-e  of 
liliysieiuns  still  points  to  alcohol  as  tho  most  trustworthy  remedy.  Although 
some  hold  that  alcohol  in  this  condition  is  not  indicated,  1  believe  that  it 
is  in  numy  instances  the  only  renu'dy  capable  of  tiding  tho  i)atient  over 
tlu'  most  dangerous  period.  It  slujuld  be  given  when  the  pnls(>  becomes 
Kiiiall,  frequent,  and  feeble,  or  very  compressible,  and  when  the  heart- 
sdiuids — particularly  tho  second  pulmonic  sound — begin  to  lose  their 
force.  The  amount  will  vary  with  tho  age  of  tho  palii'iit  and  with  his 
luiliits.  Beginning  with  four  to  six  ounces  in  the  day  the  (pumtity  may 
l)c  increased,  if  necessary,  to  twelve  or  sixteen  or  even  twenty  ounces. 

Of  medicinal  agents  strychnine  is  one  of  tho  most  valuab' j  and  has 
conu'  into  favor  as  u  useful  cardiac  tonic.  It  may  bo  given  in  doses  of 
fnnu  a  thirtieth  to  a  twentieth  of  a  grain.  \o  certainty  has  as  yet  been 
reached  as  to  tho  value  of  digitalis  in  the  failing  heart  of  fever.  'I'lie 
pruetico  is  very  general,  but  it  is  a  drug  to  bo  used  with  caution  in  this 
condition.  When  there  aro  signs  of  sudden  or  rapid  heart-failure,  hypo- 
ilcniiic  injections  of  ether  will  sometimes  i)rove  most  serviceable.  Of 
iitlicr  stiiiudants  ammonia  is  one  of  the  most  valuable  and  is  l)est  given  in 
tho  form  of  tho  aromatic  s[)irits,  whicdi  is  (piite  as  satisfactory  and  inucdi 
less  nauseous  than  the  usually  administered  carbonate  of  ammonia.  Cam- 
phor  and  nuisk  may  also  be  employed. 

Fnlliiwing  the  practice  which  is  employed  in  spreading  erysi[)elas, 
some  writers  have  rocommeiuled  direct  antiseptic  inje(!tions  into  the  lung 
tissue  itself.  Lepine  has  used  with  benelit  very  dilute  bicddoridc  injec- 
tions. In  eases  of  gangrene  following  pneumonia,  it  might  be  of  advan- 
t!i;H'  to  use  iodoform  oil  or  bichloride  solutions. 

The  question  of  the  use  of  arterial  sedatives  has  not  yet  bi'cn  settled. 
Aconite  ami  veratrum  viride  and  tartar  emetic  are  largely  used  and  loudly 
rcconiinended  by  many  physicians.    I  have  uover  s^eu  such  bouetlt  from 


!'  ;•,   'l-'      i 


532 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


w 

1 

tlii'ir  early  use  a.-i  would  wiirnuit  a  rcoommoiidiition,  and  wlu-n  an  artoriul 
si'dativo  is  iiidiwited  in  t^'^  robust,  full-blooded,  houlthy  ii'dividual,  1  niudi 
prefer  the  lanoet. 

Jvxpeclorants  are  rarely  of  any  value  in  pneumonia.  If  any  one  wishes 
to  be  eonvineed  (*f  the  futility  of  such  remedies,  let  him  study  their  actidii 
oil  a  series  of  cases  of  sthenic  pneuiiionia,  in  which  it  would  be  a  real  ;:;uii 
to  loosen  tlic  cough  and  give  to  the  sputa  a  certain  degree  of  lluidilv.  Nor 
in  the  stage  of  resolution  can  tuey  be  said  to  be  of  uny  special  service.  In 
cases  of  tardy  resolutio"  I  have  noi,  he^itated  to  use  i)ilocar])ine,  as  su". 
gested  by  Kie.ss. 

For  the  distressing  cough  and  the  pain  in  the  side,  opium  in  sonu'  form 
may  be  given,  cither  the  hyjiodermic  of  nu)r])hia  or,  for  the  cough  alone, 
Dover's  jtowder.  There  has  berMi  a  feeling  in  the  profession  thai  ojiiuni  was 
counter-indicated  in  pneumonia,  l)ut  1  fully  agree  with  Looniis  that  it  may 
be  given  with  sal'i'ty  and  with  the  greatest  comfort  to  the  i)alient.  \\  iih 
marked  cerebral  symj)toms  an  ice-t  ap  may  be  u.sed.  1  f  there  is  delirium,  the 
patient  shoidd  be  <'an'fully  watched.  For  these  symi)toins  th.e  cold  b.itli  is 
by  far  the  most  eilicient  renu'dy,  and  it  or  the  cold  pack  .should  be  resorted 
to  without  he  -'ation.  For  the  complications,  in  the  more  .serious  ones, 
such  as  meningitis  ami  endocarditis,  l)ut  Utile  can  be  done.  I'leiirisv 
with  large  effusion  may  rccpiire  aspiratioii.  If  then;  is  doubt  as  to  the  ex- 
istence of  iluid  the  exploratory  needle  should  be  used.  It  may  be  neres- 
sary,  in  pericarditis  with  extensive  elTusion,  to  aspirate  the  sac. 

f'arcful  feeding  forms  an  essential  i)art  of  the  treatment.  The  diet 
should  be  light  and  made  up  of  articles  whicdi,  wliile  nourishing,  are  :iot 
heavy  and  not  apt  (o  induce  flatuleiu-y.  Milk  or  milk-whey,  b -otlis, 
beef-juice,  and  eggs  constitute  the  main  articles  of  food.  The  starchy 
articles,  as  a  rule,  should  be  excliuled,  because  they  tend  to  iiuluce  flatu- 
lency. If  the  milk  also  has  this  eflVi'f,  it  is  better  to  u.se  the  whey  and 
egg-white  or  beef-juices.  IJefore  leavin;.;  the  question  of  diet  it  may  be 
mentioned  that  the  use  of  cold  drinks,  such  as  soda  or  Aiiollinaiis  water, 
not  only  gives  relief  to  the  distressing  thirst,  but  also  helps  to  r.ducc  tliu 
fever,  ami  may  diminisli  slightly  the  viscidity  of  the  expectoration. 


III.   CHRONIC   INTERSTITIAL  PNEUMONIA 

{Cirrhosis  of  Lung). 

Tliis  consists  in  the  gradual  sul)stitution  to  a  greater  or  less  extent  of 
connective  tissue  for  the  normal  lung.  It  is  a  fibroiil  change  which  may 
have  its  starting  point  in  the  tissue  about  the  l)ro)udii  and  blood -ves-seLs, 
the  interlobular  .septa,  the  alveolar  walls,  or  in  the  pleura.  So  diverse  are 
the  ditfe.ent  forms  .ind  .so  varied  the  conditions  under  which  this  change 
occurs  that  a  j)roper  cla.ssi(icaticn  is  extremely  ditlicult.  We  may  rocog- 
uizo,  however,  two  chief  forma — the  local,  which  involves  only  u  'imited 


,i|  ',r 


CHRONIC  INTERSTITIAL  PNKUMONIA. 


533 


area  of  the  lung  suhstimce,  and  the  dijj'u.^e,  invadin'^  cither  both  lungs  or 
iiu  entire  organ. 

Etiology. — Local  fibroid  cliaiige  in  the  lungs  is  common.  It  is  a 
constant  accompuniment  of  tuborele  and  in  every  ease  of  jilithisi^*  tho 
oliniiiic  interstitial  changes  play  a  very  important  rolr.  In  tumors,  al)- 
scos-',  "Uinmata,  hydatids,  and  emphysema  it  also  occurs.  l''il)roid  pro 
('{'ssis  are  frequently  mot  with  at  tiie  api(!es  of  the  lung  and  may  he  due 
(itli  •!•  to  a  limited  healed  tul»erculosis,  to  lihroitl  iiiduration  in  eonse- 
nuen(X>  of  |)igment,  or,  in  a  few  instances,  may  result  from  thickening  of 
tlio  pleura. 

/h'fl'use  Intemtitial  Pncutnouia  is  met  with  under  the  following  cir- 
oniiistanees :  1.  Asa  sequence  of  acute  fibrinous  pneumonia.  Although 
oxticnicly  rare,  this  is  recogi\l/ed  as  a  possible  termination.  From  un- 
known causes  resolution  fails  to  take  i)lace.  A  gradual  proci'ss  of  organ- 
izatiiiii  goes  on  in  the  librinons  pluj>  .vithiii  the  air-cells  and  tlic  alvolar 
Willis  become  greatly  thickened  by  a  new  growth,  lirst  of  nuclear  ami 
sul)se(|uently  librillated  connective  tissue.  .Macroscopically  there  is  pro- 
iliKTil  a  smooth,  grayish,  honn^geneous  tissue  wlii(di  has  the  peculiar  translu- 
ci'iuv  of  all  new-formed  connective  tissne.  Tiiis  has  been  called  gray  in- 
ilurution.  The  subse<pient  history  of  this  form  n(>eds  more  careftd  study. 
\  majority  of  the  cases  terminate  within  a  few  months,  and  instances 
'.vliicli  have  been  followed  from  tlu;  outset  are  very  rare. 

Ill  one  of  Charcot's  cases,  (pioted  by  Hastian,  death  occurred  about 
three  inontlis  and  u  half  after  the  onset  of  the  aeute  disease  aiul  the  lung 
was  two  thirds  the  normal  size,  grayish  in  color,  and  hard  as  cartilage.  In 
the  only  case  of  the  kind  which  has  (N)me  under  my  observation,  the  pa- 
liiMit  (lied  about  ii  month  from  the  onset  of  the  chill.  The  lung  was  uni- 
fiiriiily  solid  ;.;•  I  grayish  in  color.  In  certain  regions  the  llbrinous  mouhls 
in  the  air-cells  were  f-itt^y,  wliile  in  others  there  were  areas  of  a  grayish 
translucent  aspect,  firm,  smooth,  not  at  all  granular,  and  resembling  recent 
connective  tissue,  ^licroscopically,  these  areas  showecl  advanccij  libroiil 
ehnnixe  and  great  thick(Miing  of  the  alveolar  Widls,  while  the  librin  plugs 
of  [\w  air-cells  were  undergoing  fibroid  transformation. 

'i.  Chronic  /{ronr/i))-/'neuini)in'(f. — The  relation  of  bnmdio-pneunKmia 
1 )  (ivrhosis  of  the  lung  has  been  specially  studied  by  Charcot,  who  states 
tliat  it  may  follow  tho  acute  or  subacute  form  of  this  discasi'.  'i'hc  fibrosis 
I'Xt. 'litis  from  tho  bronchi,  which  are  usually  found  dilat^'il.  The  alveolar 
walls  are  tliii;kened  and  tlu;  lobules  converted  into  firm  grayish  masses, 
in  which  there  is  no  truce  of  normal  lung  tissue.  This  process  may  go  on 
I'.iui  involve  au  entire  lobo  or  even  the  whole  lung.  Many  of  these  cases 
iiiv  tuberculous  from  the  outset. 

:!.  Phnrogciioidi  fiifersfifial  Pnriniinm'ii.  -OMircnt  applies  this  term 
I)  that  fo  lu  of  cirrhosis  of  the  lung  which  follows  iiivasioTi  from  tho 
pKiini.  Doubt  has  been  expressed  by  some  writers  whether  this  really 
occurs.     While  Wilson  Fo.v  is  probably  correct  in  questioning  whether  aa 


'u¥  !l 


534 


I)ISf:ASES  OF  THi.   RESPIRATORY  SYSTEM. 


If 


entire  lung  ean  beeome  cirrhosod  by  tbc  gradual  invasion  from  tbe  pleura 
I  think  there  can  be  no  doubt  that  there  are  instances  of  primitive  drv 
pl(>urisy,  whicii,  as  Sir  Andrew  Clark  has  ])ointed  out,  i^raduallv  cum. 
presses  tiie  lun^  and  at  the  same  time  leads  to  interstitial  cirrhosis.  'I'his 
nuiy  be  due  in  part  to  the  fibroid  change  which  follows  prolonged  cdni- 
pression.  In  some  cases  there  seems  to  be  a  distinct  connection  iKtwccu 
tlie  greatly  thickened  pleura  and  the  dense  strands  of  fi])rons  tissue  jiass- 
ing  from  it  into  the  lung  substance,  histaiu-es  occur  in  which  one  Idlic 
or  the  gri'ater  piirt  of  it  presents,  on  section,  a  mottled  apjiearauce,  owiutr 
to  the  increased  thickness  of  the  interlobular  septa — a  condition  which 
may  exist  without  ii  trace  of  involvment  of  the  pleura.  In  many  other 
eases,  however,  the  extension  seems  to  be  so  (h'liiutely  Mssociati'd  with  ph-ii- 
ri.sy  that  tiu-ri'  is  no  doul)t  as  to  the  causal  coniu'ctioii  between  the  twn 
processes.  In  these  instances  tiio  lung  is  removed  with  great  ditlicnhv, 
owing  to  the  thickness  and  clo.se  adhesioi\  of  the  pleura  to  tlu'  chest  wnll. 

4.  C/iroitir  hitrrstitud  Piicumania^  due  to  iidudation  of  dust.  Zenker 
has  pro()osed  the  term  /)iini»io)i(ik(t//i(isi.^  for  the  group  of  diseases  due  to 
the  irritating  effects  of  dust,  in  certain  occupations,  sui'!;  as  coal-iuinin<r, 
stone-cutting,  axe-grinding,  and  working  in  iron  dust.  It  is  essentially  u 
chronic  l)ronclio-piu'umonia  leading  to  fibroid  iiuliiration,  at  first  lUMlular 
and  pt'ribronchial,  .ind  fimilly  involving  large  areas  of  the  lung  ti.ssiie, 
which  ar(>  converted  into  dense  grayish-brown  or  black  masses.  The  suh- 
ject  will  rtceive  separate  consideration. 

'I !  '  term  cirrhosis  should  be  limited  strictly  t"  those  cases  in  v.hieli 
a  lung  is  involved  in  the  fibroid  jirocess,  whetlu'r  origiiuiting  in  the 
parenchyma  or  in  the  pK'ura.  It  should  not  be  applied  to  fibroid  phtlii-i< 
of  tulieri'idous  origin. 

Morbid  Anatomy.  -'I'he  disease  is  uinlateral ;  the  chest  (if  the 
affected  side  is  sunken,  defonned,  aiul  the  shoiddcr  much  depre.'Jsed.  On 
opening  the  thorax  the  lieart  is  seen  drawn  far  over  to  the  affected  side. 
Tlu'  unafTcctcd  lung  is  emphysematous  and  covers  the  greater  portinn  ef 
the  mediastinum.  It  is  scarcely  <'rcdil)le  in  how  snudl  a  spare,  close  to 
the  spine,  the  cirrhosed  lung  may  lie.  Indci'd,  it  may  be  overlnuked.  as 
liappciU'd  ill  the  t-ase  of  a  physician  of  my  acipiaintance,  who  left  instnic- 
tions  that  his  lung  should  l»e  sent  to  Palnu-r  Howard,  of  .Montreal.  It 
was  reported,  however,  that  :it  the  autopsy  no  lung  coidil  lie  found  I  Tiie 
adhesion?  between  the  pleural  nu'inbranes  may  be  «'xtremely  (Wn^i'  iim! 
thick,  i)arlii'idiirly  in  the  pleurogenous  cases :  but  when  the  disease  li:is 
originated  in  the  lung  there  iiuiy  be  little  thickening  of  the  pleiiia.  I  ln' 
orgim  is  airless,  firm,  and  hard.  It  stronixly  resists  cutting,  and  on  section 
shows  a  gravisli  fibroid  tissue  uf  varialilc  amount,  through  which  p.ass  the 
blt)o(l-vessels  aiul  broiu'hi.  The  latter  may  be  eilher  slightly  or  enor- 
mously dilated.  There  are  instatu'cs  in  which  ilie  entire  lung  is  eonverleil 
into  a  series  of  broufihiectatie  cavities  ami  the  ciirhosis  i.s  appiu'cnf  onlv 
in  certain   areas  or  at  the   ro'it.     'I'he  tuberculous  cases  can  usnallv  lie 


ln|mP' 


f|,'H||,| 


CnilONIC   INTERSTITIAL   PNEUMONIA. 


680 


iji  ■ 


(li.riMTiitiutod  by  the  proscnco  of  iiii  apical  cavity,  not  l)r(»nciiioetivtic,  nnd 
(iftcu  largo;  and  tlic  other  luii<r  almost  invariably  shows  tuber,  uloua 
livsions.  There  are  eases  in  which  it  is  (lil}i(nilt  to  tletenniiie  sutisfacitorily 
^  the  true  nature.  A  question  of  some  interest  in  eoniu'ction  with  ehroiiio 
interstitial  pneumonia  is,  Do  softeniiij,'  and  cavity  formation  ever  occur 
aiiart  from  caseation  and  tuberculosis?  That  is  to  say,  are  there  cuvitica 
ill  ;i  cirrhotic  lung  wliicli  may  be  duo  to  a  simi)Ie  necrosis?  l'udoul)tedly, 
thou;,di  they  are  rare;  I  have  seen  them  in  at  least  two  instaiuvs  of  un- 
tliracosis,  and  Charcot  *  refiTi  t:)  theui  as  "  iiIcc/tk  da  jioumon,'''  U)  d\A- 
tiii;;tiish  them  from  the  abscess  cavity  of  acute  pneuiiionia  or  a  tuberculous 
cavity.  The  other  lunj;  is  always  gnnitly  enlarged  ami  emphysematous. 
The  heart  is  hypertropiiied,  particuhirly  t!ui  right  veutri.de,  and  there 
iiiav  he  marked  atheromatous  chang(>s  in  the  ])uhnonary  artery.  An 
iUiivluid  I'onditioii  of  tlu>  vis(;cra  is  found  in  some  cases. 

Symptoms  and  Course. — It  is  essentially  a  chronic  disease,  ox- 
tending  over  a  period  of  many  years,  and  when  once  tin  citndition  is 
cstaldishod  the  health  may  be  fairly  gi)od.  In  a  well-marked  ca.se  the 
jiatii'iit  (  omplaii\s  o)dy  of  his  chronic  cough,  jierhaps  of  slight  shortness 
ot  lircath.  In  other  respects  ho  is  (piite  well,  and  is  usiudly  able  to  do 
light  work.  The  cases  are  commonly  regarded  as  phthisical,  though  there 
may  he  scarcely  a  .symptom  of  that  a1f(>ction  except  the  cough.  There 
arc  instances,  however,  of  fibroid  phthisis  which  cann-zt  be  distiiigui<hr(l 
fi'din  cirrhosis  of  the  lung  except  by  the  presence  of  tubercle  bacilli  in 
the  expectoration.  As  the  i)ronchi  are  usually  dilated,  the  symptoms  and 
jiliysical  signs  nuiy  be  those  of  liroiichiectasis.  The  cough  is  paroxy.snud 
and  the  expectoration  is  generally  copious  and  of  muco-[)urulent  or  sero- 
jinrnlcut  nature.  It  is  sonu'times  fetid,  ilat'iorrbage  is  by  no  means 
infro<|nent,  and  occurred  in  more  than  one  half  of  the  casi's  analyzecl  by 
Hastian.  Walking  (m  the  level  and  in  the  onliiuiry  adairs  or  life  the  patient 
may  show  no  shortness  of  breath,  but  in  the  ascent  c»f  stairs  and  on  exer- 
tidii  I  here  may  be  dyspno*a. 

Physical  Signs. — fiisprrfinii. — The  affected  side  is  immoldlc.  retracted, 
and  shrnidscii,  and  contrasts  in  a  striking  way  with  the  volununous  souml 
.Mdf,  The  intercostal  spaces  an;  obliterated  and  the  rib  ,  may  oven  over- 
l.ili.  The  shouliler  is  drawn  down  and  from  behind  it  is  seen  that  the 
.-^jiint'  is  bowed.  The  heart  is  greatlv  displaced,  bein'_'  drawn  over  by  tlui 
slirinkage  of  the  lung  to  the  alTccted  side.  When  the  left  lung  is  afToted 
tlicre  nniy  be  a  large  area  of  visible  impidse  in  tin-  .si-cond,  tliini.  and 
f'lnlli  interspaces.  .Mensuration  shows  a  great  diminution  in 
siili',  and  with  the  saddle-ta)»e  the  expitusioii  imiy  be  si'cn  to  be  n 
Tile /i(;v')/,s',«,'/();/  note  varies  with  the  condition  of  the  brontdii.  It  ma^  no 
iilisiilntily  ilull,  parti  .iarly  at  the  bane  or  at  the  apex.  In  the  axilla 
there  m«y  bo  u  Hat  tympany  or  even  an  amphoric   note  over  a  largo 


H^'tt.^ 


'pp' 

'% 

4 

11 

i 

1 

n 

)  ! 


(1    is 


CKuvrog  complClL'S  do  .1   51.  ('Imrcot,  tnmo  v,  |).  1' '.). 


»;^  . 

1lii 

H 

686 


DISEASKS  OF  TIIK   RESPIRATORY  SYSTEM. 


Baoculiiti'd  broncluis.  On  tlic  opposite  side  tUo  percussion  note  is  nsiiallv 
liypcrresonant.  On  uiisculla/ion  the  bruuth-soiiiuls  liavo  cither  a  civ- 
(•rnous  or  iunplioric!  (piality  at  tlie  upcx,  and  at  tlie  base  arc  feeble,  wiih 
imicous,  l)iil)biiiifr  rules.  Tlie  voiee-sounds  arc  usually  exajriferated.  Car- 
diac nuiniiiirs  are  not  unconiinon,  particularly  late  in  the  disease,  \\\\vn 
the  right  heurt  fails.  These  are,  of  course,  the  idiysical  signs  of  the  di:. 
ease  Avlieu  it  is  well  established.  They  naturally  vary  considerably,  ar- 
cording  to  the  stage  of  the  i)roeess.  The  disease  is  essentially  chronic, 
and  may  persist  for  tifteen  or  twenty  years.  Death  occurs  .sometimes  fnnii 
lia'inorrhage,  more  commoidy  from  gradual  failure  of  the  I'ight  heart  willi 
dropsy,  and  occasionally  from  amyloid  degeneration  of  the  organs. 

The  diiiijnosis  is  never  dillicult.  It  may  be  impossible  to  say,  without 
a  clear  history,  whetlu'r  the  origin  is  ])leuritic  or  piUMinumic.  Hetwrcn 
ca.ses  of  this  kind  and  libroid  jihtliisis  it  is  not  always  easy  to  discriminate, 
as  the  coiuliti()n.s  may  bo  almost  identical.  When  tuberculosis  is  ])reseiit, 
liowever,  even  ii\  long-.><tanding  cases,  bacilli  arc  usually  present  in  the 
Kputa,  and  there  mav  be  signs  of  disease  in  tbe  other  lung. 

Treatment.  —  It  is  oidy  for  an  intercurrent  alTection  or  for  au  w^'jsw.. 
vation  of  tlu^  cough  that  the  ])atient  seeks  relief.  Xothing  can  be  done 
for  the  condition  itself.  When  i)os.sible  the  patient  should  live  in  a  mi!! 
climate,  ami  should  avoid  exposure  to  cold  ami  damp.  A  distressiir: 
feature  in  some  cases  is  the  ))utrefaction  of  the  contents  of  the  dilatcil 
tubes,  for  which  the  same  measures  nuiy  be  used  as  in  fetid  bronchitis. 


\' 


IV.    BRONCHO-PNEUMONIA   {('apiUary  Bronchitai). 


This  is  essentially  an  innammation  of  tlie  terminal  bronchus  and  the 
air-ve.sicles  which  make  up  a  pulmonary  lobule,  whence  the  term  broiiclio- 
pneumonia.  It  is  also  known  as  lobular,  in  contradistinction  to  lobar  pneu- 
monia. The  term  catarrhal  is  less  a])i)licable.  The  ))rocess  begins  in  ;il! 
cases  with  an  inllamnudion  of  the  capillary  broneiu,  which  is  a  conditio  i 
rarely  if  ever  found  without  involvement  of  the  lobidar  structures,  so  tliitt 
it  is  now  customary  to  consider  the  affections  together. 

Etiology.  —  l{roncho-])neumonia  is  as  a  rule  a  secondary  aiTv'etinn 
nii-t  with  under  the  following  circumstances  : 

1.  As  a  sequenci!  of  the  infectious  fevers — measles,  diphtlu'ria,  wIkkiI)- 
{ng-(;ough,  scarlet  fever,  and,  less  frequent'y,  small-pox,  erysipelas.  ;;iul 
typhoiil  fever.  In  ehildri'n  it  forms  the  most  serious  compli-'ation  ef 
these  dist'ascs,  and  in  reality  causes  more  deaths  tban  are  due  directlv  *e 
(lie  fevers.*  In  large  citi(^s  it  ranks  lu-xt  in  fatality  to  infantile  tliarrh.ia. 
Following,  as  it  does,  the  contagious  diseases  which  ])rineipally  alT' 
children,  we  find  that  a  large  majority  of  cases  occur  during  early  \~- 


Cyclopa'diu  of  tlie  Disoascs  of  Children,  vul.  ii. 


BIIONCIIO-I'NEUMONIA. 


537 


According  to  Morrill's  Boston  statistics,  it  ii  most  fatal  diirinj,'  tlu;  first 
t\V(t  years  of  life.  The  nuinbor  of  cases  in  a  community  increases  or  de- 
creases with  the  prevalence  of  measles,  scarlet  fever,  and  diphtheria.  It  is 
most  prevalent  in  the  winti'r  ai'.d  spring  months.  In  the  febrile  alTections 
of  adults  broncho-pneumonia  is  not  very  common.  Thus  in  typhoid  fever 
it  is  not  so  fre(|uent  as  lobar  j)neum())iia,  though  is(dated  areas  of  consoli- 
dation at  the  bases  are  by  no  means  rare  in  protracted  ca.ses  of  this  disease. 
In  old  people  it  is  an  extremely  common  alTection,  following  di'bilitaling 
causes  of  any  sort,  and  supervening  in  tlu^  course  of  chronic  Bright's  dis- 
ease and  various  acute  and  chronic  maladies. 

2.  In  the  second  division  of  this  alTection  are  embraced  the  cases  of 
so-called  aspiration  or  deglutition  piu'umonia.  Whenever  the  sensitive- 
ness of  the  larynx  is  benuPibed,  as  in  the  coma  of  apoplexy  or  ura-mia, 
minute  parti(  les  of  food  or  drink  are  allovved  to  pass  the  rm<^  and,  reach- 
infi  iinally  the  smaller  tubes,  excite  an  intense  inllanimation  similar  to  the 
valgus  pneumonia  which  loUows  the  section  of  the  pne\unogastrics  in  the 
ddjf.  Cases  are  very  common  after  operations  about  the  moutii  and  nose, 
after  tracheotomy,  and  in  cancer  of  tli((  larynx  and  (I'sophagus.  The 
asiiinitetl  parti(des  in  some  instances  induce  such  an  intense  broncho- 
piieuniv  nia  that  supi»uration  or  even  gangrcjie  supervenes. 

;{.  The  most  common  and  fatid  form  of  broncho-pneumonia  is  that 
excited  by  the  tubercle  bacillus,  which  has  already  been  considered. 

Among  general  pre(lis|iosing  causes  may  be  mentioned  age.  As  just 
noted,  it  is  prone  to  attacdv  infants,  and  a  majority  of  cases  of  piu'umonia 
in  children  uiulcr  five  years  of  age  are  of  this  form.  At  the  ojtposite 
extreme  of  life  it  is  also  common,  ])articularly  in  association  with  various 
debilitating  circumstances  and  chronic  diseases  incident  to  tiie  old.  In 
children  rickets  and  diarrluea  are  marked  |>re(lisp(,sing  causes,  and  bron- 
(■ho-iuiennionia  is  one  of  the  most  fre(pient  post-moi'tt'Ui-room  lesions  in 
infants'  homes  and  foundling  asylums.  The  disease  ])rovails  more  exten- 
sivel\  among  tho  poorer  classes,  because  their  cbiMren  are  of  necessity 
nmre  i'X|>(ised  and  cannot  have  the  needful  care  and  nursing,  particularly 
uficr  fi'uptive  fevers. 

Morbid  Anatomy. — In  the  lungs  of  a  child  dead  of  bronchu- 
imetnuonia,  after  measles  or  diiditheria,  tho  appearances  are  very  charac- 
teristic. ()i\  the  ideural  surfaces,  ])articularly  toward  the  base,  arc  seen 
depressed  bluish  or  blue-brown  areas  of  collajise,  lietween  wbi(di  tho  lung 
ti-;sue  is  of  a  lighter  color.  Here  and  there  are  projecting  [lorlions  over 
whirh  the  jdeura  nuiy  bo  slightly  turbid  or  graiuilur.  The  lung  is  fuPer 
an(!  lirmer  than  normal,  and,  tlnuigh  in  great  part  crepitant,  there  can  be 
f>'lt  in  plaei'S  througliout  tlm  su!)stance  solid,  nodular  bodies.  The;  dark 
ili'pri'ssed  areas  may  bo  isolated  or  a  large  section  of  one  lobe  nuiy  be  in 
the  condition  of  collajjse  or  atelectasis,  (iradual  inilation  l)y  a  blo\v-j)ipe 
inoort(;d  in  tho  bronchus  will  distend  a  great  majority  of  these  collai)sed 
areas.    On  section,  tho  general  surface  has  a  dark  reddish  color  and  usu- 


^   H     i'lM 

■M^l 

ill 

■ 

■ 

ll'l 

m 

1 

i 

tfcT 

m^'t;:i'>.i 


i/  ^,  I  i. ' 


^a 


538 


DISEASES  OP  TIIK  RESPIRATORY  SYSTEM. 


liWy  drips  Mood.  Projecting  ubove  tlio  level  of  the  section  are  lighter  nd 
or  nMldi.sli-gray  areas  rei)resontiiig  the  ]tatelu'.s  of  broiieho-pneumonia. 
These  may  l)e  isohited  and  sei)araled  from  each  other  hy  tracts  of  iiniii- 
f]a»ned  tissne  or  they  may  1)0  in  groups  or  the  greater  jiart  of  a  lo])o  nuiv 
he  involve(L  Study  of  a  favoraitk'  section  of  an  i^solated  ]»atch  sliows:  {n) 
A  dilated  central  hronchiole  full  cf  tenaciourt  purulent  nuu-UH.  A  fortu- 
nate section  parallel  to  the  long  axis  may  show  a  racemose  arrangeiiu'iit 

the  alveolar  jiassages  full  of  miu-o-pus.  (//)  Surrounding  the  hroucluis 
for  from  '.i  to  i>  mm.  or  even  more  is  an  area  of  grayish-red  consolidation, 
usually  elevated  above  the  surface  and  firm  to  the  toucli.  Uidiko  the 
consolidation  of  lobar  ))neumonia,  it  may  ])resent  a  ])erfectly  smooth  sur- 
face, though  in  some  instances  it  is  distinctly  granular.  In  a  hite  stage  of 
the  disease  small  grayish-white  ])oints  nuiy  be  seen,  which  on  pressure  inav 
be  sfjueezed  out  as  purulent  droplets.  A  section  in  the  axis  of  the  lolnilc 
may  present  a  somewhat  gra))e-like  arrangement,  the  stalk  and  steins 
representing  the  bronchioles  and  alveolar  jiassagea  filled  with  a  yellowish 
or  grayish-white  pus,  while  surrounding  them  is  a  re<Idish-brown  he|iati/(il 
tissue,  (r)  In  the  immediate  neighborhood  of  this  jwribronc-hial  iiillain- 
mation  the  tissue  is  dark  in  color,  smootli,  .lirless,  at  a  somewhat  lower 
levi'l  than  the  hei)atized  portion,  and  differs  distinctly  in  color  and  ap- 
])earance  from  the  other  portions  of  the  lung.  This  is  the  condition  to 
which  the  term  .■<jilnii:(i/io)i  has  been  given.  It  really  represents  a  tissue 
in  the  early  stage  of  inllanimation,  and  it  jjcrhaps  would  be  as  well  to  give 
u])  the  use  of  thi<  term  and  also  that  of  cti ru ijiraf ion, which  is  clya  mere 
advanced  stage.  The  condition  of  collapse  jsrobably  always  ])reeedes  this, 
and  it  is  dilVicult  in  some  instanci's  to  tell  the  dilfcreiu'c,  as  one  shades  into 
the  other.  In  fact,  collapse,  spleni/ation,  and  carnilication  may  be  said  in 
broncho-pneumonia  to  bo  steps  preliminary  to  the  condition  of  actual 
he])atization.  , 

While,  in  many  ca.ses,  the  areas  of  broncho-pneumonia  present  a  red- 
dish-l)rown  color  and  are  indistinctly  granular,  in  others,  parlienlarly 
in  adults,  the  nodides  nuiy  resend)le  more  closely  gray  hi'[)ati/alioii  and 
the  air-cells  are  filled  with  a  grayish,  muco-purulent  nuiterial.  Miinite 
luvmorrhages  are  sometimes  seen  in  the  neighborhood  of  the  inthmuMl 
areas  or  on  the  j)leural  surfaces.  Kmphysema  is  commoidy  seen  at  the 
anterior  Itorders  and  upper  ])ortions  of  the  hnig  or  in  lobides  adja<i'nt  to 
the  inllanu'd  oiu-s.  In  nuiny  cast's  following  dii)htheria  and  measles  tiii' 
jirocess  is  so  extensive  that  the  greater  i)art  of  a  lobe  is  involvcil,  ami  il 
looks  like  a  case  of  lobar  hejiatization.  It  has  not,  however,  the  unifoini- 
ity  of  this  alTi'ction  and  collapsed  dark  strands  maybe  seen  bet\vc(  n  ex- 
tensive! areas  of  hepatized  tissue. 

i'ractieally,  in  thi'  morbid  anatomy  of  hroiKdto-pneumonia  in  children 
we  i<ia\  recognize  three  groups  of  cases:  (1)  Those  in  whiih  tlir  liron- 
chilis  and  bron*dii<ditis  are  mo^t  marked  and  in  which  there  nuiy  lie  iie 
definite  consrdidation  and  yet  on  micr'Kseopical  examinutictu  nuiny  of  the 


RHON'CHO-PNEUMOMA. 


539 


alveolar  passafjos  and  adjacent  air-cells  appear  fdled  witli  inflammatory 
nr.Mlucts.  {'i)  'i'lu!  disseminated  hronclio-pnenmoiiia,  in  which  there  aro 
sca'.tfred  areas  of  peribronchial  hepatization  with  patcthes  of  collapse, 
while  a  considerable  proportion  of  the  lobe  is  still  creititant.  This  is  by 
far  ihe  most  common  condition.  {',])  I'seudo-lobar  form,  in  which  tho 
iM'eiiter  portion  of  tho  lolie  is  consolidated,  but  not  uniforndy,  for  inter- 
vciiiii"  strands  of  dark  congested  lung  tissue  separate  the  groups  of  hepa- 
ti/,e(l  lobules. 

Ill  the  secondary  broncho-pnoumoiwa  of  adults,  it  is  generally  tho  dis- 
seiniiiiited  form  which  is  seen. 

.Microscopically,  a  cross  section  of  a  small  broncho-pneumonic  focus 
shows  the  following  changes:  In  the  centre  is  a  bronchus  tilled  with  a 
plug  of  exudation,  consisting  of  leucocytes  and  swollen  epithelium.  Sec- 
tion in  the  long  axis  nuiy  show  irregular  dilatations  of  the  tui)e.  The 
hroiieliial  wall  is  swollen  and  inliltratcd  with  cells.  Under  a  low  ])ower  it 
i.s  reailily  seen  that  the  air-cells  next  the  bronchus  are  most  densely  filled, 
while  toward  the  periphery  of  the  focus  the  alveolar  exudation  becomes 
less.  The  contents  of  the  air-cells  are  ma<le  up  of  leucocytes  and  swollen 
fiiiiotiielial  cells  in  varying  j)roportion.  Ui-d  corpuscles  are  not  often 
present  and  a  lil)rin  network  is  rarely  seen,  though  it  may  be  present  in 
some  alveoli.  In  the  swollen  walls  are  seen  distended  capillaries  and 
munerous  leucocytes.  As  Delatield  has  pointed  out,  the  interstitial  iti- 
lliitimiation  of  the  bronchi  anrl  alveolar  walls  is  a  special  feature  of 
liroiiilio-pueumonia  which,  distinguishes  it  from  tlie  ordinary  croupous 
fori  II. 

The  histological  changes  in  the  asi»iration  or  deglutition  broncho- 
imeuiiioiiia  dilTcr  from  the  ordinary  post-febrile  form  in  a  more  intense 
iiililtiiition  of  the  air-cells  with  leuco<\vtes,  producing  suppuration  and 
fnei  lit"  ,M)l'tening,  and  even  tending  to  gangretie. 

Hroncho-pneiinuMua  may  terminate  (1)  in  mso/«/w«,  which  wh(>n  it 
oiifo  begins  goes  on  more  rapidly  than  in  librinous  j)neumonia.  Broncho- 
pneiiiiiMiiJa  of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks, 
paiti.iiliirly  if  it  follows  measles  or  diphtheria,  is  often  tubercidous.  In 
these  iii.staiices.  when  resolution  is  supposed  to  be  delayed,  caseatiim  has 
111  reality  taken  jilace.  {•>)  In  .s?//7»»m//u«,  which  is  rarely  seen  aj)art 
fi'eiii  the  aspiration  and  deglutition  forms,  in  which  it  is  extremely  crmi- 
Mioii.  (.I)  In  //<///// /v;/f,  which  occurs  under  the  .same  c<mditions.  (4)  In 
fil'i-itit/  r/iKui/rs — c/ii'itin'r  bn>H'/i()-/)neniiHinifi — a  rare  termination  in  the 
siiiiiile.  a  I'oinmon  serpience  of  the  tulierciilous  disease,  l-'ormerly  it  was 
'lii'iiLnit  that  one  of  the  most  common  changes  in  broiicho-jnieumonia, 
l'i'i''"iilarl\  in  childri'n,  was  caseation;  l)iit  this  is  really  a  tuberculous 
l"''"|'>s,  the  natural  termination  of  an  originally  sp»  .'ilic  bmncho-pneu- 
'""I'lii-  It  is  of  course  (|uitc  possible  that  a  broncho-pncunxmia,  simple 
'"  i'<  origin,  may  subsecjuently  bo  tho  scat  of  infection  by  tho  bacillus 
ti(bi'ni(totiii<. 

35 


x~\ 


m-f, 


I      >. 


640 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


lil  -  ^ 


iltiii 


Symptoms. — Mudi  confusion  has  arisen  from   tlw^  dcsoription  nf 
capillary  bront'liitis  a.s  a  Knparatc   ullcction,   whereas  it  is  only  a  p.irt. 
thniijfh  a  priiiiiiry  luid  important  one,  of  broncho-pneumonia.      At  (Ik- 
outset  it  may  he  said  that  if  in  convalescenco  from  measles  or  in  \vlnxih- 
inj^-(;oUf,di  a  child  has  an  accession  of  fever  with  c(»u<,di.  rai:id  j)ulse,  anil 
rapid  hreathin<,%  and  if,  on  uuricjultation,  fino  rales  are  heard  at  the  hasts, 
or  widely  spread  tlirou<j;hout  the  luii^fs,  even  though  neither  consolidaliun 
nor  Idowing  hreathing  can  he  detected,  the*  diagnosis  of  hroiu^ho-piicii- 
monia  may  safely  he  made.     1  have  never  seen  in  a  fatal  case  after  dipli- 
theria  or  measles  a  capillary  l)ronchitis  as  the  sole  lesion.     Tiie  onset   is 
rarely  sudden,  or  with  a  distinct  chill ;  hut  after  a  day  or  so  of  indis- 
position the  child  gets  feverish  and  begins  to  cough  and  to  get  sliort  of 
breath.     The  fever  is  extremely  variable;  a  range  of  from  H)'i°  to  |(t4"  is 
common.     'I'he  skin  is  very  dry  and  pungent.     'I'he  cough  is  hard,  dis- 
tressing, and  nuiy  bo  i)ainful.     I)y.s]»nica  gradually  becomes  a  jtroMiiiunt 
feature.     K.\})i ration  may  bo  jerky  aiul  grunting.     The  respirations  iiiav 
rise  as  high  as  (10  or  even  HO  in  the  nnnute.     Within  the  first  forty-eight 
liours  the  pi'rcussion  resommce  is  not  impaired  ;  the  note,  indeed,  inav  lie 
vory  full  at  tho  anterior  borders  of  tlm  lungs.     On  auscultation,  iiiaiiv 
rdles  are  heard,  chiefly  tlie  fine  8ubcre])itant  variety,  with  sibilant  rhoiiclii. 
There  may  really  he  no  signs  indicating  that  the  parenchyma  of  the  lung  is 
involved,  and  yet  even  at  this  early  stage,  Avithin  forty-eight  hours  df  the 
onset  of  the  pulmonary  symptoms,  I   have   repeatedly,  after  diphtheria, 
found  scattered  nodules  of  lobular  hepatization.     M(»rthrup,*  in  liis  thor- 
ough article  on  the  subject,  notes  a  case  in  which  death  occurred  within 
the  flrst  twenty-four  hours,  and,  in  addition  to  tho  extensive  involvement 
of  the  smaller  hnmchi,  the  intralobular  tissue  also  was  involved  in  ])hi(cs. 
'i'he  dyspmea  is  constant  and  progressive  and  .soon  signs  of  delicient  ai'Tu- 
tion  of  the  blood  are  noted.     The  face  bocomea  a  little  sutfused  and  the 
finger-tips  bluish.     The  child  has  aji  anxious  expression  and  gradually 
enters  upon  the  most  distressing  stage  of  asphyxia.     At  first  the  urgtiiiy 
of  the  symptoms  is  marked,  hut  soon  the  l)enuinbing  influeiu'c  of  tlic  car- 
bon dioxide  on  the  nerve-centres  is  seen  and  the  (duld  no  longer  makes 
strenuous  etforts  to  breathe.     The  cough  subsides  and,  with  a  gradual 
increase  in  lividity  and  a  drowsy  restlessness,  the  riglit  ventricle  become- 
more  and  more  distended,  the  lironchial  rales  l)ecome  more  liipiid  as  the 
tubes  fill  with  mucus,  and  death  occurs  from   heart  paralysis,     'i'luse  are 
the  symptoms  of  a  severe  case  of  broncho-pneumonia,  or  what  the  older 
writers  called  siifiHuifire  ratarrh. 

The  p/n/smil  v-V/z/n  may  at  first  he  tlioso  of  capillary  bronchitis,  as  in- 
dicated ])y  the  absence  of  dulness,  the  presence  of  fine  siibcrcpitani  ami 
whistliuir  rales.  In  nuiny  cases  death  takes  place  befori-  any  dclimlc  pneii- 
monic  signs  are  detected.     When  these  exist  they  are  much  more  fre(|iieiit 


Reference  Handbook  of  the  Mcdicivl  Sciences,  art.  nronclui-i'neiunoriiu. 


imON'CIlO-rNKUMONlA. 


541 


,!,  1'  ■' 


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h,.  oltler 

[is.  MS  ii>- 

[taut  iiii'l 

lillr  I'lH'H- 

fi\'(liii'l>t 

■  llli!^' 


i;t  tlio  Iniscs,  where  tlicro  niii\  la'  ar(>ii«  of  ittipuirod  rcsonniico  or  even  of 
posit i VI!  (liiliu'ss.  When  nuiiii'rous  foci  iiivolvi-  tlio  gn'iitcr  |iiirt  of  ii  lobe 
till'  brcalliitijj  iniiy  bcconK'  tiil)uliii',  l»ut  in  the  Hcuttered  luilflics  of  ordi- 
iiarv  liroiicho-piieiiinoiiiii,  followiiifj;  the  fevers,  tlio  bnditliiiif,'  is  more  com- 
iiiuiilv  harsh  than  blowing;.  In  <;rave  cases  tiuire  i.s  retraction  of  the  base 
(if  the  steriuun  and  of  tlie  lower  costal  cartilaj(es  diirin<(  inspiration,  point- 
iiiir  In  (jdicic^nt  bin;,'  expansion. 

Diagnosis. — With  lobar  juieunionia  it  may  readily  be  eonfonnded  if 
the  areas  of  eonsr)lidation  are  liir^'o  and  nutr^'d  together.     It  is  to  be  re- 
nu'ml)ered  Ihat  broncho-piiciiinonia  occurs  chielly  in  children   under  live 
vears  of  age,  whereas  lobar  piieiiinonia  in  children  i.s  nnieh  more  common 
iictwei'ii  the  ages  of  live  and  lifteen.     So  writer  has  so  clearly  brought 
(lilt  tlie  (lilTerence  between  ])neumonia  at  these  periods  as  (ierhard,*  of 
I'liiladelphia,  whose  papers  on  this  subject,  though  iiuhlished  nearly  sixty 
vcaiv  ago,  have  the  freshness  and  accuracy  which  eluinu'terize  all  the  writ- 
in^rsof  that  eminent  jjliysician.    Holt  ha.s  recently  brought  forward  ligures 
to  show  that  lobar  pneumonia  is  not  infre(juent  in  infants  under  two  years 
(if  age.     The  mode  of  onset  is  e.ssentially  dilferent  in  the  two  aifections, 
till'  one  developing  insidiously  in  the  eour.se  or  at  the  com-lusion  of  an- 
iitluT  (li.sea.se,  t\w  other  setting  in  abruptly  in  a  tdiild  in  good  health.     Ill 
Idiii.r  pneumonia  the  (lisea,se  is  almost  always  UTulatoral,  in  broncho-pneu- 
iiidiiia  bilateral.     The  chief  trouble  arises  in  eases  of  broncho-pneumo- 
nia, which  by  aggregation  of  the  foci  involves  the  groati'r  part  of  one  lobe. 
litre  the  (litliculty  is  very  great,  and  the  physical  signs  may  be  practically 
iiliiilical,  hut  in  a  broiicho-pneumoniu  it  is  umch  more  likely  that  a  lesion 
will  lie  found  on  the  other  side.     The  course  of  the  two  atTections  is  very 
iiiiliki  ;   the  lobar  pneumonia  in  children  terminates  on   the  eighth  or 
tfiiih  (lay  with  al)ruptness,  as  in  adnlts. 

A  still  more  diHicult  ([uestion  to  decide  is  whether  an  existing  broneho- 
imciiiiiuiiia  is  siniph'  or  tuberculous.  In  many  in.itanoes  the  decision  cum- 
iKit  lie  iiKKh',  as  the  circumstances  under  which  tho  diseu.so  oceuns,  tho 
iiuide  of  onset,  and  the  physical  signs  may  be  identical.  It  has  often  been 
my  (XiKMienee  that  a  ca.se  has  been  sent  down  from  tho  ehildreirs  ward  to 
till'  (lead-house  with  the  diagnosis  of  post-febrile^  broncho-pneumonia  in 
wiii'li  there  was  no  suspicion  of  the  existt^nce  of  tubertMilosis;  but  on  sec- 
tion there  were  found  tul)ercnlous  bronchial  glands  and  scattered  ureas  of 
liidiiclio-pneumonia,  some  of  which  were  distinctly  caseous,  while  others 
shiiwcd  signs  of  softening.  1  have  already  spoken  fully  of  this  in  the 
sol  ion  oil  tuberculosis,  but  it  is  well  to  emphasize  the  fact  that  thero 
arc  many  eases  of  broncho-pneumonia  in  children  which  time  alone  cn- 
iililcs  us  to  distinguish  from  tuberculosis.  The  existence  of  extensive  dis- 
liw  at  the  apices  or  central  regions  is  a  stiggestivo  indication,  and  signs 
iif  softening  may  be  detected.     In  the  vomited  nuittcr,  which  is  brought 


.■  'i 


;!|l 


*  American  Journal  of  the  Medical  Sciences,  vols,  xiv  and  xv. 


;.•f^5   3_:^ 


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'5!i'!:'    vi 


'I' 


542 


DISEASES  OF  THE  RESPIRATOllY  SYSTEM. 


up  after  spvcrc  kjk'IIs  of  cougliiiig,  .sputum  may  be  jticked  out  und  elastic 
tissue  and  l)aeilli  detected. 

It  JH  a  Huperlluous  rellnenuMit  to  make  a  diagnosis  hetwoon  eapillaiv 
l)roucliifis  and  ealairlial  piu-uinonia,  for  the  two  eonditions  arc  part  niid 
parcel  of  the  same  discasi'.  In  simple  hronchilis  involving  the  |jiii:(r 
tubes  urgent  dyspniea  and  ))ulnionarv  distress  are  rarely  j»rest!!it  and  the 
niles  arc  coarser  and  more  sii)ilant.  It  must  not  l>e  forgotten  thai,  ;h  in 
lobar  pneumonia,  cerel)ral  symptoms  may  imisk  the  true  nature  of  tlic 
disease,  and  nniy  even  lead  to  the  diagnosis  of  meningitis.  I  recall  miiiv 
than  one  instance  in  which  it  could  not  be  satisfactorily  delcrniincd 
wlietlier  tlie  infant  had  tuberculous  meningitis  or  a  cerebral  coniplicu- 
tion  of  an  acute  i)nlmonary  alTection. 

Prognosis.  —  In  children  enfeebled  Jty  constitntiojial  diseaseatid  pro- 
longed fevers  bnmcl  o-pneumonia  is  tt'rribly  fatal,  but  in  cases  coining 
on  in  conuection  with  whooping-cough  or  after  nu-asles  ri'coverv  niav 
take  place  in  the  most  de.spenito  ojises.  It  is  in  this  di.sease  that  (he  timli 
of  the  old  maxim  is  shown — "  i<ever  de-sjiair  of  a  sick  child."  The  deiitli- 
rate  in  ehililren  under  five  lias  been  variously  estiimited  at  from  tliirlv 
to  iifty  i)er  cent.  After  iliphtheria  and  measles  thin,  wiry  chiUlreii  seem 
to  stand  bromdio-pneumonia  much  bettvr  than  fat,  flabby  ones.  In  adults 
the  aspiration  or  deglutition  pneunu)nia  is  a  very  fatal  disease. 

Prophylaxis.  —  .Much  can  be  done  to  reduce  the  i)robability  of  attack 
after  fi'brilc  all'ections.  'JMuis,  in  the  convalescence  from  measles  ami 
whooping-cough,  it  is  very  imitortant  that  the  child  should  not  be  exposed 
to  cold,  partituilarly  at  night,  when  the  temperature  <d"  the  room  naturally 
falls.  In  a  nocturnal  visit  to  the  nursery — sometimes,  too,  I  am  soriv  \'> 
say,  to  a  children's  hospital — how  often  oii-c  sees  children  almost  naked, 
luiving  kicked  aside  the  bcdidothes  and  having  the  tught-(dothes  up  .iIhuiI 
the  arms!  The  use  of  liglit  tlaniud  "combinations"  obviates  this  noctur- 
nal ehill,  which  is,  I  am  sure,  un  important  factor  in  the  colds  and  pidnio- 
mvry  affections  of  young  children,  botli  in  ])rivate  houses  ami  in  institii- 
tion.s.  'I'he  cahirrhal  troubles  of  the  nosc^  and  throat  should  be  eareliilly 
attended  to,  and  during  fevers  the  mouth  should  be  washed  two  or  tlntr 
tinu's  a  day  with  an  antise|)tic  solution. 

Treatment.— 'I'he  frequency  and  the  seriou.sness  of  broncho-pneu- 
monia render  it  a  dii^ease  which  taxes  to  the  utmost  the  resources  of  tlio 
practitioner.  There  is  no  acute  ])nlmonary  alTection  over  which  lie  at 
times  so  greatly  despairs.  On  the  other  hand,  there  is  not  one  in  whi.li 
he  will  be  more  gratilieil  in  sjiving  cases  which  have  seemed  past  all  siiicur. 
The  geni'ral  arrangements  should  receive  special  attention.  The  rnem 
should  be  kept  at  an  even  temperature — about  05°  to  OS"— and  the  air 
shoidd  i)e  kept  moist  with  vapor. 

At  the  outset  the  bowels  should  be  opened  by  a  mild  purge,  cithor 
(rastor  oil  or  small  do.ses  of  calomel,  one  twelfth  to  one  sixth  of  a  grain 
hourly  until  a  movement  is  obtained,  and  care  should  be  taken  throughout 


BUON'CIIO-PNEL'MOXIA. 


543 


the  jiltiuk  to  HCMMire  a  diiily  inovcmcnt.    Tlu»  conunon  saliiio  fever  mixture 
(if  citrato  of  potuHli,  li(|Uor  aniiiioiiiiv  acetatis,  and  aroiiiati(^  spirits  of  aiM- 
riioiiia  may  be  jjivoti  evory  two  or  three  hoiirx.     If  tlio  disease  emiies  on 
iilinii>lly  with  hii^li  fever,  minim  or  minim  and  a  hidf  doses  of  tlie  tincture 
of  iironite  may  \n>,  ^dveii  with  it.    The  pain,  the  distressiuLf  >yinptoms,  ami 
tlh    iucessiint  eou^'h  often  (h-mand  opium,  wliicii  must  of  course  he  used 
wiih  ''iire  and  jud^Mueiit  in  tho  case  of  youn^  ehihlreii,  hut   which  is  ccr- 
taiiilv  not  contra-indicated  and   nuiy  hi-   usefully  j^iven   in   the  form    of 
!l(vser's  powder.     Ulisters  are  now  nirely  if  ever  employed,  and  e\cn  the 
jjicket  poultice!  has  ^'one  out  of  fashiori.     For  the  latter,  however,  I  c<in- 
fi'ss  to  a  stronj?  prejudice,  and  when  li^ditly  miide  and  fretpiently  clian<,'e(l 
it  iiiidouhtedly  gives  great  relief.     Much   more  commoidy  we  now  set', 
liiith   iu   privat(!  and  in   hospital    practice,   the  jacket  of  cottoii-hattinj,'. 
Icc-|)oultices  to  the  ciii'st  I  have  seen  used  apparently  with  great   hene- 
tit,  ami  they  are  warndy  recommended   hy  many  (Ji-rmaii  physicians  ah 
well  as  hy  (ioodhart  and  others   in    Kiitrland.     The  diet  slioidd   c<in>ist 
(if  milk,  broths,  and  egg  albumen.     Milk  often  curds  and  is  disagreeable. 
Ku'L'-uhite  is  particularly  suitable  and  very  acceptable  when  given  in  cold 
u:(t(r  with  a  littlf!  sugar.     It  forms,  indeed, an  excellent  medium  for  the  ad- 
tiiiiii.'iratiou  of  the  stimulants.     If  the  pulse  shows  signs  of  failing,  it  is  best 
to  liigin  early  with  brandy.     As  in  all   febrih*  alTections  of  children,  cold 
wiitir  should  be  constantly  at  the  bedside,  and  the  child  should  be  encour- 
au'i'il  to  drink  freely.     With  these  measures,  in  many  cases  the  disease  ])ro- 
gres-es  to  a  I'avorahk    ter!iiinati(»n,  but  too  often  other  and  more  seriouH 
syinpiiiins  arise.     Cough   beconu-s  more  distressing,   dyspiuea  increases, 
the  (iiiiinous  rattling  <if  tin;  mucus  can  be  heard  in  the  tubes,  the  child's 
coler  is  not  so  good,  and  there  is  greater  restlessness.     Under  these  cir- 
ciuiistances  stimulant  expectorants— aminoiua,  sipiills,  and  senega — should 
1)1'  iriveii.    Together  tlu-y  make  a  very  disagreeal)Io  dose  for  a  young  child, 
piirtii  ularly  with  the  carbonate  of  ammonia.     Tho  aromatic  spirits  of  am- 
iimiiia  is  somewhat  l)etter.    If  the  carbonate  is  employed,  it  must  be  given 
iu  <mall  (loses,  not  more  than  a  grain  to  an  infant  of  eighteen  months.     If 
till'  child  has  increasing  ditliculty  in  getting  up  the  mucus,  an  emetic 
slmuld  i»e  given — either  the  wine  of  ipecac  or,  if  necessary,  tartar  emetic. 
Tlicrc  is  no  neee.ssitv,  however,  to   keep  the  child  constantly  nauseated. 
KiKiagh  should  be  given  to  cause  prompt  emesis,  and  the  benetit  results  in 
ilii'  expulsion  of  mucus  from  the  larger  tubes.     In  this  stage,  too,  strych- 
nine i-i  undoubtedly  helpful  in  stimulating  the  de,  ressed  respiratory  cen- 
tre.    W  iih  commencing  cyanosis,  inhalations  of  oxygen  nuiy  be  employerl, 
soinctiuies  with  great  l)enefit. 

With  rapid  failure  of  th(^  lieart,  loud  mucous  rattles  in  the  throat,  and 
nicivasiiij,  li.idity,  every  measure  should  be  usi'il  to  arouse  the  child  and 
fxcite  ecughing.  Alternate  douches  of  hot  and  cold  water,  electricity, 
whicii  I  II. (ve  sjen  applie(l  with  good  results  at  Wiederhofcn-'s  clituc  in 
^  iiiiiia,  and  ijvpodermie  injections  of  ether  may  be  tried.    For  tho  reduc- 


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544 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


tion  of  temperature,  particularly  if  cerebral  symptoms  are  promiueut,  there 
is  nothing  so  satisfactory  as  the  wet  pack  or  the  cold  bath.  In  the  case 
of  children,  wlien  the  latter  is  used  it  should  be  graduated,  beginning  with 
a  temperature  which  is  pleasantly  warm  and  gradually  reducing  it  to  ^.V 
or  80°.  Even  when  the  temperature  is  not  high,  the  cerebral  symptuuis 
are  greatly  relieved  by  the  bath  or  the  pack. 


V.  EMPHYSEMA. 

Rupture  of  superficial  vesicles  may  produce  pneumothorax.  In  tlio 
case  of  deep-seated  alveoli  the  air  esca})es  into  the  interlobular  connective 
tissue  and  causes  a  condition  comparable  to  ordinary  subcutaneous  emphy- 
sema. It  is  not  a  very  serious  conilition  ami  rarely  ])roduoes  symptoms. 
It  usually  results  from  violent  expiratory  efforts,  as  in  whoo])ing-coiigli. 
The  air-bubbles  esca])e  into  the  interlobular  tissue,  in  which  they  iciok 
like  little  rows  of  beads,  and  when  extensive,  the  lobules  are  distinctly  out- 
lined by  them  (interstitial  emphysema).  There  may  be  large  bulUv  Ijc- 
neath  the  pleura.  A  very  rare  event  is  the  rupture  close  to  the  root  of 
the  lung  and  the  passage  of  air  along  the  trachea  into  the  subcutaneous 
tissues  of  the  neck. 

The  condition  in  which  the  infundibular  passages  and  the  alveoli  ;ire 
dilated  is  called  vesicular  empJiysetua. 

A  practical  division  may  be  made  into  compensatory,  h^'pcrtropliic, 
and  atrophic  forms. 

I.  CoMPf:xsATOU7  Emphysema. 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  inspiration, 
either  another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in 
order  to  occupy  the  s])ace.  The  former  almost  invariably  occuirs.  Wo 
have  already  mentioned  that  in  broncho-pneumonia  there  is  a  vicarious 
distention  of  the  air-vesicles  in  the  adj  icent  healthy  lobules,  and  the  samo 
happens  in  the  neighborhood  of  tuberculous  areas  aiul  cicatrices.  In  gcu- 
eral  pleural  adhesions  there  is  often  compensatory  cmphysenui,  particu- 
larly at  the  anterior  margins  of  the  lung.  The  most  advanced  example  nf 
this  form  is  seen  in  cirrhosis,  when  the  unaffected  lung  increases  greatly 
in  size,  owing  to  distention  of  the  air-vesicles.  A  similar  though  less 
nuirked  condition  is  seen  in  extensive  pleurisy  with  effusion  and  in  itncu- 
mothorax. 

At  first,  this  distention  of  the  air-vesicles  is  a  simple  j)hysiologi<'iiI 
process  and  the  alveolar  walls  are  stretched  but  not  atrophied.  I  Iti- 
mately,  however,  in  many  cases  they  waste  and  the  contiguous  air-cells 
fuse,  producing  true  emphysema. 


W- 


EMPHYSEMA. 


545 


II.  ITypERTROPiiic  Emphysema. 

This  form,  also  known  as  substantive  or  idiopathic  emphysema,  is  a 
well-marked  clinical  affection,  characterized  by  enlarifemont  of  the 
lunsfs,  due  to  distention  of  the  air-cells  and  atrojjhy  of  their  walls,  and 
clinically  by  imperfect  aeration  of  the  Mood  and  more  or  less  nuirked 
(lysprupa. 

Etiology. — Emphysema  is  the  result  of  persistently  high  iiitra- 
jilvcohir  tension  acting  upon  a  congenitally  weak  lung  tissue.  If  the 
ini'cliauical  views  which  have  prevailed  so  long  as  to  its  origin  were  true, 
the  disease  would  certainly  be  much  more  common  ;  since  violent  respira- 
torv  efforts,  believed  to  be  the  essential  factor,  are  perfornu'd  by  a  majority 
111'  tlie  working  classes.  Strongly  in  favor  of  the  view  that  the  nutritive 
change  in  the  air-cells  is  the  primary  factor  is  the  marketily  hereditary 
chanicter  of  the  disease  and  tiie  frequency  with  which  it  starts  early  in 
life.  "^I'hese  are  two  points  upon  which  scarcely  suflicient  stress  has  been 
laid.  To  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first  observations 
on  tlie  hereditary  character  of  emphysema.  Working  under  Louis's 
iHroctions,  he  found  that  in  18  out  of  Si8  cases  one  or  both  parents  were 
utTeclcd. 

I  have  been  impressed  by  the  frequency  of  the  condition  in  children, 
and  the  number  of  cases  in  which  on  inquiry  symptoms  pointing  to  the 
oi'L'nrrence  of  the  disease  in  childhood  can  be  obtained.  It  nuiy  develop, 
too,  in  .several  mendjers  of  the  same  family.  AVe  are  still  ignorant  as  to 
the  natnre  of  this  congenital  pulmonary  weakness.  Cohnheim  thinks  it 
iirol)ably  due  to  a  defect  in  the  development  of  the  elastic-tissue  fibres,  a 
statement  Mhieh  is  borne  out  by  fippinger's  observations. 

lleigliteued  pressure  within  the  air-cells  nuiy  be  due  to  forcible  in- 
spiration or  expiration.  Much  discussion  has  taken  place  as  to  the  part 
played  by  these  two  acts  in  the  production  of  the  disease.  The  inspiratory 
theory  was  advanced  by  Laennec  and  subsequently  modified  by  (iairdner, 
who  lu'ld  that  in  the  chronic  bronchitis  areas  of  col]a])se  were  induced, 
and  compensatory  distention  took  place  in  the  adjacent  lobides.  This 
iini|uesti()nably  does  occur  in  the  vicarious  or  compensatory  emphysema, 
hut  it  ])rol)iibly  is  not  a  factor  of  much  moment  in  the  form  now  under 
consideration.  The  expiratory  theory,  whicdi  was  supported  by  ^Mendel- 
sohn  and  -lenuer,  accounts  for  the  condition  in  a  nuudi  more  satisfactory 
way.  In  all  straining  elTorts  and  violent  attacks  of  coughing,  the  glottis 
is  dosed  and  the  chest  Avails  are  strongly  compressed  by  muscular  efforts, 
fjo  that  the  strain  is  thrown  upon  those  parts  of  the  lung  least  protected, 
as  the  a})ices  and  the  anterior  margins,  in  which  we  always  find  the 
I'inpliysema  most  advanced.  The  sternum  and  costal  cartilages  gradually 
yield  to  the  heightened  intrathoracic  pressure  and  are,  in  advanced 
<'as(>s,  ])ushed  forward,  giving  the  characteristic  rotundity  to  the  thorax. 
As  mentioned,  the  cartilages  gradually  become  calcified.     One  theory  of 


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546 


DISEASES  OP  THE  RESPIRATORY  SYSTEM, 


the  dispase  is  that  there  is  a  griulual  enhirfremont  of  the  thorax  and  tlio 
hmgs  increase  in  vohime  to  fill  up  the  space. 

Of  other  etiolof^ical  factors  occupation  is  the  most  important.  The 
disease  is  met  with  in  ])layers  on  wind  instruments,  in  glass-hlowers,  and 
in  occupations  necessitating  heavy  lifting  or  straining.  Whooping-co'iirh 
and  hronchitis  play  an  imjjortant  n'/te,  not  so  much  in  the  changes  which 
they  induce  in  the  hronchi  as  in  conserpience  of  the  jjrolonged  attacks  of 
coughing. 

Morbid  Anatomy. — The  thorax  is  capacious,  usually  barrel-shaped, 
and  the  cartilages  are  calcified.  On  removal  of  the  sternum,  the  antcridr 
mediastinum  is  found  completely  occupied  by  the  edges  of  the  lungs,  and 
the  pericardial  sac  may  not  be  visible.  The  organs  are  very  large  and 
have  lost  their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax 
or  when  phiced  on  the  table.  The  pleura  is  pale  and  there  is  often  an 
absence  of  pigment,  sometimes  in  patches,  termed  by  Virchow  albinism  of 
the  lung.  To  the  touch  they  have  a  peculiar,  downy,  feathery  feel,  and 
pit  readily  on  pressure,  "j'his  is  one  of  the  most  marked  features.  Be- 
neath the  pleura  greatly  enlarged  air-vesicles  may  be  readily  seen.  Tlioy 
vary  in  size  from  -^  to  3  mm.,  and  irregular  bullae,  the  size  of  a  walnut 
or  larger,  may  project  from  the  free  margins.  The  best  idea  of  the 
extreme  rarefaction  of  t'^e  tissue  is  obtiiined  from  sections  of  a  lung  dis- 
tended and  dried.  At  the  anterior  margins  the  structure  muy  form  an 
irregular  series  of  air-chambers,  resembling  the  frog's  lung.  On  careful 
inspection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or  even 
of  the  alveoli  may  be  seen  on  these  large  emphysematous  vesicles.  'J'li(uii:h 
general  throughout  the  organs,  the  distention  is  more  marked,  as  a  rule, 
at  the  anterior  margins,  and  is  often  specially  developed  at  the  inner  sur- 
face of  the  lobe  near  the  root,  where  in  extreme  cases  air-spaces  as  large 
as  an  a^^  may  sometimes  he  found.  Microscopically  there  is  seen  atro]diy 
of  the  alveolar  walls,  by  Avhich  is  produced  the  coalescence  of  neighboring 
air-cells.  In  this  process  the  cajiillary  network  disappears  before  the 
walls  are  completely  atrophied,  "j'he  loss  of  the  elastic  tissue  is  a  special 
feature.  It  is  stated,  indeed,  that  in  certain  cases  there  is  a  congenital 
defect  in  the  development  of  this  tissue.  The  epithelium  of  the  air-cells 
undergoes  a  fatty  change,  but  the  large  distended  air-spaces  retain  a  i).ivo- 
ment  layer. 

The  bronchi  in  emphysema  show  important  changes.  In  the  larger 
tubes  the  mucous  membrane  may  be  rough  and  thickened  from  ehi'onic 
bronchitis ;  often  the  longitudinal  lijies  of  submucous  elastic  tissue  i^taiul 
out  prominently.  In  the  advanced  cases  many  of  the  smaller  tu])es  are 
dilated,  particularly  when,  in  addition  to  emphysema,  there  are  perii)ron- 
chial  fibroid  changes.  Bronchiectasis  is  not,  however,  an  invariable  ac- 
companiment of  emphysema,  but,  as  Laennec  remarks,  it  is  difficult  to 
understand  why  it  is  not  more  common.  Of  associated  morbid  changes 
the  most  important  are  found  iu  the  heart.    The  right  chambers  are 


I't> 


ii  rule, 

im>r  ?ur- 

large 

iitr(i]iliy 

liboriiig 

oiv  the 

a  !^]H'ci;il 


EMPHYSEMA. 


547 


(lilatod  aiul  hj-portropliied,  the  trictispid  orifice  is  largo,  and  tlio  valve 
st"Miients  are  often  thickened  at  the  edges.  In  advanced  cases  th(>  cardiac 
livpcrtropliy  is  general.  'JMie  pulmonary  artery  and  its  branches  may  be 
wide  a!id  show  marked  atheromatous  changes. 

'riic  changes  in  the  other  organs  are  those  commonly  associiiteil  with 
prolonged  A'enous  congestion. 

Syniptoms. — 'I'hc  ilisease  may  ]k'  toleraldy  advanced  before  any 
sticcial  syi.ijttoms  develop.  A  child,  for  instance,  may  be  somewhat  short 
of  lircath  on  going  np-stairs  or  may  bo  unalile  to  run  and  play  as  otber 
chililrcn  without  g'  'at  discomfort;  or,  ])erhaps,  has  attacks  of  slight 
llviiUtv.  I)oubtless  much  deiJcnds  n]>on  the  completeness  of  cardiac  com- 
]ii'iis,ition.  When  this  is  perfect,  there  may  be  no  special  interrupti^m  of 
the  |iuIinonary  circulatiim  and.  excejjt  in  violent  exertion,  tiiere  is  no 
iiitciiVrence  with  the  aeration  o_  the  blood.  In  well-developed  cases  the 
fdllowing  are  the  most  important  symptoms  :  J)//sj)ii(ea,  which  may  bo. 
felt  oiilv  on  slight  exertion,  or  may  be  persistent,  and  aggravated  by  in- 
tercurrent attacks  of  bronchitis.  ^Fhe  res])irations  are  often  harsh  and 
\vhc'Ozv,  and  expiration  is  distinctly  prolonged. 

Cijitnosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  atrectious  with  the  exception  of  congenital  heart-disease.  So  far  as  1 
kiidw  it  is  the  only  disease  in  Avhich  a  patient  may  be  able  to  go  about  iind 
cveu  to  walk  into  the  hospital  or  consulting-room  with  a  liviilit '  of  start- 
liiiiT  intensity.  The  contrast  between  the  extreme  cyanosis  and  the  com- 
pMrative  comfort  of  the  patient  is  very  striking.  In  other  affections  of 
the  heart  and  lungs  associated  with  a  similar  degree  of  cyanosis  the  pa- 
tient is  invai'iably  in  bed  and  usually  in  a  state  of  orthopn(ea. 

Ilrii)irJ/i/ls  with  associated  cough  is  a  frecpient  symptom  and  often 
the  direct  cause  of  the  pulmonary  ilistress.  The  contrast  between  eini)hy- 
sematoiis  patients  in  the  winter  and  summer  is  marked  in  this  respect.  In 
the  latter  they  may  be  comfcn-table  and  able  to  attend  to  their  work,  but 
with  the  cold  and  changeable  weather  they  are  laid  up  with  athicks  of 
hniiiehitis.  Finally,  in  fact,  the  two  conditions  become  inseparable  and 
the  patient  has  persistently  more  or  less  cough.  The  acute  bronchitis 
may  [iroduce  attacks  not  unliko  asthma.  In  some  itistances  this  is  true 
spasmodic  asthma,  with  which  emphysenni  is  frequently  associated. 

As  age  advances  and  with  successive  attacks  of  bronchitis  the  condi- 
tion ircts  slowly  worse.  In  hospital  ])ractice  it  is  common  to  admit  pa- 
tients over  sixty  with  well-marked  signs  of  advanced  emjihysema.  The 
afteetion  can  generally  he  told  at  a  glance — the  rounded  shoulders,  barrel 
olie.st,  the  thin  yet  oftentimes  m vascular  form,  and  sometimes,  I  think,  a 
Very  characteristic  facial  expression. 

There  is  another  group,  however,  of  younger  patients  from  twenty-five 
to  forty  years  of  ago  who  winter  after  winter  have  attacks  of  intense  cya- 
nosis ill  consequence  of  an  aggravated  broiudiial  catarrh.  On  infpiiry  we 
find  that  these  patients  have  been  short-breathed  from  infancy,  and  they 


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548 


DISEASES  OP  THE  RESPIRATOUY  SYSTEM. 


belonf]f,  I  ])olievo,  to  a  category  in  which  there  has  been  a  primary  defect 
of  stnictiiro  in  the  hmg  tissue. 

Physical  Signs. — hisjicrtiiiiu — Tlio  tliorax  is  markedly  altered  in  sluipc; 
the  antcro-jtostcrior  (lianieter  is  incri-ased  and  may  be  even  greater  than 
tlie  lateral,  so  that  the  chest  is  barrel-shaped.  The  appearance  is  some- 
what as  if  tlie  cjiest  was  in  a  permanent  inspiratory  position.  'i'h(>  shr- 
num  and  costal  cartilages  are  prominent.  The  lower  zcme  of  the  thorax 
looks  large  and  the  intercostal  spaces  are  nuich  Avideiu'd,  ])artieiilarlv  in 
the  hy|)och()ndria('  regions.  The  sternal  fossa  is  deep,  the  clavicles  r-taiid 
out  with  great  i)rominence,  and  the  neck  looks  shortened  from  the  eleva- 
tion of  the  thorax  and  the  sternum.  A  zone  of  dilated  venules  niav  be 
seen  along  the  line  of  attachment  of  the  diaphragm.  Though  this  is 
common  in  emphysema,  it  is  by  no  means  ])eculiar  to  it.  Andrew,  of 
Bartholomew's  JIos[)ital,  and,  according  to  Duckworth,  Laycock  have 
called  attention  to  it.  This  network  in  the  loAver  thoracic  region,  ju^t 
above  the  costal  margin  and  following  its  curves,  is  a  well-nnirked  feature 
in  many  ])ersons,  and  is  seen  not  only  in  emphysema,  but  in  many  cases 
of  hepatic  trouble. 

Behind,  the  curve  of  the  spine  is  increased  and  the  back  is  remarkably 
rounded,  so  that  the  scapula)  seem  to  be  almost  horizontal.  Mensuration 
shows  the  rounded  form  of  the  chest;  the  antero-posterior  diameter  may 
exceed  the  ti'ansverse.  The  respiratory  movements,  which  may  look  ener- 
getic and  forcible,  exercise  little  or  no  intluence.  The  chest  docs  not 
expand,  but  there  is  a  general  elevation.  The  inspiratory  effort  is  short 
and  (piick  ;  the  exjui'atory  movement  is  prolonged.  There  may  be  retrac- 
tion instead  of  distention  in  the  njjper  abdominal  region  during  inspira- 
tion, and  there  is  sometimes  seen  a  transverse  cui've  crossing  the  abdomen 
at  the  level  of  the  twelfth  rib.  The  apex  beat  of  the  heart  is  not  visible, 
and  there  is  usiudly  marked  pulsation  in  the  epigastric  region.  'I'ho  cer- 
vical veins  stand  out  prominently  and  may  pulsate. 

ralpatioii. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost. 
The  apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower 
sternal  region  and  very  distinct  pnlsation  in  the  epigastrinm.  Percus.^inn 
gives  greatly  increased  resonance,  full  and  drum-like — what  is  sojuetimcs 
called  hyjiei-resonance.  The  note  is  not  often  distinctly  tyin|»aiiitic  in 
quality.  Till'  ])ercussion  note  is  greatly  extended,  the  heart  dulness  may 
be  obliterated,  the  n])per  limit  of  liver  dulness  is  greatly  lowered,  and  tlie 
resonance  may  extend  to  the  costal  margin.  Behind,  a  clear  jiereiission 
note  extends  to  a  mnch  lower  level  than  normal.  The  level  of  (<])lenic 
dulness,  too,  may  be  lowered. 

On  anKcultalion  the  breath-sounds  are  nsnally  enfeebled  and  may  be 
masked  by  bronchitic  rales.  The  most  characteristic  feature  is  the  ])ro- 
longation  of  the  expiration,  and  the  normal  ratio  may  be  reversed — 4  to  1 
instead  of  1  to  4.  It  is  often  wheezy  and  harsh  and  associated  with  course 
rdles  and  sibilant  rhonchi.     It  is  said  that  in  interstitial  emphysema  there 


n^lFt^TTflf'" 


y  defect 

1  sluipc; 
;er  than 

is  sonic- 
'lio  ster- 
3  thorax 
ulurly  in 
Ics  stand 
lie  cleva- 
1  may  be 
li  this  is 
1(1  re w,  of 
H'k    have 
;;ion.  just 
'd  featui'C 
lany  eases 

'inarkahly 
Misuralion 
leter  may 
h)ok  ener- 
,  does  not 
■t  is  sliort 
be  retrac- 
inspira- 
dnlouien 
t  visible, 
Tlie  eer- 

not  lost, 
the  ItAver 

sometimes 
niiiitic  in 
iiess  may 
and  tlie 
lereiission 
of  splonic 

id  may  be 
s  the  ]'ri> 
;ed— 1-  to  1 
ith  coarse 
3cnni  there 


EMPHYSEMA. 


549 


may  be  a  friction  sound  heard  not  unlike  that  of  pleurisy.  As  already 
noted,  the  cardiac  impulse  may  be  barely  felt  in  the  lower  stenud  region. 
The  heart-sounds  are  usually  clear ;  but  in  advanced  cases,  when  there  is 
marked  cyanosis,  a  tricuspid  regurgitant  nuirniur  nuiy  be  heard.  Accent- 
uatii'U  of  the  pulnu)nury  second  sound  is  ])rcsent. 

The  course  of  the  disease  is  slow  l)ut  progressive,  the  recurring  attacks 
I  if  hi'ouchitis  aggravating  the  condition.  Deatii  may  occur  from  intercur- 
rent pneumonia,  either  lobar  or  lobular,  and  dropsy  may  supervene  from 
cardiac  failure.  Occasionally  death  results  from  overdistention  of  the 
heart,  with  extreme  cyanosis.  Duckworth  has  called  attt'Ution  to  fatal 
iuvmorrhage  in  em]»liysema.  It  certainly  is  not  common.  In  an  old  em- 
physematous patient  at  the  Montreal  (General  Hospital  death  followed  the 
erosion  of  a  main  l)rancli  of  the  pulmonary  artery  by  an  ulcer  near  the 
bifurcation  of  the  trachea. 

Treatment. — I'ractically,  the  measures  mentioned  in  connection 
with  bronchitis  should  be  employed.  Ko  remedy  is  known  which  has  any 
inliuenco  over  the  })rogress  of  the  condition  itself.  Broiudiitis  is  the  great 
liaiiirer  of  these  patients,  and  therefore  when  ])ossii)le  they  should  live  in 
an  e(iuable  clinuite.  In  conse([uence  of  the  venous  engorgement  they  are 
liable  to  gastric  and  intestinal  disturbance,  and  it  is  particularly  important 
to  kce]i  the  l)o\\i  -  regulated  and  to  av'oid  the  Matuleiu'y  whiidi  often  seri- 
(Uisly  aggravates  'le  dyspncKi.  Patients  who  come  into  the  hospital  in 
a  state  of  urgent  dyspno'a  and  lividity,  \vith  great  engorgenu^nt  of  the  veins, 
particularly  if  they  are  young  aiul  vigorous,  slunild  be  bled  freely.  On 
more  than  one  occasion  1  have  saved  the  lives  of  persons  in  this  condition 
by  venesection.  Inhalation  of  oxygen  may  be  used  and  the  re.nedies 
iriveii  already  mentioned  in  connection  with  bronchitis.  Strychnine  will 
be  found  specially  i.seful. 

III.  Atrophic  Emphysema, 

This  is  really  a  senile  change  and  is  called  by  Sir  William  .Tenner  small- 
liiiiii-ed  eini)hysenui.  It  is  really  a  primai'y  atrophy  of  the  lung,  coming 
im  ill  advanced  life,  and  scarcely  constitutes  a  si)ccial  affec.'tion.  It  occurs 
ill  ••  withered-looking  old  persons"  who  may  perhaps  have  had  a  winter 
cough  and  shortness  of  breath  for  years.  In  striking  contrast  to  the  essen- 
tia! or  hypertrophic  emphysema,  the  chest  in  this  form  is  small.  The  ribs 
are  olili(piely  placed,  the  decrease  in  the  diameter  being  due  to  greatly  in- 
rreased  oblicpiity  in  the  position  of  the  ribs.  The  thoracic  muscles  are 
usually  atroiibied.  In  advanced  cases  of  this  alfection  the  lung  presents  a 
remarkable  appearance,  being  converted  into  a  series  of  hirge  vesicles,  on 
the  walls  of  which  the  remnants  of  air-cells  may  be  seen.  It  is  a  condition 
for  which  nothiu":  can  be  done. 


.  ti 


W  t 

-    I  f 

Pi  1 


550 


DISEASES  OF  THE  RESPIRATORY  SYSTEM, 


VI.  GANGRENE  OF  THE  LUNG. 


Etiology. — (Jan^roiie  of  the  liiiif?  is  not  an  affection  prr  sr,  l)iit  oc- 
curs ill  a  variety  of  conditions  wlien  necrotic  areas  undergcj  piitrcfaciidn. 
It  is  not  easy  to  s^ay  wliy  spliacelus  should  occur  in  one  case  and  Hdt  in 
another,  as  the  germs  of  putrefaction  are  always  in  the  air-pas.sa;rt's.  mikI 
yet  necrotic  territories  rarely  become  piiiirrenoiis.  Total  obstruct]', n  df  n 
pulmonary  artery,  as  a  rule,  causes  iiil'arction,  and  the  area  slint  oil"  (lots 
not  often,  tlioiigli  it  may,  sphacehite.  Anotlier  factor  would  seem  to  lie 
necessary — ])robably  a  lowered  tissue  resistance,  the  result  of  general  or 
local  causes.  It  is  met  with  (1)  as  a  se([uence  of  lobar  pneumonia.  This 
rarely  occurs  in  a  ])rcviously  healthy  jierson — more  commonly  in  the  dc- 
bilitated  or  in  the  dialjctic  subject.  (:i)  (iangrene  is  very  ju-oiie  to  fcillow 
the  aspiration  ])neumonia,  since  the  foreign  particles  rapidly  uiiderpro 
putrefactive  changes.  Of  a  similar  nature  are  the  cases  of  gangrene  ihic 
to  ])erf()ration  of  cancer  of  the  o'sophagus  into  the  lung  or  into  a  broiiclius. 
(3)  The  ])utrid  contents  of  a  bronchiectatic,  more  commonly  of  a  tiiher- 
culous,  cavity  may  excite  gangrene  in  the  neighboring  tissues.  1'he  ]iress- 
ure  bronchiectasis  following  aneurism  or  tumor  may  lead  to  extensive 
sloughing.  (4)  Gangrene  may  follow  sim])le  embolism  of  the  ])iiliii(iiiMrv 
artery.  ^More  commonly,  however,  the  embolus  is  derived  from  a  part 
which  is  mortified  or  comes  from  a  focus  of  bone  disease.  Lastly,  gan- 
grene of  the  lung  may  occur  in  conditions  of  debility  during  eoiivaks- 
cence  from  protracted  fever — occasionally,  indeed,  Avithout  our  being  abk' 
to  assign  any  reasonable  cause. 

Morbid  Anatomy. — Laennec,  who  first  accurately  describctl  pul- 
monary gangrene,  recognized  a  ditfuse  an.d  a  circumscribed  form.  The 
former,  though  rare,  is  sometimes  seen  in  connection  -with  ])iiouni(iiiia, 
more  rarely  after  obliteration  of  a  large  branch  of  the  pulmonary  arttiv. 
It  may  involve  the  greater  jiart  of  a  lobe,  and  the  lung  tis-sue  is  coiniTttd 
into  a  horribly  offensive  greenish-black  mass,  torn  and  ragged  in  tlic  ((.iitiv. 
In  the  circumscribed  form  there  is  well-marked  limitation  between  the 
gangrenous  area  and  the  surrounding  tissue.  The  focus  may  be  single  or 
there  may  be  two  or  more.  The  lower  lobe  is  more  commonly  fdlVcted 
than  the  upper,  and  the  peripheral  more  than  the  central  jiortioii  of  the 
lung.  A  gangrenous  area  is  .it  first  uniformly  greenish  brown  in  color; 
but  softening  rapidly  takes  place  with  the  formation  of  a  cavity  with 
shreddy,  irregular  walls  and  a  greenish,  offensive  fluid.  The  lung  tissue 
in  the  immediate  neighborhood  shows  a  zone  of  deep  congestion,  often 
consolidation,  and  outside  this  an  intense  (rdema.  In  the  embolic  case.-; 
the  plugged  artery  can  sometimes  be  found.  "When  rapidly  extciulintr, 
vessels  may  be  opened  and  violent  haemorrhage  ensue.  Perforation  of  the 
pleura  is  not  uncommon.  The  irritating  decomposing  material  usually 
excites  the  most  intense  bronchitis.  Embolic  processes  are  not  infrei|uent. 
There  is  a  remarkable  association  in  some  cases  between  circumscribed 


GANGRENE  OP  THE  LUNG. 


551 


ffiiiiirrene  of  tlie  lung  and  abscess  of  the  bniin.  I  have  seen  two  such 
oasi's.  One  of  thew,  a  young  man,  an  Arab,  was  l)r()ugbt  to  tlio  Uiii- 
voi-itv  Hospital,  almost  exsanguine  from  pulmonary  luvmorrliage.  He 
irrailiially  recovered.  There  were  very  limited  signs  in  tiie  middle  lobe 
(if  the  right  lung,  which  ])ersisted,  but  no  bacilli  were  found.  Thero  was 
no  tVtor  of  the  breath.  Weeks  afterward  he  developed  severe  headache, 
and  in  a  few  days  became  comatose  and  died.  There  was  a  circumscribed 
urea  of  healing  gangrene  at  the  margin  of  the  1  iig  with  great  increase  of 
lihnnis  tissue  about  it.  The  artery  going  to  this  somewhat  wedge-shaped 
area  was  obliterated.  The  contents  of  the  encai)sulated  cavity  were  very 
frtid.  There  was  a  large  limited  abscess  in  the  parieto-temporal  region 
(111  the  right  side. 

Symptoms  and  Course. — Usually  definite  symptoms  of  local  pul- 
inoiiary  disease  precede  the  characteristic  features  of  gangrene.  These, 
of  lourse,  are  very  varied,  depending  on  the  nature  of  the  trouble.  The 
s|iatiiin  is  very  characteristic.  It  is  intensely  fetid — nsnally  profuse — 
and,  if  expectorated  into  a  conical  glass,  separates  into  three  1;  vers — a 
),rrt'uiii-;h-brown,  heavy  sediment;  an  intervening  thin  liquid,  whicii  some- 
times has  a  greenish  or  a  brownish  tint ;  and,  on  top,  a  thick,  frothy  layer. 
Spread  on  a  glass  plate,  the  shreddy  fragments  of  lung  tissue  can  readily 
1)0  picked  out.  ^Microscopically,  elastic  fibres  arc  found  in  abundance, 
with  granular  matter,  pigment  grains,  fatty  crystals,  bacteria,  and  lepto- 
tlirix.  It  is  stated  that  elastic  tissue  is  sometimes  al)sent,  1)ut  I  have  never 
nut  with  such  an  instance.  The  peculiar  i)lugs  of  s})ntum  which  occur 
ill  Itrouchiectasy  are  not  found.  Blood  is  often  present,  and,  as  a  rule,  is 
iiuich  altered.  The  sputum  has,  in  a  majority  of  the  cases,  an  intensely 
fitid  o(^lor,  whicli  is  communicated  to  the  breath  and  may  permeate  the 
entire  room.  It  is  much  more  offensive  than  in  fetid  bronchitis  or  in 
absd'ss  of  the  lung.  The  fetor  is  particularly  marked  when  there  is  free 
coiiiiiuniication  between  the  gangrenous  cavities  and  the  bronchi.  On 
several  occasions  I  have  found,  post  mortem,  localized  gangrene,  which 
hiul  been  unsuspected  during  life,  and  in  which  there  had  been  no  fetor 
of  tlu"  l)reath. 

The  pliysical  signs,  when  extensive  destruction  has  occurred,  are  those 
of  cavity,  but  the  limited  circumscribed  areas  may  be  ditiicult  to  detect. 
Hnjiichitis  is  always  present. 

Among  the  general  symptoms  may  be  mentioned  fever,  usually  of 
iiiiidei-ato  grade ;  the  pulse  is  rapid,  and  very  often  the  constitutional  de- 
pression is  severe.  But  the  only  special  features  indicative  of  gangrene 
are  the  sputa  and  the  fetor  of  the  breath.  The  patient  generally  sinks 
from  exhaustion.  Fatal  haemorrhage  may  ensue.  I  have  already  men- 
tu»ned  a  case  in  whicli  a  ha}morrhage  from  a  circumscribed  gangrene 
nearly  proved  fatal,  and  I  have  seen  one  fatal  instance  after  pneumonia. 

Treatment. — The  treatment  of  gangrene  is  very  unsatisfactory.  The 
iiulieations,  of  course,  are  to  disinfect  the  gangrenous  area,  but  this  is 


Ail 


663 


DISEASES  OF  THE  IlESPIRATORY  SYSTEM. 


often  inipns.sihlo.  An  antisoptio  spriiy  of  oarbolie  acid  may  bo  (Mii|i!(i\(d. 
A  }j;o()d  2)lan  is  for  tiic  patient  to  us(f  ov(!r  the  nioiitli  and  nose  an  iiilinh  r, 
whicli  may  bo  ehar<j;ed  with  a  sohition  of  earbolie  acid  or  creosote.  IT  ihc 
si<.,Mis  of  cavity  arc  distinct  an  attempt  sliould  be  made  to  cleanse  it  \i\ 
direct  injections  of  an  antiseptic  solution.  If  the  ])atient's  condilion  is 
good  and  the  <,fan^renous  re<,don  can  be  localized,  an  attemjjt  sliould  lie 
made  to  treat  it  sur^'ic^ally.  Suc^-essful  cases  have  been  reported.  'J'lic 
general  condition  of  the  patient  is  ahvaya  such  us  to  demand  the  greatest 
cure  in  tin;  matter  of  diet  and  nursing. 


VII.  ABSCESS  OF  THE  LUNG. 

Etiology. — Suppuration  occurs  in  tlie  lung  under  the  followitij.' 
conditions:  (1)  As  a  sequence  of  inilammation,  either  lobar  or  lol)ul:ir, 
Apart  from  the  ])urulent  infiltration  this  is  unquestionably  rare,  and  even 
in  lobar  i)neumoniu  the  abscesses  are  of  smuU  size  and  usually  involve,  as 
Addison  remarked,  several  points  at  the  same  time.  On  the  other  hainK 
abscioss  formation  is  extremely  frequent  in  the  deglutition  and  aspiration 
forms  of  lobular  ])neumonia.  After  wounds  of  the  neck  or  operations 
upon  the  throat,  in  suppunitive  disease  of  the  nose  or  larynx,  oeeasionully 
even  of  the  ear  (Volkmann),  infective  particdes  reach  the  bronchial  tubes 
by  aspiraticm  and  excite  an  intense  inflammation  which  often  ends  in 
suppuration.  Cancer  of  the  a>sophagus,  })erforating  the  root  of  the  luiij; 
or  iTito  the  bronchi,  may  produce  extensive  sui)puration.  The  abscesses 
vary  in  si  m  a  Avalnut  to  an  orange,  und  have  ragged  and  irregular 

walls,  and  ,  .     lont,  sometimes  necrotic,  contents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infectious 
emboli,  are  extremely  common  in  a  large  proportion  of  all  cases  of  i)ya'iuia. 
They  may  occur  in  enormous  numbers  and  present  very  definite  char- 
acters. As  a  rule  they  are  superficial,  beneath  the  pleura,  and  often 
wedge-shaped.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intense  hyperivmia,  su])puration  soon  follows  with  the  format  ion 
of  a  definite  abscess.  The  jdeura  is  usually  covered  with  greenish  lyiuiih, 
and  perforation  sometimes  takes  place  with  the  production  of  pneuuid- 
thorax. 

(3)  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies, 
and,  in  the  right  lung,  perforation  from  abscess  of  the  liver  or  sui)puraliiig 
echinococcus  cyst  are  occasional  cai^ses  of  pulmonary  abscess. 

(4)  Suppurative  processes  jilay  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  which  are  due  to  them. 

Ssnnptoms. — Abscess  following  pneumonia  is  easily  rccogni/eil  by 
an  aggravation  of  the  general  symptoms  and  by  the  physical  signs  of  cav- 
ity and  the  characters  of  the  expectoration.  Embolic  abscesses  cannot 
often  be  recognized,  and  the  local  symptoms  are  generally  masked  in  the 


PNEUMONOKONIOSIS. 


553 


ponoral  pyffmio  manifostiitions.  The  chiiraotors  of  tho  sputum  arc  of  ^rcat 
iiniHirtaiici'  \\\  (iL'tcruiinin;^  the  prcsciicc  of  ahsct'SH.  'I'lic  odor  is  otlVusivc, 
vet  it  rart'ly  ha.s  tliu  liorrililo  fetor  of  {j;aiif,'reui!  or  of  putrid  hroucliitis. 
Ill  tho  i>iiH  fraj^'int'iits  of  luuj,'  tissue  can  be  soon,  and  the  elastic;  tiaHUO  nuiy 
lie  very  abundant.  'I'ho  jn'esonoo  of  tiiis  witii  tlio  physical  si^ns  rarely 
leaves  anv  (piestion  as  to  the  nature!  of  the  trouble.  Kndtolic  cases  usually 
run  a  fatal  course.     Hecovery  occasituially  oc(.'urs  after  pneumonia. 

Medicinal  treatment  is  of  little  avail  iti  abs(!es.s  of  the  Inntf.  When 
well  (leiined  and  sui»erlicial,  an  attempt  should  always  bo  made  to  open 
iind  drain  it.  A  number  of  successful  cases  have  already  been  treated  in 
this  way. 

VIII.   PNEUMONOKONIOSIS. 

Under  tins  term,  introduced  l)y  Zenker,  is  embraced  those  diseases  of 
tho  liin<rs  due  to  the  inhalation  of  dusts  in  various  occupations.  They 
have  received  various  names,  accordinj?  to  the  nature  of  the  inhaled 
jiartieles — a nf/infcosis,  or  coal-miner's  disease;  fu'derosis,  due  to  the  in- 
halation of  metallic;  dusts,  particularly  iron  ;  chal'cosis,  due  to  the  inbala- 
tidii  of  mineral  dusts,  producins?  the  so-called  stone-cutter's  phthisis,  or 
the  "  <,n'inder's  rot "  of  the  Shetlield  workers. 

The  dust  })articles  inhaled  into  the  lungs  are  dealt  with  extensively  by 
the  ciliated  ei)itbelium  and  by  the  phagocytes,  Avhich  exist  normally  in  tho 
re-piratory  organs.  The  ordinary  mucous  corpuscdos  take  in  a  large  num- 
ber of  the  particles,  -which  fall  upon  the  trachea  and  main  bronchi.  The 
cilia  swee]!  the  mucus  out  to  a  jioint  from  -which  it  (tan  be  expelled  by 
eouirhing.  It  is  doubtful  if  the  particles  ever  reach  tho  air-cells,  but  tho 
.swollen  alveolar  cells  (in  which  they  are  in  numbers)  probably  pick  them 
up  oil  the  way.  The  mucous  and  tho  alveolar  cells  arc  the  iu)rmal 
respiratory  scavengers.  In  dwellers  in  the  country,  in  -which  the  air  is 
l)ure,  they  are  able  to  prevent  the  access  of  dust  particles  to  the  Inng 
tissue,  so  that  even  in  adults  these  organs  present  a  rosy  tint,  very 
(litTerent  from  the  dark,  carbonized  appearance  of  tho  lungs  of  dwellers  in 
cities.  A\'hen  the  impurities  in  the  air  are  very  abundant,  a  certain  pro- 
portion of  the  dust  particles  escapes  these  colls  and  penetrates  the  mucosa, 
reaeliing  the  lymph  spaces,  whore  they  are  attacked  at  once  by  the  cells 
of  the  connective-tissue  stroma,  which  are  capable  of  ingesting  and  retain- 
in.i;  a  large  quantity  In  coal-miners,  coal-heavers,  and  others  whose 
occupations  necessitate  the  constant  breathing  of  a  very  dusty  atmosphere 
even  tiieso  forces  are  insufficient.  Many  of  the  particles  enter  the  lymph 
streinn  and,  as  Arnold  has  shown  in  his  beautiful  researches,  are  carried 
(1)  to  the  lymph  nodules  surrounding  the  bronchi  and  Idood- vessels;  (2) 
to  the  interlobular  septa  beneath  the  pleura,  Avhore  they  lodge  in  and 
between  the  tissue  elements;  aiul  (.3)  along  th  ;  larger  lymph  channels  to 
the  substernal,  bronchial  and  tracheal  glands,  in  which  the  stroma  cells  of 


^f:rf\ 


ill 


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irnkt*--'^ 


!(;^' 


U 


I    M 


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ij.i     t  1  'Mill 


6S4 


DISEASKS  OF  THE  IIESI'IIIATOUY  SYSTEM. 


till*  fnlliciiliir  conlH  (lis|)os(>  of  tlu^m  jK'rnmiiotidy  mid  provoiit  tliom  fnim 
ciitia'iiij;  till'  <jciii'nil  rirculutioii.  Ocoasioually  iti  iiiitlinicosis  tlic  carhiiii 
graiii.s  lio  rt'acli  tliii  /^'I'liiTal  circulation,  ami  the  coal  iliist  is  I'oiiinl  in  tiio 
livor  anil  Kplci-n.  Ah  Wcigcrt  hua  hIiowii,  this  ocourn  wlimi  the  densclv 
pifi;riiciit('il  itroiichial  <flajnls  closely  ailhcri!  to  tlu!  puliuoiiary  veins,  tliroii;,'li 
the  walls  of  which  the  carhon  pai'ticles  i)ass  to  the  <,'eiienil  circiiliitiun. 
The  Iiinjjf  tissue  has  a  reniark.al)le  tolerance  for  these  ])articles,  pniliMl.lv 
bocausi^  a  lar;,'e  j)roportion  of  them  is  wareliouseil,  so  to  speak,  in  ino. 
toplasniie  cells.  |{y  constant  exi)osiire  a  limit  is  reai-heil,  ami  tliiic  is 
broiif^ht  about  a  very  iletiiiite  patholoj^i.-al  eonilition,  an  interstitial  sclero- 
sis. In  coal-miners  this  may  occur  in  patches,  even  before  the  lini;,'  tissue 
is  uniformly  infiltrated  with  the  dust.  In  others  it  appears  only  after  the 
entire  orjfans  have  become  so  hideii  that  they  uro  dark  in  color,  and  an 
ink-like  juice  flows  from  the  cut  surfi -'e.  Tlie  lungs  of  a  miner  may  he 
black  throiiglioiit  and  yet  show  no  local  lesions  and  ho  evorywla'ro 
ere])itant. 

Aa  already  mentioned,  tlie  particles  are  deposited  in  large  numhiTs  in 
the  follicular  cords  of  the  tracheal  and  bronchial  glands  and  of  the  peri- 
bronchial and  })eri-arterial  lymph  nodules,  an  I  in  these  they  finally  excite 
proliferation  of  the  connective-tissue,  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  tc  ^s  are  only  moderately  carhon i/.ei I 
the  broncliial  glands  sclerosed  and  hard.  In  antbracosis  the  lihroid 
changes  usually  begin  in  tlie  peri-bronchial  lymph  tissue,  and  in  the  liuiy 
stage  of  the  process  tlie  sclerosis  may  be  largely  confined  to  these  re<,nons. 
A  Nova  Scotian  miner,  aged  thirty-six,  died  under  my  care,  at  the  .Mont- 
real General  llospital,  of  blnck  small-jiox,  after  an  illness  of  a  few  davs. 
In  his  lungs  (externally  coal-black)  there  were  round  and  linear  patches 
ranging  in  size  from  a  nea  to  a  hazel-niit,  (if  an  intensely  black  color,  air- 
less and  firm,  and  surrounded  by  a  crepitant  tissue,  slate-gray  in  color. 
In  the  centre  of  each  of  these  areas  was  a  small  bronchus.  Many  of  them 
were  situated  just  beneath  the  pleura,  and  formed  typical  examples  of 
limited  fibroid  broncho-pnenmonia.  In  addition  there  is  usually  thicken- 
ing of  the  alveolar  walls,  particularly  in  certain  areas.  By  the  gradual 
coalescence  of  these  fibroid  patches  large  portions  of  the  lung  may  be 
converted  into  firm  grayish-black,  in  the  case  of  the  coal-miner— steel- 
gray,  in  the  case  of  the  stone-worker — areas  of  cirrhosis.  In  the  case  of  ii 
Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of  these 
fibroid  areas  measured  18  by  G  cm.  and  4'o  cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which 
is  present  in  a  large  proportion  and  really  causes  the  chief  symptoms.  A 
third  is  the  occurrence  of  emphysema,  which  is  almost  invariably  associ- 
ated with  long-standing  cases  of  pneumonokoniosis.  With  the  changes  so 
far  described,  unless  the  cirrhotic  area  is  unusually  extensive,  the  case  may 
present  the  features  of  chronic  bronchitis  with  emphysema,  but  linally 
another  element  comes  into  play.     In  the  fibroid  areas  softening  occurs, 


PNEUMON'OKONIOSIS. 


555 


pnibiihly  a  process  of  necrosis  similar  to  thut  by  which  sof toning  is  pro- 
(liici'd  in  libro-niyoiniitu  of  the  uterus.  At  first  those  are  •tniall  and  con- 
tiiiu  !i  dark  lujuid.  Chan'ot  calls  llicrn,  as  already  riientioi\ed,  nlrvn's  dii 
iiiiiDiion.  'I'liey  rarely  .ittain  a  larj,'e  size  uidess  a  coinnumii'ation  is 
t'i)riiiid  with  the  bronchus,  in  which  case  they  may  bec(,tne  converted 
intt)  suppurating  (uivities.  The  question  has  been  much  discussed  of 
lute  as  to  what  part  the  tubercle  l)acillus  plays  in  these  cases  of  pneu- 
nidiiokoniosis  with  cavity  formation.  In  some  it^stances  there*  is  (icr- 
tainly  a  tuberculous  i)rocess  ingraftetl,  but  that  large  excavations  may 
occur,  or  in  other  instances  bronchiectasis  without  the  j)resence  of  bacillis, 
1  liavc  convinced  myself  by  the  examimition  of  several  characteristic  spec- 
inifus. 

'I'he  sidn'osis  induced  by  the  oxide  of  iron  causes  an  interstitial  pneu- 
monia similar  to  anthraeosis.  Workers  in  brass  and  in  bronze  an;  liable 
to  a  similar  affection. 

('halicosis,  due  to  the  deposit  of  particles  of  silex  and  alumina,  is 
fduud  in  the  makers  of  mill-stones,  particularly  the  Frc  i  '.  mill-stones, 
luul  also  in  knife  ami  axe  grinders  and  stone-cutters.  AnalMuically,  thivS 
I'orrii  is  characterized  by  the  production  of  TU)dnle8  of  varinis  sizes,  which 
are  cut  with  the  greatest  difficulty  and  sometimes  preseat  a  cnnous  gray- 
isli,  even  glittering,  crystalloid  appearance. 

Workers  \v  f'av  aiul  in  cotton,  and  grain-shovellers  are  also  subject  to 
tlicse  chronic  interstitial  changes  in  the  lungs.  In  uU  these  occupations, 
us  show.,  by  Creenhow,  to  whose  careful  studies  we  owe  so  much  of  our 
knowledge  of  these  diseases,  the  condition  of  the  lung  may  ultimately  be 
almost  identical. 

'riio  .syiiiptovis  do  not  come  on  until  the  patient  has  worked  for  a  vari- 
able number  of  years  in  the  dusty  atmosphere.  As  a  rul«»  there  are  cough 
and  failing  health  for  a  prolonged  period  of  time  before  complete  disa- 
hility.  The  coincident  emphysema  is  responsible  in  great  part  for  the 
s'.iortiiess  of  breath  and  whee/.y  condition  of  these  patients.  Tb.e  expec- 
toration is  usually  muco-purulcnt,  often  profuse ;  in  a  case  of  anthra- 
eosis, very  dark  in  color — the  so-called  "  black  spit" ;  in  a  case  of  chalicosis 
there  may  be  seen  under  the  mieroscqpe  the  bright  angular  })articles  of 
silica. 

Even  when  there  are  physical  signs  of  cavity  tubercle  bacilli  are  not 
necessarily,  and  indeed  in  my  experience  they  are  not  usually  present.  It 
is  remarkable  for  how  long  a  time  a  coal-miner  may  contii\ue  to  bring 
up  sputum  laden  with  coal  particles  even  when  there  are  only  signs 
of  a  clirr)nic  bronchitis.  Maiiy  of  the  particles  are  contained  in  the 
cells  of  the  alveolar  epithelium.  In  these  instances  it  ai)pears  that  an 
attempt  is  made  by  the  leucocytes  to  rid  the  lungs  of  some  of  the  carbon 
grains. 

The  diagnosis  of  the  condition  is  rarely  difficult ;  the  expectoration  is 
usually  characteristic.     It  must  always  be  borne  in  mind  that  chronic 
36 


li  r 

i-' 

'    1     ' 
I 


r 


V  t 


f 


i 

fU  1 


tS"' 


n. 


n-iv! 


556 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


bronchitis  and  empi.yseina  form  essential  parts  of  the  process  and  that  in 
late  stages  there  may  be  tuberculous  infection. 

The  treatment  of  the  condition  is  practically  that  of  chronic  bronchitis 
and  emphysema. 


IX.  NEW  GROWTHS  IN  THE  LUNGS. 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are 
rare,  secondary  growths  a:'e  not  uncommon. 

The  primary  growths  of  the  lung  are  either  encephaloid,  scirrhus  or 
epithelioma.  Recent  observations  show  that  the  latter  is  tlie  most  ('(im- 
mon  form.  Sarcoma  also  is  occasionally  found  as  a  primary  growth,  and 
stil!  more  rarely  enchondroma. 

The  secondary  growths  may  be  of  various  forms.  Most  coninionly 
they  follow  tumors  in  the  digestive  or  genito-urinary  organs ;  not  infre- 
quently also  tumors  of  the  bone.  'J'here  may  be  encephaloid,  scirrluitf,  epi- 
thelioma, colloid,  melano-sarcoma,  enchondroma,  or  osteoma. 

Primary  cancer  or  sarcoma  usually  involves  oidy  one  lung.  Tlie  sec- 
ondary growths  are  distributed  in  both.  The  primary  growth  goneiallv 
forms  a  large  mass,  which  may  occupy  the  greater  jjart  of  a  lung.  Occasion- 
ally the  secondary  growths  are  solitary  and  confined  chiefly  to  the  pleura, 
as  in  a  remarkable  example  which  came  under  my  observation,  in  which  tlie 
disease  was  secondary  to  a  myelo-sarcoma  of  the  wrist.  The  tumor  mass 
occupied  a  large  portion  of  the  left  side  of  the  thorax.  It  grew  from  tlie 
pleura  and  extended  only  slightly  into  the  lung,  Avhich  was  compressed 
and  airless.  The  metastatic  growths  are  nearly  always  disseminated. 
Occasionally  they  occupy  a  large  portion  of  the  pulmonary  tissue.  In  a 
case  of  colloid  cancer  secondary  to  cancer  of  the  pancreas,  I  found  both 
lungs  voluminous,  heavy,  only  slightly  crepitant,  and  occu])ied  by  circular 
translucent  masses,  varying  in  size  from  a  pea  to  a  lai'ge  walnut. 

There  are  numerous  accessory  lesions  in  the  pidmonary  new  growths. 
There  may  be  pleurisy,  either  cancerous  or  sero-fibrinous.  The  elliision 
may  be  hemorrhagic,  but  in  200  cases  of  cancer,  primary  or  secondary,  of 
the  lungs  and  pleura  analyzed  by  Moutard-Martin,  ha^morrhagic  ell'usion 
occurred  in  only  twelve  per  cent.  The  tracheal  and  bronchial  glands  are 
usually  affected,  the  cervical  glands  not  infrequently,  and  occasionally  even 
the  inguinal. 

The  disease  is  most  common  in  the  middle  period  of  life.  The  jiri- 
mary  form  affecis  the  sexes  equally,  but  secondary  cancer  is  much  more 
frequent  in  women  than  in  men.  The  conditions  which  prcdisposr  to  it 
are  quite  unknoAvn.  It  is  a  remarkable  fact  that  the  worker>  in  the 
Schneeborg  cobalt  mines  are  very  liable  to  primary  cancer  of  tiie  lungs. 
It  is  stated  that  in  this  region  a  considerable  proportion  of  all  deaths  ui 
persons  over  forty  are  due  to  this  disease.  ' 


mors  are 


NEW  GROWTHS  IN  THE  LL'NGS. 


557 


Symptoms. — The  clinical  features  of  neoplasms  of  the  lungs  arc  by 
no  nioiins  distinctive,  particularly  in  the  case  of  primary  growths.  The 
itiitiuiit  may,  indeed,  as  noted  by  Walshc,  present  no  symptoms  pointing 
to  intrathoracic  disease.  Among  the  more  important  syin])tom8  are  pain, 
mrtioularly  when  the  pleura  is  involved ;  dyspnaui,  which  is  apt  to  be 
paroxysmal  when  duo  to  pressure  upon  the  trachea;  cough,  whi(!h  may  be 
dry  and  painful  and  accompanied  by  the  expectoration  of  a  dark  mucoid 
sputum.  This  so-called  prune-juice  expectoration,  which  was  present  ten 
times  in  eighteen  cases  of  primary  cancer  of  the  lung,  was  thought  by 
Stokes  to  be  of  great  diagnostic  value. 

In  numy  instances  there  are  sig?is  of  compression  of  the  large  veins, 
producing  lividity  of  the  face  and  upper  extremities,  or  o  •casionally  of 
only  one  arm.  Compression  of  the  trachea  and  bronchi  may  give  rise  to 
urgent  dyspncBa.  The  heart  may  be  pushed  over  to  the  opposite  side. 
The  ])neumogastric  and  recurrent  laryngeal  nerves  are  occasionally  in- 
volved in  the  growth. 

Physical  Signs. — The  patient,  according  to  Walshe,  usually  lies  on  the 
aiTeeted  side.  On  inspection  this  side  may  be  enlarged  and  immobile  Jind 
the  intercostal  spaces  are  obliterated.  This  is  more  commonly  due  to  the 
effusion  than  to  the  growth  itself.  The  external  lymph-glands  may  be 
eiihirged,  particularly  the  clavicular.  The  sigTis,  on  percussion  anc^  aus- 
cultation, are  varie  .\  depending  much  upon  the  presence  or  absence  of 
iluid.  Signs  of  consolidation  are,  of  course,  present ;  the  tsictile  fremitus 
is  absent  and  the  breath-sounds  are  usually  diminished  in  intensity.  Oc- 
casionally there  is  typical  bronchial  breathing.  Among  other  symptoms 
may  bo  mentioned  fever,  which  is  present  In  a  certain  number  of  cases. 
Emaciation  is  not  necessarily  extreme.  The  duration  of  the  disease  is 
from  six  to  eight  months.  Occasionally  the  disease  runs  a  very  acute 
course,  as  noted  by  Carswell.  Cases  are  reported  in  which  death  occurred 
in  a  month  or  six  weeks,  and  in  one  instance — Jaccoud — the  patient  died 
ill  a  week  from  the  onset  of  the  symptoms. 

Diagnosis. — In  secondary  growths  this  is  not  difficult.  The  devel- 
opment of  pulmonary  symptoms  Avithin  a  year  or  two  after  the  removal  of 
a  cancer  of  the  breast,  or  after  the  amputation  of  a  limb  for  osteo-sarcoma, 
or  the  onset  of  similar  symptoms  in  connection  witl  ancer  of  the  liver, 
or  of  the  uterus,  or  of  the  rectum,  would  be  extremely  suggestive.  In 
prnuary  cases  the  unilateral  involvement,  the  anomalous  character  of  the 
pliysical  signs,  the  occurrence  of  prune-Juice  expectoration,  the  progress- 
ive wasting,  and  tJ-.e  secondary  involvement  of  the  cervical  glands  are  the 
important  pomts  in  the  diagnosis. 


0hm 


.  i 


*  i 


li^t 


sauiiw- 


558  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

y.  DISEASES  OF  THE  PLEURA. 

I.  ACUTE  PLEURISY. 

Anatomically,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy 
and  pleurisy  with  effusion.  Another  classification  is  into  primary  or  sec- 
ondary forms.  According  to  the  course  of  the  disease,  a  division  may  be 
made  into  acute  and  chronic  pleurisy,  and  as  it  is  impossible,  at  present 
to  group  the  various  forms  etiologicuUy,  this  is  perhaps  the  most  satisfac- 
tory division.     Tlie  following  forms  of  acute  pleurisy  may  be  considered : 


I.  Fibrinous  on  Plastic  Pleurisy. 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lynij)]!  of 
variable  thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the 
fibrin  may  exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  alloc- 
tion,  following  cold  or  exposure.  This  form  of  acute  plastic  pleurisy 
without  fluid  exudate  is  not  common  in  perfectly  healthy  individuals. 
Cases  are  met  with,  however,  in  which  the  disease  sets  in  with  the  usual 
symptoms  of  pain  in  the  side  and  slight  fever,  and  there  are  the  i)liysieal 
signs  of  pleurisy  as  indicated  by  the  friction.  After  persisting  for  a  few 
days,  the  friction  murmur  disappears  and  no  exudation  occurs,  riiiou 
takes  place  between  the  membranes,  and  possibly  the  pleuritic  udhosions 
which  are  found  in  such  a  large  percentage  of  all  bodies  examined  after 
death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases 
of  the  lung,  such  as  pneumonia,  which  is  always  accompanied  by  a  ('(Mtaiu 
amount  of  pleurisy,  usually  of  this  form.  Cancer,  abscess,  and  gaiigroiio 
also  cause  plastic  pleurisy  when  the  surface  of  the  lung  becomes  iiuolvod. 
This  condition  is  specially  associated  in  a  large  number  of  cases  with 
tuberculosis.  Pleural  pain,  stitch  in  the  side,  and  a  dry  cough,  with 
marked  friction  sounds  on  auscultation  are  the  initial  phenomena  in 
many  instances  of  phthisis.  The  signs  are  usually  basic,  but  Buriiey  Yeo 
has  recently  called  attention  to  the  frequency  with  which  they  occur  at 
the  apex. 

II.  Sero-fibuinous  Pleurisy. 

In  a  majority  of  cases  of  inflammation  of  the  pleura  there  is,  with  the 
fibrin,  a  variable  amount  of  fluid  exudate,  which  produces  the  condition 
known  as  pleurisy  with  efl'usion. 

Etiology. — For  generations  physicians  have  considered  cdIiI  the 
potent  factor  in  inducing  pleurisy.  This  may  be  true  in  many  cases,  hat 
modern  views  of  serous  inflammations  scarcely  recognize  cold  as  anything 
more  than  a  predisposing  agent,  which  permits  the  action  of  various 
micro-organisms.    WiJ  have  not  yet,  however,  brought  all  the  acuto  plou- 


ACUTE  PLEURISY. 


659 


risios  into  the  category  of  microbic  affections,  and  the  fact  remains  that 
pl(>'.irisy  does  follow  with  great  rapidity  a  sudden  wetting  or  a  chill.  Of  late 
vcars  an  attempt  has  been  made,  particularly  by  French  writers,  to  show 
tliiit  tlie  majority  of  acute  pleurisies  are  tuberculous.  In  this  connection 
tlie  following  facts  may  be  admitted :  (1)  In  a  limited  number  of  cases 
of  pleurisy  coming  on  abruptly  in  healthy  persons  the  disease  has  been 
shown — («)  by  post-mortem,  in  cases  of  accidental  or  sudden  death,  (b)  by 
the  subsequent  history — to  be  tuberculous ;  (2)  in  a  larger  proportion  of 
those  cases  Avhich  come  on  insidiously  in  persons  who  have  been  in  failing 
health  or  who  are  delicate  the  disease  is  tuberculous  from  the  outset;  (3) 
the  iieute  pleurisy,  which  occurs  as  a  secondary,  often  a  terminal,  event  in 
chronic  affections,  such  as  cirrhosis  of  the  liver,  Bright's  disease,  and 
cancer,  is  very  frequently  tuberculous.  I  confess  that  the  more  carefully 
I  have  studied  the  question  the  larger  does  the  proportion  appear  to  be  of 
priuuiry  pleurisies  of  tuberculous  origin.  The  subsequent  history  of  cases 
of  acute  pleurisy  forces  us  to  conclude  that  in  at  least  two  thirds  of  tho 
cases  it  is  a  curable  affection.  This  may  well  bo  so,  according  to  our  pres- 
ent ideas  of  local  tuberculous  disease.  One  of  the  most  interesting  con- 
tributions to  this  question  has  been  made  from  the  records  of  Henry  I. 
Bowditc.h,  of  Boston,  to  whom  we  are  indebted  for  so  many  important 
contributions  to  our  knowledge  of  pleurisy.*  Of  90  cases  of  acute  pleu- 
risy which  had  been  under  observation  between  1849  and  1879,  32  died 
of  or  had  phthisis — a  percentage  large  enough  to  indicate  what  an  impor- 
tant roln  tuberculosis  plays  in  the  etiology  of  this  disease. 

Morbid  Anatomy. — In  sero-fibrinous  pleurisy  the  serous  exudate 
is  abundant  and  the  fibrin  is  found  on  tho  pleural  surfaces  and  scat- 
tered through  the  fluid  in  the  form  of  flocculi.  The  proportion  of 
these  constituents  varies  a  great  deal.  In  some  instances  there  is  very 
little  membranous  fibrin ;  in  others  it  forms  thick,  creamy  layers  and  ex- 
ists in  the  dependent  part  of  the  fluid  as  whitish,  curd-like  masses.  The 
fluid  of  sero-fibrinous  pleurisy  is  of  a  citron  color,  either  clear  or  slightly 
turbid,  depending  on  the  number  of  formed  elements.  In  some  instances 
it  has  a  dark-brown  color.  The  microscopical  exymination  of  the  fluid 
sliows  leucocytes,  occasional  swollen  cells,  which  may  possibly  be  derived 
from  tho  pleural  endothelium,  shreds  of  fibrillated  fibrin,  and  a  variable 
iiiunber  of  red  blood-corpuscles.  On  boiling,  the  fluid  is  found  to  be  rich 
in  albumen.  Sometimes  it  coagulates  spontaneously.  Its  composition 
closely  resendjles  that  of  blood-serum.  Cholesterin,  uric  acid,  and  sugar 
are  occasionally  found.  The  amount  of  the  effusion  varies  from  a  half  to 
four  litres. 

Tlic  lung  in  acute  sero-fibrinous  pleurisy  is  more  or  less  compressed.  If 
the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic ;  but  in  an  exten- 
sive ctlusion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 

*  Vincent  Y.  Bowditch,  in  Boston  Medical  and  Surgical  Journal,  1889. 


fi  ' 


ti: 


f 

K    '5 


560 


DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


lying  close  to  the  spine,  dark  and  airless,  or  even  bloodless — i.  c.,  car- 
nified. 

In  large  exudations  the  adjacent  organs  are  displaced.  In  large  riglit- 
sided  pleurisies  the  liver  is  much  depressed.  Rather  varying  stattmiciits 
are  made  ^vitll  reference  to  the  position  of  the  heart  and  as  to  whether  or 
not  it  rotates  on  its  axis.  In  a  number  of  post-mortems  I  have  carefully 
studied  its  position,  both  in  pneumothorax  and  in  large  effusions,  and  am 
speak  with  some  degree  of  certainty  on  the  following  points:  (1)  Even  in 
the  most  extensive  left-sided  exudation  there  is  no  rotjition  of  thi;  iipcx 
of  the  heart,  which  in  no  case  was  to  the  right  of  the  mid-sternal  line; 
(3)  tlie  relative  position  of  the  apex  and  ba.se  is  usually  maintained ;  in 
some  instances  the  apex  is  lifted,  in  others  the  whole  heart  lies  more  trans- 
versely ;  (.3)  the  riglit  chambers  of  the  heart  occupy  the  greater  portion  of 
the  front,  so  that  the  disj)lacement  is  rather  a  definite  dislocation  of  tlu; 
mediastinum,  witli  the  pericardium,  to  tlie  right,  than  any  special  twisting 
of  the  heart  itself ;  (4)  the  kink  or  twist  in  the  inferior  vena  cava  describcl 
by  Bartels  was  not  present  in  any  of  the  ciscs. 

Symptoms. — Prodromata  are  not  uncommon,  but  the  disease  may  set 
in  abruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side. 
It  is  remarkal)le,  however,  with  what  frequency  the  disease  comes  on  in- 
sidiously. The  pain  in  the  side  is  the  most  distressing  symptom,  am!  is 
usually  referred  to  the  nipple  or  axillary  regions.  It  must  be  remeinbenM], 
however,  that  pleuritic  pain  may  l)e  felt  in  the  abdomen  or  low  down  in 
the  back,  particularl}  when  the  dia])hragmatic  surface  of  the  pleiuii  is 
involved.  It  is  lancinating,  sliarp,  and  severe,  and  is  aggravated  by  cough. 
At  tliis  early  stage,  on  auscultation,  sometimes  indeed  on  palpation,  a  diy 
friction  rub  can  be  detected.  The  fever  rarely  rises  so  rapidly  as  in  pneu- 
monia, and  does  not  reach  the  same  grade.  A  temperature  of  from  10"2° 
to  103°  is  an  average  ])yrexia.  It  may  drop  to  normal  at  the  end  of  ii 
week  or  ten  days  witliout  tlie  appearance  of  any  definite  change  in  Ww 
physicrd  signs,  or  it  may  persist  for  several  weeks.  The  temperatui-c;  of 
the  affected  is  higher  than  that  of  the  sound  side.  Cough  is  an  (>!iily 
symptom  in  acute  pleurisy,  but  is  rarely  so  distressing  or  so  frequent  as  in 
pneumonia.  There  are  instances  in  which  it  is  absent.  The  expectora- 
tion is  usually  slight  in  amount,  mucoid  in  character,  and  occasionally 
streaked  with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  ])Mi'tly 
to  the  pain  in  tlie  side.  Later  it  results  from  tlie  coni{)ression  of  tlu'  lun;:, 
particularly  if  the  exudation  has  taken  place  ra[)idly.  When,  however, 
the  fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  without 
inducing  shortness  of  breath,  except  on  exertion,  and  the  patient  will  lie 
quietly  i'  ')e(l  without  evincing  the  slightest  respiratory  distress.  When  the 
effusion  i.,  large  the  patient  usually  prefers  to  lie  upon  the  affected  side. 

Physical  Sig^ns. — Inspection  shows  some  degree  of  immobility  on  the 
affected  side,  depending  upon  the  amount  of  exudation,  and  in  largo  eilu- 


ACUTE  PLEURISY. 


561 


pioii.-;  an  inorease  in  volume,  which  may  appear  to  bo  much  more  than  it 
really  is  as  determined  by  mensuration.  The  intercostal  spaces  are  oblit- 
erated. In  right-sided  effusions  the  ai)ex  beat  may  be  lifted  to  the  fourth 
interspace  or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  the 
axilla.  When  the  exudation  is  on  the  left  side  the  heart's  impulse  may 
n(pt  be  visible;  but  if  the  effusion  is  large  it  is  seeu  in  the  third  and 
fourtli  spaces  on  the  right  side,  and  sometimes  as  far  out  as  the  nip])le, 
or  t'vcn  l)eyoiul  it. 

Palpatiini  enables  us  more  sxiccessfully  to  determine  the  deficient 
ninvemcnts  on  the  affected  side,  aiul  the  obliteration  of  the  intercostal 
spaces,  and  more  accurately  to  define  the  position  of  the  heart's  impulse. 
In  simple  sero-fibrinous  eifusion  there  is  rarely  any  Oidcma  of  the  chest 
walls.  It  is  scarcely  ever  possible  to  obtain  lluctuatior.  Tactile  fremitus 
is  tr'vatly  diminished  or  abolished.  If  the  elfusion  is  slight  there  may  be 
oiilv  eiifeeblement.  The  absence  of  the  voice  vibrations  in  effusions  of 
any  size  constitutes  one  of  the  most  valuable  of  physical  signs.  In  children 
there  may  be  much  elfusion  with  retention  of  fremitus.  In  rare  cases  the 
vibrations  may  be  communicated  to  the  chest  walls  through  localized 
pleural  adhesions. 

Mensuration. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a 
(litference  of  from  half  an  inch  to  an  inch,  or  even,  in  large' effusions,  an 
inch  and  a  half,  may  be  found  between  the  two  sides.  Allowance  must 
he  miide  for  the  fact  that  the  right  side  is  naturally  larger  than  the  left. 
With  the  saddle-tape  the  diiference  in  expansion  between  the  two  sides 
can  bo  conveniently  measured. 

Pcrcumion. — Early  in  the  disease,  when  the  pain  in  the  side  is  severe 
and  the  friction  murmur  evident,  there  may  be  no  alteration,  but  with 
the  gradual  accumulation  of  the  fluid  the  resonance  becomes  '^  feotive, 
and  tiiially  gives  place  to  absolute  dulness.  From  day  to  day  the  gradual 
increase  in  height  of  the  fluid  may  be  studied.  In  a  pleuritic  effusion 
rising  to  the  fourth  inb  in  front,  the  percussion  signs  are  usually  very 
suggestive.  In  the  subclavicular  region  the  attention  is  often  aroused  at 
once  by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is 
heard  perhrqis  nu)re  commonly  in  this  situation  with  pleural  elfusion 
than  in  any  other  condition.  It  shades  insensibly  into  a  flat  note  in  the 
lower  niamnuiry  and  axilbvy  regions.  Skoda's  resonance  may  be  obtained 
also  '  ind,  just  al)ove  the  limit  of  effusion.  The  dulness  has  a  peculiarly 
ivsistant,  wooden  quality,  differing  from  that  of  pneumonia  and  readily 
reeognizcd  by  skilled  fingers.  It  has  long  been  kiiown  that  when  the 
patient  is  in  the  erect  posture  the  upper  line  of  dulness  is  not  horizontal, 
hut  is  higher  behind  than  it  is  in  front,  forming  a  parabola.  Ellis  and 
Clarland,  of  Boston,  who  have  made  a  careful  study  of  this  question,  state 
tliat  the  line  of  dulness  from  behind  forward  may  sometimes  be  repre- 
sented by  a  curved  line  resembling  the  letter  S.  The  condition  is  fully 
considered  in  Garland's  exhaustive  work  on  Pneumo-dynamics. 


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562 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


On  the  right  side  tlio  dulness  passes  without  change  into  that  of  tlip 
liver.  On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate 
Traube's  semiluniir  space.  If  the  effusion  is  moderate,  the  phenonienon 
of  movable  dulness  nuiy  be  obtained  by  marking  carefully,  in  the  sittiiij; 
posture,  the  ui)per  limit  in  the  mammary  region,  aJid  then  in  the  r(!fnnn- 
bent  posture,  noting  the  change  in  the  height  of  dulness.  This  infallible 
sign,  of  fluid  cannot  always  be  obtained.  In  very  cojjious  exudation  the 
dulness  may  reach  the  clavicle  and  even  extend  beyond  the  sternal  mar- 
gin of  the  oj)p()site  side. 

Auscultation. — Early  in  the  disease  a  friction  rub  can  usually  bo  hoard, 
which  disappears  as  the  fluid  accumulates.  It  is  a  to-and-fro  diy  riiii, 
close  to  the  ear,  and  has  a  leathery,  creaking  character.  1'here  is  another 
pleural  friction  sound  which  closely  resembles,  and  is  scarcely  to  be  dis- 
tinguished from,  the  fine  crackling  crepitus  of  pneumonia.  This  may  be 
heard  at  the  commencement  of  the  disease,  and  also,  as  ])ointed  out  in 
1844  by  MatiDonnell,  Sr.,  of  Montreal,  when  the  effusion  has  receded  and 
the  pleural  layers  come  together  again. 

Witli  even  a  slight  exudation  there  is  weakened  or  distant  breathing;. 
Often  inspiration  and  expiration  are  distinctly  audible,  though  distant. 
and  have  a  tubular  quality.  Sometimes  only  a  puffing  tubular  expiration 
is  heard,  which  may  have  a  metallic  or  amphoric  quality.  Loud  resoniint 
rAles  accompanying  this  may  forcibly  suggest  a  cavity.  These  pseudo- 
cavernous  signs  are  met  with  more  frequently  in  children,  and  often  lead 
to  error  in  diagnosis.  Above  the  line  of  dulness  the  breath-sounds  are 
usually  harsh  and  exaggerated,  and  may  have  a  tubular  quality. 

The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered 
voice  is  said  to  be  transmitted  through  a  serous  and  not  through  a  ])uru- 
lent  exudate  (Baccelli's  sign).  There  may,  howeVer,  be  intensification— 
bronchojihony.  The  voice  sometimes  has  a  curious  nasal,  squeaking  char- 
acter, which  was  termed  by  Laennec  ceyophony,  from  its  supposed  resem- 
blance to  the  bleating  of  a  goat.  In  typical  form  this  is  not  common,  but 
it  is  by  no  means  rare  to  hear  a  curious  twang-like  quality  in  the  voice, 
particularly  at  the  outer  angle  of  the  scapula. 

In  the  examination  of  the  heart  in  cases  of  pleuritic  effusion  it  is  w(  11 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sterinuii 
there  may  be  no  impulse.  The  determination  of  the  situation  of  the  orpin 
may  rest  with  the  position  of  maximum  loudness  of  the  soujuls.  In  tlic 
disphuicd  organ  a  systolic  murmur  may  be  heard.  When  the  lappet  of  lunir 
over  the  pericardium  is  involved  on  either  side  there  may  be  a  pleuro-jiori- 
cardial  friction. 

The  course  of  acute  sero-fibrinous  pleurisy  is  very  variable.  After  i)or- 
sisting  for  a  week  or  ten  days  the  fever  subsides,  the  cough  and  pain  dis- 
appear, and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  in  wliioh 
the  effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
Many  instances  come  under  observation  for  the  first  time,  after  two  or 


ACUTE   PLEURISY. 


563 


tlirco  weeks'  indisposition,  with  the  fluid  at  a  level  with  the  clavicle.  The 
fever  may  last  from  ten  to  twenty  days  without  exciting  anxiety,  though, 
as  a  rule,  in  ordinary  pleurisy  from  cold,  as  wc  say,  the  temperature  in 
ciiscs  of  moderate  severity  is  normal  within  eight  or  ten  days.  Left  to 
itself  tlie  'liitural  tenden(!y  is  tc  resorj>tion ;  but  this  may  tiike  place  very 
slowlv.  Even  after  it  has  persisted  for  months  a  sero-Hbrinous  exudate 
iiiiiv  completely  liisappear.  With  the  absorption  of  the  fluid  there  is  a 
r('(hix-friction  crepitus,  either  leathery  and  creaking  or  crackling  and  rale- 
like, and  for  months,  or  even  longer,  the  defective  resonance  and  feeble 
breathing  are  heard  at  the  base. 

A  sero-fil)rinous  exudate  may  persist  for  months  Avithout  change,  par- 
tif'uiiirly  in  tuberculous  cases,  and  will  sometimes  reaccumulato  after  asj)i- 
ration  and  resist  all  treatment.  The  change  of  the  exudate  into  pus  will 
be  spoken  of  in  connection  with  em])yema.  Death  is  a  rare  termination 
of  soro-flbrinous  effusion.  AVhen  one  i)leura  is  full  and  the  heart  is  greatly 
dislocated  the  (iondition,  although  in  a  nuijority  of  cases  producing  re- 
iiiiirkably  little  disturbance,  is  not  without  risk.  Sudden  death  may  occur, 
ami  its  possibility  under  these  circumstJinces  should  always  be  considered. 
I  have  seen  two  instances — one  in  right  and  the  other  in  left  sided  eifu- 
sion — both  due,  apparently,  to  syncope  following  slight  exertion,  such  as 
getting  out  of  bed.  In  neither  ctise,  however,  wiis  the  amount  of  fluid 
excessive.  Weil,  Avho  has  studied  carefully  this  accident,  concludes  as 
follows:  (1)  That  it  may  be  due  to  thrombosis  or  embolism  of  the  heart 
or  nulinouary  artery,  unlema  of  the  opposite  lung,  or  degeneration  of  the 
heart  nniscle ;  (2)  such  alleged  causes  as  mechanical  impediment  to  the 
circulation,  OA>'ing  to  dislocation  of  the  heart  or  twisting  of  the  great  ves- 
sels, require  further  investigation.  It  occurs  more  frequently  in  right  than 
in  left  pleurisies,  and  the  etTusitm  is  usually  serous.  Death  may  occur 
without  any  premonitory  symptoms,  usually  during  some  movement  or 
effort. 

III.  PuiiULENT  Pleurisy  {Empyemn). 

Etiology. — Pus  in  the  pleura  is  met  with  under  the  following  con- 
ditions: [(()  As  a  serpience  of  acute  sero-fibrinous  pleurisy.  It  is  not 
always  easy  to  say  why,  in  certain  cases,  the  exudate  becomes  punilent. 
It  rarely  does  so  in  the  acute  pleurisies  of  healthy  individuals.  In  chil- 
dren many  cases  are  probably  purulent  from  the  outset.  Aspiration, 
which  is  said  to  favor  the  occurrence  of  empyema,  in  my  experience  does 
so  very  rarely,  [b)  Purulent  pleurisy  is  common  as  a  secondary  inflam- 
mation in  various  infectious  diseases,  among  which  scarlet  fever  takes 
the  first  place.  It  has  long  been  known  that  the  pleurisy  superven- 
ing in  the  convalescence  of  tliis  disease  is  almost  always  j)urulent.  It 
should  he  remembered  that  it  is  latent  in  its  onset,  and  that  there  may  be 
no  j)nlmonary  symptoms.  The  pleurisy  following  typhoid  fever  is  also 
usually  purulent.    Other  infectious  diseases — measles  and  whooping-cough 


■^t,:0^-^' 


664 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


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— are  more  mroly  followed  by  this  conplication.  Of  late  years  especial 
attention  has  been  paid  to  the  connection  of  pneumonia  with  empyctiiu, 
and  it  has  been  shown  that  very  many  cases  come  on  insidiously  either  in 
the  course  of  or  during  convalescence  from  this  disease;  and,  lastly,  a  hiii- 
ited  nund)er  of  tuberculous  pleurisies  early  beconus  purulent,  (r)  Km- 
pyema  results  from  local  causes — fracture  of  the  rib,  ])enetrating  woiiiids, 
nudignant  disease  of  the  lung  or  oesophagus,  antl,  perhaps  most  fretpiciitlv 
of  all,  the  pei'foration  of  the  pleura  by  tuberculous  cavities. 

The  bacteriology  of  em^jyema  is  of  some  im])ortance.  A  sterile  exu- 
date suggests  tuberculosis.  In  many  cases  the  pneumococci  are  pi-csciit, 
and  these,  as  a  rule,  run  a  very  favorable  course.  The  strepto(H)eci  are 
found  most  commoidy  in  the  secondary  cases  in  connection  with  sej)tie 
processes.  In  a  few  instances  psorosperms  liave  been  found  in  the  exu- 
date. 

Morbid  Anatomy. — On  oi)ening  an  empyema  post  mortem,  we 
usually  find  that  the  elfusion  has  separated  into  a  clear,  greenish-yellow 
serum  above  and  the  thick,  cream-like  pus  below.  The  fluid  may  be 
scarcely  more  than  turbid,  with  flocculi  of  fibrin  through  it.  In  other  in- 
stances it  is  uniforndy  thick  and  creamy,  without  any  fibrin.  It  usually 
has  a  heavy,  sweetish  odor,  but  in  some  instances — particularly  those  fol- 
lowing wounds — it  is  fetid.  In  cases  of  gangrene  of  the  lung  or  })leura 
the  pus  has  a  horribly  stinking  odor.  Microscopically  it  has  the  charac- 
ters of  ordiiuiry  pus.  The  pleural  membranes  are  greatly  thickened,  and 
present  a  grayish-white  layer  from  1  to  2  mm.  in  thickness.  On  the 
costal  jdeura  there  may  be  erosions,  and  in  old  cases  fistulous  comnninica- 
tions  are  common.  The  lung  may  be  compressed  to  a  very  snudl  limit, 
and  the  visceral  pleura  also  may  show  perforations. 

Symptoms.— Purulent  pleurisy  may  begin  abruptly,  with  the  symp- 
toms already  described.  More  frequently  it  comes  on  insidiously  in  the 
course  of  other  diseases  or  follows  an  ordiruiry  sero-fibrinous  pleurisy. 
There  may  be  no  pain  in  the  chest,  very  little  cough,  and  no  dyspiuea, 
unless  the  side  is  very  full.  Symptoms  of  septic  infection  are  rarely 
wanting.  If  in  a  child,  there  is  a  gradually  developing  pallor  and  weak- 
ness ;  sweaLs  occur,  and  there  is  irregular  fever.  A  cough  is  by  no  mmn 
constant. 

Physical  Signs.— Practically  they  are  those  already  considered  in  pleu- 
risy with  effusion.  There  are,  however,  one  or  two  additional  points  to 
be  mentioned.  In  empyema,  particularly  in  children,  the  disi)ro]i(trtion 
between  the  sides  may  be  extreme.  The  intercostal  spaces  may  not  only 
be  obliterated,  but  may  bulge.  Much  more  frequently  there  is  (edema  of 
the  chest  walls.  The  network  of  subcutaneous  veins  may  be  very  distinct. 
It  must  not  be  forgotten  that  in  children  the  breath-sounds  may  tie  loud 
and  tubular  over  a  purulent  effusion  of  considerable  size.  Whispered 
pectoriloquy  is  usually  not  heard  in  empyema  (Baccelli's  sign).  The  dis- 
location of  the  heart  and  the  displacement  of  the  liver  are  more  marked 


ACUTE  PLEURISY. 


665 


ill  empyema  than  in  sero-fibrinous  efFusion — probably,  as  Senator  suggests, 
owin"  to  the  greater  weight  of  the  Huid. 

A  (uirioiis  phenomenon  associated  generally  with  empyema,  but  which 
iiKiV  occur  in  the  sero-fibrinous  exudate,  is  pulsntitKj  plenrixy,  first  de- 
scribed by  MacDoiinell,  Sr.,  of  Montreal.     Of  42  cases  'M)  oecmrrcd  on 
tlu' iv'ft  side.     In  all  but  one  case  the  fluid  was  purulent.     Pneumothorax 
iiiMV  be  present.     There  are  two  groups  of  cases,  the  intraj)leural  pulsat- 
iiii,'  pleurisy  and  the  pulsating  emj)ye7na  necessitatis,  in  which  there  is  an 
external  pulsating  tumor.     No  satisfactory  explanation  has  been  offered 
liDW  the  iieart  impulse  is  thus  forcibly  communicated  through  the  effusicm. 
Mmpyema  is  a  chronic  affection,  which  in  a  few  ii\stances  termiiuites 
imtmallv  in  recovery,  but  a  nuijority  of  cases,  if  left  alone,  end  in  death. 
The  following  are  some  modes   of  natural  cure:   (ti)  By  absorption  of 
the  tluid.     In  small  effusions  this  may  take  place  gradually.     The  chest 
wall  sii\ks.     The  pleural  layers  become  greatly  thickened  and  enidose  be- 
tween them  the  inspissated  pus,  in  which  lime  salts  are  gradually  deposited. 
Such  a  condition  may  be  seen  once  or  twice  a  year  in  the  post-mortem 
room  of  any  large  hospital,     (b)  By  perforation  of  the  lung.     Although 
in  this  event  death  may  take  ])lace  rapidly,  by  inundation  of  the  bronchial 
tulies,  yet  in  many  cases  it  occurs  gradually  and  recovery  follows.     Since 
ISlo,  when  I  saw  a  case  of  this  kind  in  Traube's  clinic,  and  heard  his 
rciimrks  on  the  subject,  I  have  seen  a  number  of  instances  of  the  kind 
and  can  corroborate  his  statement  as  to  the  favorable  termination  of  many 
(if  them.     Empyema  may  discharge  either  by  opening  into  the  bronchus 
and  forming  a  fistula  or,  as  Traube  pointed  out,  by  producing  nc  rosis  of 
tlie  pulmonary  pleura,  sufficient  to  allow  the  soakage  of  the  pus  through 
tiio  spongy  lung  tissue  into  the  bronchi.     In  the  first  way  pneumothorax 
usually,  tiiongh  not  always,  develops.     In  the  second  way  the  pus  is  dis- 
charged without  formation  of  pneumothorax.      Even  with   a  bronchial 
fistula  recovery  is  possible.    (6')  By  perforation  of  the  chest  wall — empyema 
necenailntis.     This  is  by  no  means  an  unfavorable  method,  as  many  cases 
recover.     The  perforation  may  occur  anywhere  in  the  chest  wall,  but  is, 
asCrnveilhier  remarked,  more  common  in  front.     It  may  be  anywhere 
from  the  third  to  the  sixth  interspace,  usually,  according  to  Marshall,  in 
the  iifth.    It  may  perforate  in  more  than  one  place,  and  there  may  be  a 
fistulous  communication  which  opens  into  the  pleura  at  some  distance 
from  the  external  orifice.     The  tumor,  when  near  the  heart,  may  pulsate. 
The  (lis('hurge  may  persist  for  years.     In  Oopeland's  Dictionary  is  men- 
tioned an  iii.stance  of  a  Bavarian  physician  who  had  a  pleural  fistula  for 
thirteen  years  and  enjoyed  fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  (rsophagus, 
peritonsruni,  pericardium,  or  the  stomach.  Very  remarkable  cases  are 
those  which  pass  down  the  spine  and  along  the  psoas  into  the  iliac  fossa, 
and  simulate  a  psoas  or  lumbar  abscess. 


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666 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


IV.  TuBKRCULoua  Pleurisy. 


Tliia  hiifl  already  been  considered.  Iloro  it  is  suRicient  to  say  that  it 
occurs  as:  {a)  An  acute  utToction,  ac('om])anie(l  hy  abundant  siTo-lihiinoim 
fluid.  In  this  category  come  certainly  a  proportion  of  the  cases  rcf^Mnlcd 
as  acute  ])h'urisy  from  cold,  (b)  As  a  subacute  affection,  latent  in  its 
origin  and  insidious  in  its  course,  frequently  preceding  the  develnpinciii 
of  or  coming  on  concurrently  with  ]>ulnionary  tuberculosis,  (r)  As  an 
acute  pleurisy,  the  result  of  direct  extension  from  the  lung  in  ciiscs  of 
well-marked  phthisis,  and  in  which  the  fluid  may  he  either  sero-til)riii(ius 
or  purulent.  (</)  Chronic  adhesive  tuberculous  pleurisy,  which  niav  Im- 
unilateral  or  lulateral,  unaccompanied  by  exudati(m  and  characterized  hv 
great  thickening  of  the  pleural  membranes,  in  Avhich  are  tubercles  ami 
caseous  nuisses  of  varying  sizes. 

The  sym])toms  aiul  physical  signs  of  tuberculous  pleurisy  with  exuda- 
tion do  not  require  any  description  other  than  that  already  given  in  con- 
nection with  the  sero-fibrinous  and  purulent  forms. 

V.  Other  Varieties  of  Pleurisy. 

Hsemorrhagic  Pleurisy.— A  bloody  effusion  is  met  with  under  the  fol- 
lowing coiulitions:  (a)  In  the  jdeurisy  of  asthenic  states,  such  as  cancer, 
Bright's  disease,  and  occasionally  in  the  malignant  fevers.  It  is  inter- 
esting to  note  the  frequency  Avith  which  liaemorrhagic  pleurisy  is  ftiniid 
in  cirrhosis  of  the  liver.  It  occurred  in  the  very  patient  in  whom  Laeiniei' 
first  accurately  described  this  disease.  While  this  may  be  a  simple 
liaemorrhagic  pleurisy,  in  a  majority  of  the  cases  Avhich  I  have  seen  it 
has  been  tuberculous,  (b)  Tuberculous  pleurisy,  in  which  the  Ijloody 
effusion  may  result  from  the  rupture  of  newly  formed  vessels  in  the  soft 
exudate  accom])anying  the  eruption  of  miliary  tubercles,  or  it  may  come 
from  more  slowly  formed  tubercles  in  a  pleurisy  secondary  to  extensive 
pulmonary  disease,  (c)  Cancerous  pleurisy,  whether  primary  or  second- 
ary, is  frequently  liaemorrhagic.  (d)  Occasionally  luemorrhagic  exudation 
is  met  with  in  perfectly  healthy  individuals,  in  whom  there  is  not  the 
slightest  suspicion  of  tuberculosis  or  cancer.  In  one  such  case,  a  large, 
able-bodied  man,  the  patient  was  to  my  knowledge  healthy  and  stronsr 
eight  years  afterward.  And,  lastly,  it  must  be  remembered  that  duriii}; 
aspiration  the  lung  may  be  wounded  and  blood  in  this  way  got  mixed 
with  the  sero-fibrinous  exudate.  The  condition  of  haemorrhagic  pleurisy 
is  to  be  distinguished  from  haemothorax,  due  to  the  rupture  of  anourisni 
or  the  pressure  of  a  tumor  on  the  thoracic  veins. 

Diaphragmatic  Pleurisy.— The  inflammation  may  bo  limited  jiartly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  pleurisy,  but 
there  may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  circum- 
scribed, on  the  diaphragmatic  surface.     In  these  cases  the  pain  is  low  in 


ACUTP]   PLEURISY. 


667 


I   T7" 


rl 


the  zone  of  the  (liaphragm  imd,  as  (Jiu'noaii  do  Muasy  pointed  out,  may 
l)f  iiiti'iisilied  by  prassuro  at  the  point  of  iiisiM'tion  of  the  diaphraj^ni  at 
the  tenth  rib.  The  diaphra^nn  is  fixed  and  tiio  respiration  is  thoraciic 
mill  siiort.  Andral  noted  in  certain  cases  severe  dyspno'a  and  attacks 
siiiiiiliitinij  angina.  As  mentioned,  the  ctTusion  is  usually  ])lasti(',  not 
si'idiis.  Serous  or  purulent  elTusions  of  any  size  limited  to  the  diaphrag- 
iiiiitir  surface  are  extremely  rare. 

Encysted  Pleurisy. — The  elt'usion  nuiy  be  circumscribed  by  adiiesions 
or  separated  into  two  or  more  pockets  or  loculi,  which  communicate  with 
ciirli  other.  This  is  most  common  in  empyema.  In  these  cases  there 
liiivc  usually  been,  at  different  parts  of  the  pleura,  nudtiple  adhesions  by 
which  the  tluid  is  limited.  In  other  instances  the  recent  false  membranes 
may  encapsulate  the  exudation  on  the  diaphragmatii!  surface,  for  example, 
or  the  part  of  the  pleura  posterior  to  the  mid-axillary  line.  The  con- 
dition may  be  very  puzzling  during  life,  and  present  special  ditliculties  in 
(liiii^uosis.  In  some  cases  the  tactile  fremitus  is  retained  along  certain 
liiK's  of  adhesion.  The  exploratory  needle  should  be  freely  used  when 
thiM-c  is  any  doubt. 

Interlobar  Pleurisy  forms  an  interesting  and  not  uncommon  variety. 
In  nearly  every  instance  of  acute  pleurisy  the  interlobular  serous  surfaces 
are  also  involved  and  closely  agglutinated  together,  aiul  sometimes  the 
Huid  is  encysted  between  them.  In  a  recent  case  of  this  kind  following 
pneumonia,  there  was  between  the  lower  and  upper  and  middle  lobes  of 
the  right  side  an  enormous  purulent  collection,  which  looked  at  first  like 
a  large  abscess  of  the  lung.  These  collections  may  perforate  the  bronchi, 
and  the  cases  present  special  diflficulties  in  diagnosis. 

Diagnosis  of  Pleurisy. — Acute  plastic  pleurisy  is  readily  recog- 
nized. In  the  diagnosis  of  pleuritic  eifusion  the  first  question  is,  Does  a 
litiid  exudate  exist?  the  second,  What  is  its  nature?  In  large  effusions 
tlie  increase  in  the  size  of  the  affected  side,  the  immobility,  the  absence  of 
tactile  fremitus,  together  with  the  displacement  of  organs,  give  infallible 
indieations  of  the  presence  of  fluid.  The  chief  difficulty  arises  in  effusions 
of  moderate  extent,  when  the  dulness,  the  presence  of  bronchophony, 
and,  perhaps,  tubular  breathing  may  simulate  pneumonia.  The  chief 
points  to  be  borne  in  mind  are :  {n)  Differences  in  the  onset  and  in  the 
sjenerul  characters  of  the  two  affections,  more  particularly  the  initial  chill, 
till'  higher  fever,  more  urgent  dyspnoea,  and  the  rusty  ex[)ectoration,  which 
characterize  pneumonia,  {b)  Certain  physical  signs — the  more  wooden 
character  of  the  dulness,  the  greater  resistance,  and  the  marked  diminu- 
tion or  the  absence  of  tactile  fremitus  in  pleurisy.  The  auscultatory  signs 
may  bo  deceptive.  It  is  usually,  indeed,  the  persistence  of  tubular  breath- 
ing, particularly  the  high-pit'^hed,  even  amphoric  expiration,  heard  in 
some  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal  spaces 
are  more  commonly  obliterated  in  pleuritic  effusion  than  in  pneumonia. 
As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable  sign. 


i 


1^ 


\       '     !      '  L.         *'■ 


-1   /JJ 


568 


DISKASKS  op  THE   IIESPIIIATOIIY  SYSTEM. 


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4-t  8aiaH8.    It 


Nowiuiiiys  with  the  liyp-Klorniic,  noedlt!  tho  qiicHtion  is  ciisiiy  scttli-il.  A 
BiipiiniU*  Hiiiall  Hyriti^(*  with  ii  ciipiicity  of  two  druchnis  shoiiid  h(!  rcscivod 
for  nxplonitory  piirposos,  luul  tho  iiet'dlo  whould  ho  h)ii;,'fr  and  liimor 
than  in  tlio  ordiimry  hypixk'rriiio  iiiHtriiniont.  Witii  curofid  prcUiiiiiiiirv 
(liHinfcction  tiio  iiistruiiiont  can  ho  uscMi  witli  impunity,  and  in  cases  of 
douht  tho  oxph)ratory  punctiiro  shoidd  ho  niado  without  Ju'sitatioii. 
I  havo  nover  80on  tho  sIi,','hto.st  ill  elToots  follow  its  uso.  Cases  are 
reported  of  pnoiiinothorux  resulting  from  it,  hut  thoy  aro  extreiiiclv 
rare.  Tho  hypodorniio  noodlo  is  ospooially  usoful  in  those  oases  in  wliicli 
thoro  aro  ])soudo-oavernou8  8i<j;ns  at  tho  haso.  In  oases,  too,  of  iimssive 
pneumonia,  in  which  tho  hronohi  aro  pluj^'j^od  with  fihrin,  if  the  pulierit 
has  not  bceu  seen  from  tho  outset,  the  diagnosis  may  bo  impossiblo  with- 
out it. 

On  the  loft  side  it  may  bo  difficult  to  dilTorentiato  a  very  lurjjo  peri- 
cardial fnmi  a  pleural  olfusion.  Tho  retention  of  rosonan(!o  at  tlie  base, 
tho  i)rosoTioo  of  tSkoda's  resonance  toward  the  axilla,  the  absence  of  dis- 
location of  tho  heart-beat  to  the  right  of  the  sternum,  tho  feebleness  of 
tho  pulso  and  of  tho  heart-sounds,  and  tho  urgency  of  the  dyspiKea,  diit 
of  all  pro[)ortion  to  tho  extent  of  the  otfusion,  aro  tho  ((liicf  points  tn  lie 
considered,  irnilatoral  hydrothorax,  whicdi  is  not  at  all  unconuiioM  in 
heart-disease,  presents  signs  identical  with  those  of  sero-fibrinous  etriisiitii. 
Certain  tumors  within  the  oliest  nuiy  simulate  pleural  effusion.  It  should 
be  remembered  that  many  intrathoracic  growths  aro  acf^ompanied  l)y  <'.\ii- 
dation.  Malignant  disease  of  the  lung  and  of  tho  pleura  and  hydatids  of 
the  pleura  ])rotluco  extensive  dulness,  with  suppression  of  tho  breath- 
sounds,  simulating  closely  effusion. 

On  the  right  side  abscess  of  the  liver  ar.d  hydatid  cysts  may  rise 
high  into  the  jjloura  and  produce  dulness  and  onfeeblod  breathing.  Often 
in  these  cases  thoro  is  a  friction  sound,  which  should  excite  siisnirjon, 
and  the  ixpper  outline  of  the  dulness  is  sometimes  plainly  convex.  In  all 
these  instances  the  exploratory  puncture  should  bo  made. 

The  second  qxxestion,  as  to  the  nature  of  the  fluid,  is  quickly  de(dde(l 
by  the  nse  of  the  needle.  The  persistent  fever,  the  occun'once  of  sweats, 
and  tho  increase  in  the  pallor  suggest  the  presence  of  pus.  In  cliildreu 
the  comi)lexion  is  often  sallow  and  earthy.  Tho  nnexpected,  however, 
often  happens,  and  rei)eatedly,  in  protracted  cases,  even  in  children,  when 
the  general  symptoms  and  the  appearance  of  the  patient  has  been  most 
strongly  suggestive  of  pus,  the  syringe  has  withdrawn  clear  liiud.  <»n 
the  other  hand,  effusions  of  short  duration  may  be  purulent,  even  wlien 
the  general  symptoms  do  not  suggest  it.  The  following  statement  may 
be  made  with  reference  to  the  prognostic  import  of  the  bacteriological 
examination  of  the  aspirated  fluid  :  The  presence  of  the  pneumoeoeciis  is 
of  favorable  significance,  as  such  cases  usually  get  well  rapidly,  even  with 
a  single  aspiration.  The  pus  organisms — staphylococci  and  streptococci- 
are  more  common  in  empyema  of  septic  origin,  and  such  cases  are  uotori- 


ACUTE  PLKURISY. 


509 


oiislv  It-Hs  liopcfiil  tliiiii  otiiors.     A  storilc  fluid  iiitli(^!it«'>(  in  ii  iniijority  o! 
iiistiiiicfs  11  tiil)t'rculi)us  ()ri;,Mii. 

Treatment. — At  tho  onsot  tho  wvcrr  pain  may  doinmul  loochcH, 
wlii  li  usuiilly  givo  relief,  l)iit  ii  liypodcrinic  of  luorpliiu  is  more  cU'wtivc 
'i'l:i'  I'liqiicliii  ciiutcry  may  !>('  li<,'litly  hut  freely  applieij.  It  is  widl  to 
iiiliiiiuister  a  mercurial  or  saline  purj^e.  Fixing  tlie  side  liy  eareful  strap- 
iiiiiir  witli  Ion;;  strips  of  adhesive  plaster,  wiiich  should  pass  well  over  tho 
niiiMIe  line,  drawn  tij^htly  and  eveidy,  gives  great  relief,  and  I  can  (Cor- 
roborate tho  statenuint  of  F  T.  Ifolterts  us  to  its  etlicacy.  Cupping,  wet 
ordrv,  is  now  seldom  emi)loyed.  IMisti'rs  arc  of  no  special  service!  in  tho 
iiciitc  stages,  although  they  relieve  the  pain.  The  ice-hag  may  he  used  as 
ill  pneumonia.  The  geiu'ral  treatment  (>f  the  early  stage  should  be  re.st 
ill  lit'd  and  a  li(piid  diet.  Medicines  are  rarely  recpiired.  A  Dover's 
powder  may  ho  given  at  night.     Mercurials  are  not  indicated. 

When  tho  ell'usion  has  taken  place,  mustard  plasters  or  iodine,  pro- 
ducing slight  counter-irritation,  appear  useful,  particularly  in  the  later 
stages.  The  following  rational  plan  is  succe-ssful  in  some  cases.  It  is 
Imsed  upon  tho  idea  that  if  the  blood  serum  is  depleted  or  if  it  is  kept 
I'liiKciit rated,  the  liquid  will  be  absorbed  from  the  lymjjh  spaci-s,  of  which 
the  pleura  is  one,  to  ecpialize  the  loss.  To  do  this  tho  jiatient  should 
liavu  the  daily  amount  of  liquid  food  greatly  restricted.  If  there  is  no 
fever,  a  meat  diet,  with  an  egg  and  dry  bread  ;>iul  eight  to  ton  ounces 
of  liquid  ill  tho  form  of  milk  or  water,  should  bo  given.  Salt  articles  of 
food  limy  be  used,  but  I  do  not  think  it  necessary  to  give,  as  some  do, 
(loses  of  salt.  Tho  second  element  in  tho  treatment  is  the  active  depletion 
of  blood  serum,  which  is  eifected  in  tho  way  introduced  by  Matthew  Ilay. 
Every  morning,  if  the  patient  is  robust,  otherwise  every  second  morning, 
fioiii  lialf  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts  is  given  an  hour 
before  breakfast,  in  as  concentrated  a  form  as  is  ]K)ssiblo.  T'his  [iroducos 
copious  licjuid  discharges.  I  have  seen  large  exudations  disappear  rapidly 
waeii  this  plan  was  followed.  By  acting  upon  the  skin  and  kidneys,  tho 
'Mine  end  may  bo  obtained,  but  with  much  less  certainty.  The  vapor  or 
hot  bath  may  bo  used  and  an  occasional  dose  of  ))ilocarpin.  Diuretics, 
such  as  digitalis,  squills,  and  acetate  of  potash,  may  sometimes  bo  required. 
I  rarely  resort,  however,  to  dinreticr.  or  diai)lioretic8  in  the  treatment  of 
lileiirisy  with  elfusion.     Iodide  of  potassium  is  of  doubtful  benefit. 

Aspiration  of  the  iluid  is  the  most  thorough  and  satisfactory  method 
and  sliould  be  resorted  to  whenever  the  effusion  becomes  largo  or  if  it  re- 
sists tho  ordinary  methods  of  treatment.  The  credit  of  introducing  aspi- 
ration in  pleuritic  effusions  is  due  to  Morrill  Wyman,  of  Cambridge,  Mass., 
and  Henry  I.  Bowditch,  of  Boston.  Years  prior  to  Dieulafoy's  work,  as- 
piration was  in  constant  use  at  tho  Massachusetts  (loneral  Hospital  and 
was  advocated  repeatedly  by  Bowditch.  As  the  question  is  one  of  some 
historical  interest,  I  give  the  author's  conclusions  concerning  aspiration, 
expressed  more  than  forty  years  ago,  and  which  practically  represent 


;;  :l . 


f     'I. 


.%'\ 


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a    .  -tit  ; 


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'1, 


"fcitl! 


Tl^- 

;1 

'  1  * 

'^i 

!?.' 

J_ 

4  >' 

i 

570 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


the  opinion  of  clinical  physicians  to-day  :  "  (1)  The  operation  is  perfectly 
simple,  but  slightly  painful,  and  can  be  done  with  ease  upon  any  patient 
in  however  advanced  a  stage  of  the  disease.  (2)  It  should  be  perfortniMl 
forthwith  in  all  cases  in  which  there  is  complete  filling  up  of  one  side  of 
the  chest.  (3)  lie  had  determined  to  use  it  in  any  case  of  even  moderate 
effusion  lasting  more  than  a  few  weeks  and  in  which  there  should  seem 
\o  be  an  indisposition  to  resist  ordinary  modes  )f  treiitment.  (4)  He 
urged  this  i)ractice  upon  the  profession  as  a  very  important  measure  in 
practical  medicine ;  believing  that  by  this  method  death  may  frequoiitlv 
be  prevented  from  ensuing  either  by  sudden  attack  of  dyspnani  or  sul),st'- 
quent  plithisis,  and,  finally,  from  the  gradual  wearing  out  of  the  powers 
of  life  or  inability  to  absorb  the  fluid.  (5)  lie  believed  that  this  operation 
would  "ometimes  prevent  the  occurrence  of  those  tedious  cases  of  spon- 
taneous evacuation  of  purulent  fluid  and  those  great  contractions  of  the 
chest  which  occur  after  long-(  oaiinued  effusion  and  the  subsequent  dis- 
charge or  absorption  of  a  fluid." 

There  is  scarcely  anything  to  be  added  to-day  to  these  observations. 
When  the  fluid  reaches  to  the  clavicle  the  indication  for  aspiration  is  im- 
perative, even  though  the  patient  be  comfortable  and  present  no  signs  of 
pulmonary  distress.  The  presence  of  fever  is  not  a  contra-indication ; 
indeed,  sometimes  with  serous  exudates  the  temperature  falls  after  sispi- 
ration. 

The  operation  is  extremely  simple  and  is  practically  without  risk. 
The  spot  selected  for  puncture  should  be  either  in  the  seventh  interspace 
in  the  mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  inter- 
space. The  arm  of  the  patient  should  be  brought  forward  witli  the  hand 
on  the  opposite  shoulder,  so  as  to  widen  the  interspaces.  The  needle 
should  be  thrust  in  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  the 
intercostal  artery,  the  wounding  of  which,  however,  is  an  excessively  rare 
accident.  The  fluid  should  be  withdrawn  slowly.  The  amount  will  de- 
pend on  the  size  of  the  exudate.  If  the  fluid  reaches  to  the  clavicle  a 
litre  or  more  may  be  withdrawn  witii  safety. 

During  aspiration  if  the  patient  feels  faint  it  is  best  to  interrupt  the 
operation,  for  sudden  death  has  occasionally  happened  during  the  with- 
drawal. It  is,  however,  a  much  less  common  accident  than  sudden  death 
in  cases  of  full  pleura  without  operation.  Cough  is  a  symptom  wliicli 
frequently  develops  toward  the  close  of  aspiration.  Though  very  painful 
it  need  not  excite  alarm.  French  writers  have  described  cases  of  iiUuuni- 
nous  expectoration,  associated  v/ith  dyspnoea,  which  may  come  on  after 
the  tapping  and  prove  rapidlv  fatal.  It  must  be  an  excessively  rare  com- 
plication. The  conversion  of  :i  sero-fibrinous  into  a  purulent  ilnid  is  a 
danger  which  need  not  be  considered,  I  have  never  met  with  an  instance 
of  the  kind. 

Empyema  is  really  a  surgical  affection,  and  I  shall  make  only  a  few 
general  remarks  upon  its  treatment.     When  it  has  been  determined  hv 


CHRONIC   PLEURISY. 


571 


exploratory  puncture  that  the  fluid  is  purulent,  aspiration  should  not  be 
iioiff)rmed,  except  as  preliminary  to  operation  or  as  a  temporary  measure. 
rcrhaps  it  is  better  not  to  have  an  exception  to  this  rule,  although  the 
(Miipyemas  of  children  and  the  pneumonic  empyema  occasionally  get  well 
rapiilly  after  a  single  tapping.     It  is  sad  to  think  of  the  number  of  lives 
wliirli  are  sacrificed  annually  by  the  failure  to  recognize  that  empyema 
should  be  treated  as  an  ordinary  abscess,  by  free  incision.     The  operation 
(latt'H  from  the  time  of  Hippocrates  and  is  by  no  means  serious.     A  ma- 
jdritv  of  the  cases  get  well,  providing  that  free  drainage  is  obtained,  and 
it  niiikcs  no  difference  practically  what  measures  are  followed  so  long  as 
this  indication  is  met.     The  good  results  in  any  method  depend  upon 
the  thoroughness  Avith  which  the  cavity  is  drained.     Irrigation  of  the 
cavity  is  rarely  necessary  unless  the  contents  are  fetid.     Sudden  collapse 
has  happened  during  irrigation  and  a  remarkable  accident  is  the  occur- 
rence of  convulsions.     In  the  subsequent  treatment  a  point  of  great  im- 
jKirtance  in  facilitating  the  closure  of  the  cavity  is  the  distention  of  the 
luiiK  on  the  alfected  side.     This  may  be  accomplished  by  the  method 
advised  hy  Walter  James,  which  has  been  practised  with  great  success  in 
the  surgical  wards  of  the  Johns  Hopkins  Hospital.     The  patient  daily, 
for  a  certain  length  of  time,  increasing  gradually  with  the  increase  of  his 
strength,  transfers  by  air-pressure  water  from  one  bottle  to  another.     The 
bottles  should  be  large,  holding  at  least  a  gallon  each,  and  by  the  arrange- 
ment of  tubes,  as  in  the  Wolff's  bottle,  an  expiratory  effort  of  the  patient 
forces  the  water  from  one  bottle  into  the  other.     In  this  way  expansion 
of  the  compressed  lung  is  systematically  practised.     The  abscess  cavity  is 
itradually  closed,  partly  by  the  falling  in  of  the  chest  wall  aiul  partly  by 
the  expansion  of  the  lung.     In  some  instances  it  is  necessary  to  resect 
portions  of  one  or  more  ribs. 

The  "i)hysician  is  often  asked,  in  oases  of  empyema  with  emaciation, 
hectic  and  feeble  rapid  pulse,  whether  the  patient  could  stand  the  opera- 
tion. Even  in  the  most  desperate  cases  the  surgeon  should  never  hesitate 
to  make  a  free  incision 


II.  CHRONIC  PLEURISY. 


This  affection  occurs  in  two  forms :  (1)  Chronic  pleurisy  with  effusion, 
in  vvliieli  the  disease  may  set  in  insidiously  or  may  follow  an  acute  sero- 
libriiujus  ])lcurisy.  There  are  cases  in  Avhich  the  li(piid  persists  for  months 
without  undergoing  any  spcnal  alteration  and  without  becoming  purulent. 
'  'uh  eases  have  the  characters  wliich  we  have  described  under  pleurisy 
wih  effusion.  (2)  Chronic  dry  pleuri^ij.  The  cases  are  met  with  («)  as 
aser|ueiu'e  of  ordinary  pleural  effusion.  AVhon  the  exudate  is  absorbed 
and  the  layers  of  the  pleura  come  together  there  is  left  between  them  a 
variable  amount  of  fibrinous  material  which  gradually  undergoes  organi- 
8T 


yp 


•   if''; 


572 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


zation,  and  is  convcrtetl  into  a  layer  of  firm  connective  tissue.  This  pro- 
cess goes  on  at  the  base,  and  is  re{)i'esented  clinically  by  a  sliglit  grade  of 
flattening,  deficient  expansion,  defective  resonance  on  jjcrcussion,  and  en- 
feebled breathing.  After  recovery  from  empyema  the  flattening  and  re- 
traction may  be  still  more  marked.  In  both  cases  it  is  a  condition  wliioh 
can  be  greatly  benefited  by  pulmonary  gymnastics.  In  these  firm,  fil)r()iis 
membranes  calcification  may  o(xuir,  ])articularly  after  em^iyema.  Jt  is 
not  very  uncommon  to  find  between  the  false  membranes  a  small  pocket 
of  fluid  forming  a  sort  of  pleural  cyst.  In  the  great  majority  of  tliese 
cases  the  condition  is  one  v.hich  lu'cd  not  cause  anxiety.  Tliere  may  bo 
an  occasional  dragging  pain  at  the  base  of  the  lung  or  a  stitch  in  the  side, 
but  patients  nuiy  remain  in  perfectly  good  health  for  years.  The  most 
advanced  grade  of  this  secondary  dry  jjleurisy  is  seen  in  those  cases  of  iin- 
pyema  which  have  been  left  to  themselves  and  have  perforated  and  ulti- 
mately healed  by  a  gradual  absorption  or  discharge  of  the  pus,  with  rctnic- 
tion  of  the  side  of  the  chest  and  pernuincnt  carnification  of  the  liinf,'. 
Traumatic  lesions,  such  as  gunshot  wouu'ls,  nuiy  be  followed  by  an  identi- 
cal condition.  Post  mortem,  it  is  quite  ini})ossible  to  separate  the  layers 
of  the  pleura,  Avhich  are  greatly  thickened,  particularly  at  the  base,  and 
surround  a  con^pressed,  airless,  fibroid  lung. 

{b)  Primitive  dry  phmrisi/.  This  condition  may  directly  follow  the 
acute  plastic  pleurisy  already  described  ;  but  it  nuiy  set  in  Avithout  any 
acute  symptoms  whatever,  aiul  the  jiaticnt's  attention  nuiy  be  called  to  it 
by  feeling  the  pleural  friction.  A  constant  effect  of  this  primitive  dry 
pleurisy  is  the  adhesion  of  the  layers.  1'his  is  probably  an  invariable  result, 
whether  the  ])lourisy  is  primary  or  secondary.  The  organization  of  the  tiiin 
layer  of  exudation  in  a  pneumonia  will  unite  the  tAvo  surfaces  by  delicate 
bands.  Pleural  adhesions  are  extremely  common,  and  it  is  rare  to  examine 
a  body  entirely  free  from  them.  They  may  be  limited  in  extent  or  univer- 
sal. Thin  fibrous  adhesions  do  not  produce  any  alteration  in  the  ])erc'ussion 
characters,  and,  if  limited,  there  is  no  special  change  heard  on  ausculta- 
tion. When,  however,  there  is  general  synechia  on  both  sides  the  ex[)aii- 
sile  movement  of  the  lung  is  considerably  impaired.  We  should  naturally 
think  that  universal  adhesioTis  Avould  interfere  materially  with  the  fune- 
tiou  of  the  lungs,  but  practically  we  see  numy  instances  in  which  there 
has  not  been  the  slightest  disturbance.  The  physical  signs  of  total  adlu- 
sion  arc  by  no  means  constant.  It  has  been  stated  that  there  is  a  niarked 
disproportion  between  the  degree  of  ex]iansion  of  the  chest  walls  and  the 
intensity  of  the  vesicular  murmur,  but  the  latter  is  a  very  variable  factor, 
and  under  perfectly  normal  conditions  the  breath-sounds,  with  very  full 
chest  expansion,  may  be  extremely  feeble. 

Is  there  a  primitive  dry  pleurisy  which  gradually  leads  to  great  thick- 
ening of  the  membranes,  and  Avhich  ultimately  nuiy  invade  the  luui,'  and 
induce  cirrhotic  change?  Upon  this  question  neither  pathologists  nor 
clinicians  agree.     I  think  that  Sir  Andrew  Clark,  in  hia  Lumleian  lectures 


CHRONIC  PLEURISY. 


573 


lis  pro- 
;viule  of 
and  en- 
iind  ve- 
il wliii'l) 
,  librous 
i.     It  is 
I  pocket 
of  these 
J  may  bo 

the  side, 
L'lio  inoKt 
;cs  of  em- 
aiid  idti- 
th  retnie- 
tlie  lun<,^ 
ill!  idei\ti- 
the  layers 

biuse,  and 

follow  the 

itlnmt  any 

died  to  it 

mitive  dry 

lo  result, 

f  the  thill 

)y  delieati! 

0  examine 
or  iiiiiver- 
pcreussion 

iiuscultu- 
tho  expan- 

1  naturally 
the  fune- 

lii(di  there 
total  adlu'- 
s  11  marked 
llriand  the 
ible  factor, 
h  very  full 

ircat  thick- 
10  liing  i"»'^ 
llojiists  "<"■ 
[an  lectures 


) 


lit  the  Royal  College  of  Physicians  (1885),  has  made  good  his  claim  that 
such  a  disease  docs  exist.      At  the  outset  in  tlicse  cases  there  is  a  dry 
iileurisy,  usuiilly  at  one  base,  indicated  by  the  usual  signs;  and  this  per- 
sists in  spite  of  all  treatment.     There  is  no  evidem^e  of  fluid  ;  the  general 
licalth  may  not  be  much  impaired,  or  there  may  be  slight  fever  a:. J  dis- 
turljed  digestion.      The  cases  give  great  anxiety,  owing  to  the  natural 
suspicion  that  tuberculosis  exists.      In  time  the  evidence  of  dulness  is 
found  at  the  base.      There  are  feeble  breatliing  and  creaking,  leathery 
friction  sounds.    There  may  be  commencing  retraction  of  the  side.    t!lini- 
eally  these  cases  are  of  great  interest,  and  should,  1  think,  be  separated, 
on  the  one  hand,  f.om  the  condition  \vhi<di  follows  a  healed  empyema  or 
old  jtleurisy  with  elTusion,  and,  on  the  other,  from  tlie  rare  instances  of 
j)riinitivo  cirrhosis  of  the  lung.     However,  in  uU  three  states  there  may 
ultiinatoly  be  an  almost  identical  cdinical  pic;ture.     Anatomically  in  these 
pleuritic  cases  the  pleura,  particularly  that  surrounding  the  lower  lobe, 
,-oniotinies  the  entire  membrane,  is  thickened,  the  two  layers  are  inti- 
mately united,  and  fibrinous  bands  jiassing  from  the  pleura  traverse  the 
luiH"  tissue,  sometimes  dividing  it  in  a  remarkahlo  w'av  into  sections.    The 
hronchi  may  present  marked  dilatations,  though  this  is  not  always  the 
case,  and  the  lung  tissue  is  more  or  less  sclerosed.     The  cases  belong  to 
the  group  of  chronic  pneumonias  called  by  (,'harcot  pleurogenous.     lu 
many  instances  there  can  be  no  question  as    to  their  non-tuborculoiis 
nature.    There  are  cases,  however,  in  which,  with  chronic  pleurogenous 
pneumonia  in  the  lower  lobe,  there  are  cavity  formations  at  the  ajDcx  and 
tiiherculous  lesions  in  other  parts.     Such  may,  of  course,  be  tuberculous 
from  the  outset. 

liustly,  tlierc  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it 
both  parietal  and  costal  layers  are  greatly  thickened — ])erhaps  from  two 
to  three  millimetres  each — and  present  firm  fibroid,  caseous  masses  and 
small  tubercles,  while  uniting  these  two  greatly  thickened  layers  is  a 
reddish-gray  fibroid  tissue,  sometimes  infiltrated  witli  serum.  This  may 
he  a  local  process  confined  to  one  pleura,  or  it  may  b"  in  both.  I  have 
seen  two  typical  instances  of  it — one  in  a  young,  well-nourished  Irish  girl, 
who  died  of  malignant  scarlet  fever,  in  whom  one  pleura  was  in  the  con- 
dition above  described,  and  there  were  no  other  tuberculous  lesions.  The 
other  was  in  a  young  man  who  died  of  typhoid  fever,  in  whom  both  pleurip 
were  nniforinly  thickened  and  tuberculous  without  any  fluid  exudate. 
Tiiese  cases  are  sometimes  associated  with  a  similar  condition  of  the  peri- 
eardiuni  and  peritonaeum. 

Uicasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleu- 
risy, whether  simjile  or  in  connection  with  tuberculosis  of  an  apex.  Flush- 
ing or  sweating  of  one  cheek  or  dilatation  of  the  pujiil  are  the  common 
manifestations.  They  appear  to  be  due  to  involvement  of  the  first  thoracic 
ganglion  at  the  top  of  the  pleural  cavity. 


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574 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


III.  HYDROTHORAX. 


Ilydrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into 
the  pleural  cavities,  and  occurs  as  a  secondary  process  in  many  affections. 
The  fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are 
smooth.  It  is  met  with  more  particularly  in  connection  with  general 
dropsy,  either  renal,  cardiac,  or  hiemic.  It  may,  however,  occur  alone,  or 
with  only  slight  wdema  of  the  feet.  A  child  was  admitted  to  the  Mont- 
real General  IIosjMtal  with  urgent  dyspnoea  and  cyanosis,  and  died  tlio 
night  after  admission.  She  had  extensive  bilateral  hydrothorax,  wliicli 
had  come  on  early  in  the  nephritis  of  scarlet  fever.  In  renal  disease 
hydrothorax  is  almost  always  bilateral,  but  in  heart  alTections  one  pliMira 
is  more  commonly  involved.  The  ]>hysical  signs  are  those  of  pleural  elfu- 
sion,  but  the  exudation  is  rarely  excessive.  In  kidney  and  heart  disease, 
even  when  there  is  no  general  dropsy,  the  occurrence  of  dyspnoea  should 
at  once  direct  attention  to  the  pleura,  since  many  patients  are  carried  oiT 
by  a  rapid  effusion.  Post-mortem  records  show  the  frequency  with  Avliicli 
this  condition  is  overlooked.  The  saline  purges  will  in  many  cases  rapid- 
ly reduce  the  effusion,  but,  if  necessary,  aspiration  should  reiieatedly  be 
l)ractised. 


IV.  PNEUMOTHORAX  (Ihjdro-Ihxeumothorax  and  Pyn- Pneumothorax). 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is 
strictly  applicable,  is  an  extremely  rare  condition.  It  is  almost  invarial)ly 
associated  with  a  serous  fluid — hydro-pneumothorax,  or  with  pus— pyo- 
pneumothorax. 

litiology. — It  has  usually  been  tiinght  that  there  is  an  inherent 
tendency  to  pneumothorax,  which  is  induced  as  soon  as  the  pleura  is 
opened.  The  experiments  of  S.  "West  seem,  however,  to  indicate  the 
existence  of  a  coherent  force  between  the  pleural  surfaces  much  in  excess 
of  the  elasticity  of  the  lung,  and  sufliicient  in  certain  instances  to  ukuii- 
tain  these  organs  in  contact  with  the  thoracic  vvall,  even  when  there  is 
free  access  to  the  pleura ;  so  that  in  reality  force  is  required  to  overcome 
the  normal  adhesion  between  the  pleural  membranes. 

Pneumothorax  arises  :  (1)  In  perforative  wounds  of  the  chest,  in  wliir'n 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It 
has  followed  exploratory  puncture  with  a  hyjiodermic  needle,  as  in  two 
cases  reported  by  Herman  Biggs.  Pneumothorax  rarely  follows  fracture 
of  the  rib,  even  though  the  lung  may  be  torn.  (2)  In  perforation  of  the 
pleura  through  the  diaphragm,  usually  by  malignant  disease  of  tlu' 
stomach  or  colon.  The  pleura  may  also  be  perforated  in  cases  of  cancer 
of  the  oesophagus.  (3)  When  the  lung  is  perforated.  This  is  by  far  tlie 
most  common  cause,  and  may  occur :  (rt)  In  a  normal  lung  from  rujiture 


PNEUMOTnORAX. 


575 


of  the  uir-vesicles  during  struiuing.  Special  attention  has  lately  been 
oiillcil  to  this  accident  by  S.  West  and  l)e  II.  Hall.  The  air  may  be  ab- 
sorbed and  no  ill  effect  follows.  It  does  not  necessarily  excite  pleurisy,  as 
jKiiiitcd  out  many  years  ago  by  (Jairdner,  but  inflammation  and  effusion 
are  tlio  usual  result,  [b)  From  perforation  due  to  local  disease  of  the 
hm^S  either  the  softening  of  a  caseous  focus  or  the  breaking  of  a  tuber- 
culous cavity.  According  to  S.  West,  ninety  per  cent  of  all  the  cases  are 
(hie  to  this  cause.  Less  common  are  the  cases  due  to  septic  broucho- 
imcumonia  and  to  gangrene.  A  rare  cause  is  the  breaking  of  a  haemor- 
rliii'nc  infarct  in  chronic  heart-disease,  of  wliich  I  met  an  instance  a  few 
ytiirs  ago.  {()  Perforation  of  the  lung  from  the  j)leura,  which  arises  in 
certain  cases  of  empyema  and  })roduces  a  plouro-bronchial  listula. 

rneumothorax  occurs  chiefly  in  adults,  though  cases  are  met  with  in 
very  yonug  children.     It  is  more  frequent  in  males  than  in  females. 

Morbid  Anatomy. — If  a  trocar  or  blow-pipe  is  inserted  between 
the  ribs,  there  may  be  a  Jet  of  air  of  suflticient  strength  to  blow  out  a 
liglited  match.  On  opening  the  thorax  the  mediastinum  and  pericardium 
are  seen  to  be  pushed,  or  rather,  as  Douglas  Powell  jjoiuted  out,  drawn 
over  to  the  opposite  side;  but,  as  before  mentioned,  the  heart  is  not 
rotated,  and  the  relation  of  its  parts  is  maintained  much  as  in  the  normal 
condition.  A  serous  or  purulent  fluid  is  usually  present,  and  the  mem- 
bniiu's  are  inflamed.  The  cause  of  the  j)neumothorax  can  usually  be 
found  without  difficulty.  In  the  great  majority  of  instances  it  is  the 
perforation  of  a  tuberculous  cavity  or  a  breaking  of  a  superficial  caseous 
focus.  The  orifice  of  rupture  may  be  extremely  small.  In  chronic  cases 
tliere  may  be  a  fistula  of  considerable  size  communicating  with  the  bron- 
clii.    Tlie  lung  is  usually  compressed  and  carnitied. 

Symptoms. — The  onset  is  usually  sudden  and  characterized  by 
severe  pain  in  the  side,  urgent  dyspnoea,  and  signs  of  general  distress, 
as  indicated  by  slight  lividity  and  a  very  rapid  and  feeble  pulse.  There 
may,  however,  be  no  urgent  symptoms,  particularly  in  cases  of  long- 
standing plithisis.  On  nmro  than  oiui  occasion  I  have  found,  post  mortem, 
a  pneumothorax  wliich  was  unsuspected  during  life.  West  states  that 
even  in  healthy  adults  this  latent  ])neumothorax  may  occasionally  occur. 

Tlu-  phijsical  signs  are  very  distinctive.  Inspection  shows  marked 
cnlargeinent  of  the  affected  side  with  immobility.  The  heart  imj)ulse  is 
usually  much  displaced.  0\\  palpation  the  fremitus  is  greatly  diminished 
or  more  commonly  abolished.  On  pcrriission  the  resonance  may  be  tym- 
panitic or  even  have  an  am])horic  quality.  Tliis,  however,  is  not  always 
the  ease.  It  may  bo  a  flat  tympany,  resembling  Skoda's  resonance.  In 
some  instances  it  may  be  a  full,  hyperresouant  note,  like  emphysema; 
while  in  otliers — and  this  is  very  deceptive — there  is  dulness.  These 
extreme  variations  depend  doubtless  upon  tlie  degree  of  intrajileural  ten- 
sion, ( )n  several  occasions  I  have  known  an  error  in  diagnosis  to  result 
from  ignorance  of  the  fact  that,  in  certain  instances,  the  percussion  note 


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576 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


may  be  "  muffled,  toneless,  almost  dull "  (Walshe).  There  is  usually 
dulness  at  the  base  from  effused  fluid,  which  can  readily  be  made  to 
change  the  level  by  altering  the  position  of  the  patient.  Movable  dulness 
can  be  obtained  much  more  readily  in  pneumothorax  than  in  a  siiiijilc 
pleurisy.  On  auscnUation  the  breath-sounds  are  suppressed.  Sometinu.s 
there  is  only  a  distant  feeble  inspiratory  murmur  of  marked  amphoric 
quality.  The  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  normal  side  and  the  absence  of  the  breath-sounds  on  the  other  is 
very  suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on 
coughing  or  deep  inspiration  there  may  be  what  Laonnec  termed  Die 
metallic  tinkling.  The  voice,  too,  has  a  curious  metallic  echo.  "What  is 
somotirues  called  the  coin-sound,  termed  by  Trousseau  the  hruit  d''airaiii, 
is  very  characteristic.  To  obtain  it  the  auscultator  should  place  one  car 
on  the  back  of  the  chest  wall  while  the  assistant  taps  one  coin  on  another 
on  the  front  of  the  chest.  The  metallic  echoing  sound  which  is  produced 
in  this  way  is  one  of  the  most  constant  and  characteristic  signs  of  pneumo- 
thorax. And,  lastly,  the  nij)pocratic  succussion  may  be  obtained  when 
the  auscultator's  head  is  ])laced  upon  the  patient's  chest  and  his  Ijudy 
shaken.  A  splashing  sound  is  produced,  which  may  be  audible  at  u  dis- 
tance. A  patient  may  himself  notice  it  in  making  abrupt  changes  in 
posture.  Of  other  symptoms  displacement  of  organs  is  most  constant. 
As  already  mentioned,  the  heart  may  be  drawn  over  to  the  opposite  side, 
and  the  liver  greatly  displaced,  so  that  its  upper  surface  is  below  the  level 
of  the  costal  margin,  a  degree  of  dislocation  never  seen  in  simple  clTnsiou. 

The  diagnosis  of  pneumothorax  rarely  offers  any  difficulty,  as  the  signs 
are  very  characteristic.  In  cases  in  which  the  percussion  note  is  didl  the 
condition  may  be  mistaken  for  effusion.  I  made  this  mistake  in  a  case  of 
pulsating  pleurisy,  in  which  the  pneumothorax  followed  heavy  lifting,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  been  witli- 
drawn,  that  a  tympanitic  note  developed.  Diaphragmatic  hernia  follow- 
ing a  crush  or  other  accident  may  closely  simulate  pneumothorax. 

In  cases  of  very  large  phthisical  cavities  with  tympanitic  percussion 
resonance  and  rales  of  an  amphoric,  metallic  quality  the  question  of 
pneumothorax  is  sometimes  raised.  In  those  rare  instances  of  total  ex- 
cavation of  one  lung  the  amphoric  and  metallic  phenomena  may  be  most 
intense,  but  the  absence  of  dislocation  of  the  organs  and  of  the  succus- 
sion splash  and  of  the  coin  sound  suffice  to  differentiate  this  condition. 
Why  the  coin  sound  is  not  heard  it  is  difficult  to  determine,  unless  its 
production  is  connected  in  some  way  with  a  certain  degree  of  air-tension, 
which  is  not  present  in  a  vomica,  however  large.  The  condition  of  jiyo- 
pneumothorax  subphrenicus  may  simulate  closely  true  pneumothorax. 

The  prognosis  in  cases  of  pneumothorax  depends  largely  upon  the 
cause.  The  phthisical  cases  usually  die  within  a  few  weeks.  Pncunio- 
thorax  developing  in  a  healthy  individual  often  ends  in  recovery.  There 
are  cases  of  phthisis  in  which  the  pneumothorax,  if  occurring  early,  seems 


AFFECTIONS  OF  THE  MEDIASTINUM. 


677 


to  arrest  the  progress  of  the  tuberculosis.  This  appeared  to  be  the  case  in 
a  man  with  chronic  pneumothorax  who  was  under  my  care  in  Pliihidelphia 
f(ir  between  tliree  and  four  years.  It  may  be  a  chronic  condition,  as  in 
tho  cii.-:e  just  mentioned,  and  a  fair  measure  of  health  may  be  enjoyed. 

Treatment. — Practifudly  these  cases  should  be  dealt  with  us  ordinary 
pleurisy  with  elfusion.  Of  course,  Avhen  pneumothorax  develops  in  ad- 
vanced jihthisis  the  indication  is  to  relieve  the  pain  and  distress  either  by 
11101  phia  or  chloroform;  but  in  cases  which  develop  early  the  lluid  should 
1)0  withdrawn  by  aspiration,  or,  if  i»urulcnt,  permanent  drainage  should  bo 
obtained.  Even  when  the  condition  has  seemed  to  be  most  desperate  I 
have  known  recovery  to  take  place  after  thorough  drainage  of  the  sac. 
Portions  of  ribs  may  have  to  be  excised,  and  during  convalescence  it  is 
well  for  the  patient  to  i)ractise  expansion  of  the  lung  in  the  manner 
already  mentioned.  There  are  cases  of  pneumothorax  in  iihthisis  in 
which  the  general  condition  is  so  good  and  the  inconvenience  so  slight 
that  to  let  well  enough  alone  seems  the  best  course.  In  such  an  occa- 
sional aspiration  may  be  performed  if  the  lliiid  increases.  In  some  of  the 
instances  the  mere  tapping  of  tlie  chest  with  a  line  needle,  so  as  to  allow 
the  escape  of  some  of  the  air,  seems  to  give  relief  by  reducing  the  intra- 
thoracic pressure.  Clood  results  are  stated  to  have  followed  the  method 
introduced  by  Potain,  of  replacing  the  air  and  lluid  within  the  thorax  by 
sterilized  air. 


AFFECTIONS  OF  THE   MEDIASTJNUM. 


(1)  Simple  Lymphadenitis.— In  all  inilammatory  alTcctions  of  the 
broiu'hi  and  of  the  lungs  the  groups  of  lymph  glands  in  the  mediastinum 
become  swollen.  In  the  bronchitis  of  measles,  for  example,  and  in  simple 
broncho-pneumonia  the  bronchial  glands  are  largo  and  infdtrated,  the 
tissue  is  engorged  and  cedematous,  sometimes  intensely  hypera^mic.  Much 
stress  has  been  laid  by  some  writers  on  this  enlargement  of  the  glands  in 
the  posterior  mediastinum,  and  De  ^lussy  held  that  it  was  an  important 
factor  in  inducing  paroxysms  of  whooping-cough.  They  may  attain  a 
size  suflicieut  to  induce  dulness  beneath  the  manubrium  and  in  the  upper 
part  of  the  interscapular  regions  behind,  though  this  is  often  difficult  to 
(leterniine.  In  reality  the  glands  lie  chiefly  upon  the  spine,  and  unless 
those  which  are  deep  in  the  root  of  the  lung  are  large  enough  to  induce 
ooini)ression  of  the  adjacent  lung  tissue,  I  doubt  if  the  ordinary  bronchial 
adenopathy  ever  can  be  determined  by  percussion  in  the  upper  interscapu- 
lar region.  I  have  never  met  with  an  instance  in  which  the  compression 
of  either  bronchus  seemed  to  have  resulted  from  the  glands,  however  large. 
Tuborcidous  aifection  of  these  glands  has  already  been  considered. 

(v)  Suppurative  Lymphadenitis. — Occasionally  abscess  in  the  bronchial 
or  tracheal  lymph  glands  is  found.    It  may  follow  the  simple  adenitis,  but 


"  If 


II 


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M. 


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578 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


is  most  frequently  iissociated  with  the  presence  of  tubercle.  The  lifnild 
portion  may  gradually  become  absorbed  and  the  inspissated  contents  un- 
dergo calcification.  Serious  accident  occasionally  occurs,  as  perforutidu 
into  the  a'soijhagus  or  into  a  bronchus. 

(.'3)  Tumors;  Cancer  and  Sarcoma.— In  Hare's  elaborate  study  of  ,v.'(i 
cases  of  disease  of  the  mediastinum*  there  wore  134  cases  of  cancer,  Om 
cases  of  sarcoma,  21  cases  of  lym])homa,  7  cases  of  fibroma,  11  cases  of 
dermoid  cysts,  8  cases  of  hydatid  cysts,  and  instances  of  lipoma,  guniina, 
and  enchondroma.  From  this  we  see  that  cancer  is  the  most  common 
form  of  growth.  The  tumor  occurred  in  the  anterior  mediastinum  aliiiic 
in  48  of  the  cases  of  cancer  and  33  of  the  cases  of  sarcoma.  The  disease 
may  be  either  prinuiry  in  the  mediastinal  tissues  and  lymph  structures  or 
secondary.  Sarcoma  is  more  frequently  primary  than  cancer.  ^lales  are 
more  frequently  affected  than  females.  The  age  of  onset  is  most  eoin- 
monly  between  thirty  and  forty. 

Symptoms. — The  signs  of  mediastinal  tumor  arc  those  of  intra- 
thoracic pressure.  Di/sjmcea  is  one  of  the  earliest  and  most  con.stuiit 
symptoms,  and  may  be  due  either  to  pressure  on  the  trachea  or  on  the 
recurrent  laryngeal  nerves.  It  may  indeed  be  cardiac,  due  to  pressure 
upon  the  heart  or  its  vessels.  In  a  few  cases  it  results  from  the  pleural 
effusion  whi(!h  so  frequently  accompanies  intrathoracic  growths.  Asso- 
ciated with  the  dyspnuni  is  a  cough,  often  severe  and  paroxysmal  in  char- 
acter, with  the  brazen  quality  of  the  so-called  aneurismal  cough  when  a 
recurrent  nerve  is  involved.  ^J'he  voice  may  also  be  affected  from  a  simi- 
lar cause.  Pressure  on  the  vessels  is  common.  The  superior  vena  cava 
may  be  compressed  and  obliterated,  and  when  the  process  goes  on  slowly 
the  collateral  circulation  may  be  completely  effected.  Less  commonly 
the  inferior  vena  cava  or  one  or  other  of  the  subclavian  veins  is  com- 
pressed. The  arteries  are  much  less  rarely  obstructed.  It  is  remarkaljle 
how  little  the  aorta  may  be  involved,  though  entirely  surrounded  by  a  sar- 
comatous or  cancerous  mass.  There  may  be  dysphagia,  due  to  compres- 
sion of  the  a^sophagus.  In  rare  instances  there  are  pupillary  changes, 
either  dilatation  or  contraction,  due  to  involvement  of  the  sympathetic. 

Physical  Signs. — On  inspection  there  may  be  orthopna^a  and  marked 
cyanosis  of  the  upper  part  of  the  body.  In  such  instances,  if  of  lon,«: 
duration,  there  are  signs  of  collateral  circulation  and  the  superficial  mam- 
mary and  e])igastrio  veins  are  enlarged.  In  a  patient  with  Ilodgkin's  dis- 
ease, at  present  under  observation  and  in  whom  during  the  past  sixteen 
months  there  has  been  ])rogressive  compression  and  now  obliteration  of 
the  superior  vena  cava,  tlic  entire  subcutaneous  tissue  of  the  front  of  tk' 
thorax  seems  a  plexus  of  veins  and  the  epigastric  vessels  are  as  large  as 
the  index-finger.  Such  instances  are,  I  think,  more  common  in  lympluide- 
noma  than  in  sarcoma  or  cancer.     In  these  cases  of  chronic  obstruetion 


►  Eotbergillian  Prize  Essay  of  the  Medical  Society  of  London,  Philadelphia,  1889. 


AFFKCTIONS  OF  THE  MEDIASTINUM. 


579 


the  fiiigcr-tips  may  bo  clubbed.  There  may  bo  bulging  of  the  sternum  or 
till'  tumor  may  eroilo  the  bone  unci  form  a  prominent  8ul)cutanoous  growth. 
Tilt'  rapidly  growing  lymphoid  tumors  more  commonly  than  otlicrs  per- 
forate tho  chest  wall.  In  four  of  thirteen  cases  of  Ilodgkin's  disease,  of 
which  T  have  notes,  there  was  medhistinal  growtli,  and  in  three  instances 
the  sternum  was  eroded  and  perforated.  The  perforation  may  be  oji  one 
bide  ol!  ihe  breast-bone.  Tho  projecting  tumor  may  pulsate  lil<e  an  aneu- 
rism ;  the  heart  may  bo  dislocated  and  its  impulse  much  out  of  place.  Con- 
traction of  one  side  of  the  thorax  has  been  noted  in  a  few  instances.  On 
palpation  tho  fremitus  is  absent  wherever  tho  tumor  reaches  the  chest 
wall.  If  pulsating,  it  rarely  has  the  forcible,  heaving  impulse  of  an  aneu- 
risnial  sac.  On  auscultation  there  is  usually  silence  over  the  dull  region. 
The  heart-sounds  arc  not  transmitted  and  the  respiratory  murmur  is  feeble 
(»r  inaudible,  rarely  bronchial.  Vocal  resonance  is,  as  a  rule,  al)sent.  SigJis 
of  pleural  effusion  occur  in  a  great  numy  instances  of  mediastinal  growth, 
and  if  in  any  doid)t  tho  aspirator  needle  should  l)e  used. 

Tlie  (littynosis  of  mediastinal  tumor  from  aneurism  is  sometimes  ex- 
tremely diflicult.  An  interesting  case  reported  and  figured  by  Sokolosski, 
in  Bd.  19  of  tho  Beutsches  Archiv  fiir  klinische  Medicin,  in  which 
Ojipolzer  diagnosed  aneurism  and  Skoda  mediastinal  tumor,  illustrates 
how  in  some  instances  the  most  skilful  of  observers  may  be  unable  t(» 
agree.  Scarcely  a  sign  is  found  in  aneurism  which  may  not  l)e  du])licated 
ill  mediastinal  tumor.  This  is  not  strange,  since  the  symptoms  in  both 
are  largely  due  to  pressure.  Tho  time  element  is  im])ortant.  If  a  case 
has  persisted  for  more  than  eighteen  months  tho  disease  is  proliably 
aneurism.  There  are,  however,  exceptions  to  this.  In  the  case  of  com- 
pression of  the  vena  cava  mentioned  above,  the  disease  has  lasted  for  more 
than  two  years  and  the  patient  has  improved  so  markedly  under  the  use 
of  arsenic  that  had  ho  no  other  lymphatic  enlargements  the  diagnosis 
might  bo  uncertain.  By  far  the  most  valuable  sign  of  aneurism  is  tho 
diastolic  shock  so  often  to  be  felt,  and  in  a  majority  of  cases  to  be  heard, 
Dvor  the  sac.  This  is  rarely,  if  ever,  present  in  mediastinal  growths,  even 
when  tliey  perforate  the  sternum  and  have  communicated  pulsation.  An- 
')thor  point  of  importance  is  that  in  a  tumor,  advancing  from  the  medias- 
tinum, eroding  the  sternum  and  appearing  externally,  if  ano'irismal,  has 
fiircilile,  heaving,  and  distinctly  expansile  pulsations.  The  radiating  pain 
ill  tho  hack  and  arms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also 
a  beneficial  influence  on  it  of  iodide  of  potassium. 

Tho  frequency  of  pleural  effusion  in  connection  with  mediastinal 
tumor  is  to  be  constantly  borne  in  mind.  It  may  give  curiously  complex 
characters  to  the  physical  signs — characters  Avhich  are  profoundly  modi- 
fied after  aspiration  of  the  liquid. 

(4)  Abscess  of  the  Mediastinum. — Hare  collected  ll.j  cases  of  medi- 
astinal abscess,  in  T7  of  which  there  Avere  details  sufficient  to  permit  the 
analysis.    Of  these  cases  the  great  majority  occurred  in  males.    Forty-four 


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580 


DISEASES  OF  THE  UESPIRATOIIY  SYSTEM. 


wcro  instances  of  acnito  abscoss.  The  anterior  mediastinum  in  most  ('(nn- 
monly  tlie  seat  of  the  8ui)])uralii>!i.  Tlic  eases  are  most  frequently  associaUd 
with  trauma.  Some  liavc  foMowod  erysipehis  or  oeeurred  in  assoeiutiun 
with  eruptive  fevers.  Many  cases,  partieuhirly  the  ehronic  abscesses,  aro 
of  tubercuh)U8  origin.  Of  si/mji/oms,  pain  behind  tlie  sternum  is  tiic  most 
eonmion.  It  may  be  of  a  throbbiiifjf  eluiraeter,  and  in  the  a(uite  cases  is 
associated  with  fever,  sonu^timcs  with  chills  and  sweats.  If  the  abscess  is 
largo  there  may  bo  dyspnoea.  The  pus  may  burrow  into  the  a1)<l()iiuii, 
perforate  throu<,'h  an  intercostal  space,  or  it  may  erode  the  steriuini.  In- 
stances aro  on  record  in  which  the  abscess  has  discihariifed  into  the  traciicii 
or  trsophanfus.  In  many  cases,  particularly  of  chronic  abscess,  the  jms 
becomes  inspissated  and  produces  no  ill  effect.  The  physiciil  sir/iis  iiiuy 
bo  very  indelinite.  A  pulsating  and  fluctuating  tumor  may  appear  at  the 
border  of  the  sternuni  or  at  the  sternal  notch.  The  absence  of  bru)!,  of 
the  diastolic  shock,  and  of  tlie  ex])ansile  pulsation  usually  enables  u  cor- 
rect  diagnosis  to  bo  made.  When  in  doubt  a  lino  hypodermic  uceille 
may  be  inserted. 

(5)  Miscellaneous  Affections.— In  Hare's  monograph  there  were  7  in- 
stances of  libronia,  11  cases  of  dermoid  cysts,  8  cases  of  hydatid  cysts,  and 
cases  of  lipoma  and  gummata. 

The  thymus  (jland  may  be  enlarged  and  produce  the  pbysical  signs  of 
mediastiiuvl  tumor.  In  children  there  are  instances  of  spasm  of  the  glottis, 
which  is  believed  by  some  to  depend  upon  enlargement  of  the  thymus. 
Jacobi,*  in  his  monogra})h,  says  that  some  instances  of  sudden  death  and 
also  so-called  thymic  asthma  may  occasionally  bo  referred  to  this  cause. 
Malignant  tumors  of  the  thymus  may  attain  considerable  size  and  produce 
signs  of  tumor.  In  rare  cases  mediastinal  growths  develop  from  the  /////- 
void  gland.  These  may  be  substernal  in  position  and  directly  connected 
with  the  gland.  Kretschy  has  rej^orted  a  sarcoma  of  the  thyroid  four  and 
three  quarter  inches  in  length,  which  forms  a  mediastinal  tumor  passing 
to  the  level  of  the  ninth  dorsal  vertebra.  I  have  reported  a  somewhat  sim- 
ilar instance,  which  developed  in  the  left  lobe  of  the  thyroid  and  formed 
an  elongated  mass  which  passed  down  beside  the  trachea  to  the  bifurcation. 

(0)  Emphysema  of  the  Mediastinum.— Air  in  the  cellular  tissues  of 
the  mediastinum  is  met  with  in  cases  of  trauma  and  occasionally  iii  fatal 
cases  of  diphtheria  and  in  whooping-cough.  Champneys  has  called  atten- 
tion to  its  frequency  in  tracheotomy,  in  which  ho  says  the  conditions 
favoring  the  production  aro  division  of  the  deep  fascia,  obstruction  to  tiie 
air-passages,  and  inspiratory  efforts.  The  deep  fascia,  ho  says,  should  not 
bo  raised  from  the  trachea.  It  is  often  associated  with  pneumotliorax. 
The  condition  seems  by  no  means  uncommon.  Angel  Money  found  it 
in  10  of  28  cases  of  tracheotomy,  and  in  two  of  these  pneumothorax  also 
was  present. 

*  Transactions  of  the  Association  of  American  Pliysicians,  vol.  iii. 


SECTIOX  y. 


DISEASES  OF   THE   CIIlCULATOrwY   SYSTEM. 


I.  DISEASES  OF  THE  rERICAKDIUM. 
I.   PERICARDITIS. 

Pericauditis  is  the  result  of  iiifeotive  processes,  primary  or  secondary, 
or  arinos  by  extension  of  iiiflannnation  from  contiguous  organs. 

Etiology. — Primary,  so-called  idiopathic,  inflammation  of  this  mem- 
brane is  rare;  but  cases  are  met  Avith,  most  commoidy  in  (,'hildren,  in 
which  there  is  no  evidence  of  rheumatism  or  other  conditions  with  which 
the  disease  is  nsually  associated. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon 
ill  connection  with  the  primary  wound.  Interesting  cases  are  those  in 
wliich  the  traumatism  is  from  w'ithin,  due  to  the  jiassage  of  some  foreign 
body — such  as  a  needle,  a  pin,  or  a  bone — through  the  oosophagus  into  the 
pericardium. 

As  a  secondarji  process  pericarditis  is  met  with  in  the  following  affec- 
tions :  {(()  A  majority  of  the  cases  occur  in  connection  with  rheumatism. 
The  percentage  given  by  diiferent  authors  ranges  from  thirty  to  seventy. 
The  articular  trouble  may  be  slight  or,  indeed,  the  disease  may  bo  asso- 
ciated with  acute  tonsillitis  of  rheumatic  subjects.  Cases  arc  recorded  in 
which  the  pericarditis  has  preceded  the  articular  disease,  {b)  Septic 
processes  rank  next  to  rheumatism.  In  the  acute  necrosis  of  bone  and 
piic'rj)eral  fever  it  is  not  uncommon,  (c)  Tuberculosis,  in  which  the  dis- 
ease may  be  primary  or  part  of  a  general  involvement  of  the  serous  sacs 
or  associated  with  extensive  pulmonary  disease.  (rZ)  Eruptive  fevers.  In 
cliililren,  the  disease  is  not  infrequent  after  scarlatina.  It  is  rarely  met 
with  in  measles,  small- pox,  or  typhoid  fever.  In  other  infective  diseases, 
such  as  diphtheria  and  pneumonia,  it  is  rare,  (e)  Dyscrasias.  Certain 
altered  conditions  of  the  system  seem  to  render  the  pericardium  more 
susceptible  to  inflammation.  Of  these  gout  takes  the  first  place.  In 
chronic  Bright's  disease  pericarditis  is  by  no  means  rare.  The  pericar- 
(Ute  hrigUique  of  the  French  forms  one  of  the  most  important  groups 
of  tlie  disease  in  persons  over  fifty  years  of  age,  most  frequently  accom- 


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DISEASKS  OF  TIIK  ClUCUriATOIlY   SYSTKM. 


panyinp;  tlio  chronic  interstitial  form.    IVriciinlitis  1ms  licon  met  with  also 
in  scurvy  and  diabetes. 

I'rrinirditis  by  crtvusion  of  disease  from  contijftioiis  organs.  In  ]iU'uni- 
Ijiieiimoriia  it  forms  ouo  of  tho  most  serious  compliciatioiis,  and  was  pres- 
ent in  5  eases  in  100  post-mortems  in  tliis  disea.so  which  I  maile  at  tli, 
Montreal  (ieiieral  Hospital.  It  is  most  often  met  witli  in  th(!  plciiin- 
pneiimonia  of  ciiildren  and  of  alcoholics.  Tlie  association  witii  .siinjilc 
j)leurisy  is  much  less  common.  Jn  ulcerative  endocarditis,  puruleut  iiivo- 
carditis,  and  in  aneurism  of  tho  uorta  j)ericarditis  is  occasionally  fduiul. 
It  may  also  result  from  extension  of  disease  from  the  bronchial  glands, 
the  ribs,  stennim,  vertebra',  and  even  from  the  alulomiual  viscera. 

Pericarditis  occurs  at  all  ages.  Cases  nw  reported  in  the  fu'tus.  I;i 
tho  new-born  it  may  result  from  septic  infection  through  the  navel. 
Throughout  childhood  the  incidence  of  rheumatism  and  scarlet  fcvtr 
makes  it  a  freiiuent  affet^tion,  whereas  late  in  lif(!  it  is  most  often  asso- 
ciated with  Hright's  disease  ami  gout.  !Males  are  Homewhat  more  fre- 
quently attacked  than  females.  Climatic,  and  seasonal  influeuces  liiivc 
been  mentioned  by  some  writers.  Tho  so-calle(l  epidemics  of  ix'riciir- 
ditis  have  been  outbreaks  of  pnenmcmia  with  this  as  a  frequent  conijili- 
cation. 

Anatomically  as  well  as  clinically  the  disease  may  be  considered  iiii(Kr 
the  following  divisioivj : 

1.  Acnte,  plastic,  or  dry  pericarditis. 

2.  Pericarditis  with  effusion — sero-fibrinous,  hfrmorrhagic,  or  punilor.t. 

3.  Chronic  adhesive  pericarditis  (adherent  pericardium). 

Acute  Plastic  Pericarditis. — This,  the  most  common  form,  ovemi 
usually  as  a  secondary  process,  and  is  distinguished  by  tho  small  aiiioiiiit 
of  fluid  exudation,  which  does  not,  as  in  the  next  variety,  give  s^pocial 
characters  to  tho  disease.  It  is  a  benign  form  and  rarely,  if  ever,  of  itself 
proves  fatal. 

Anatomically  it  may  be  partial  or  general.  In  tho  mildest  grades  t'le 
serous  membrane  looks  lustreless  and  roughened.  This  is  duo  to  the 
presence  of  a  thin  fibrinous  slieeting,  which  can  be  lifted  Avith  the  knife, 
showing  the  membrane  beneath  to  bo  injected  or  in  places  ecehymotic. 
As  tho  fibrinous  sheeting  increases  ii\  ^  nicknoss  the  constant  movement 
of  the  adjacent  surfaces  gives  to  it  t;ometime3  a  ridge-like,  at  otliers  ii 
honeycombed  appearance.  With  more  abundant  fibrinons  exudation  the 
membranes  present  an  appearance  resembling  buttered  surfaces  Avliieh 
have  been  drawn  apart.  The  fibrin  is  in  long  shreds,  and  the  heart  pre- 
sents n  curiously  shaggy  appearance — the  so-called  hairy  heart  of  oW 
writers — cor  villosujii. 

In  mild  grades  tho  subjacent  muscle  looks  normal ;  but  in  tlie  more 
prolonged  and  severe  cases  there  is  myocarditis,  and  for  3  or  3  mm. 
beneath  the  visceral  layer  the  muscle  presents  a  pale,  turbid  appearunce. 


K  « 


PERICARDITIS. 


588 


Many  of  thcso  aouto  nvflps  ivro  tuboroulouR ;  covorod  by  tlio  layers  of  lymph 
tlic  ;;nmnlution8  ari.  cusily  overlookod  in  u  HuporHcial  cxauiiiiatioii. 

.Sli;,'lit  fluid  i'Xtidution  in  iiivuriahly  pn'sfiit,  (Mitanj^lcd  in  the  mcslioa 
of  iil)riii,  but  there  may  be  very  thick  tibrinous  layers  without  much 
.senilis  elTusion. 

Symptoms. — 'I'he  majority  of  cases  of  simple  plastic  pericarditis, 
like  simple  endocarditis,  present  no  symi>toms,  ami  unless  soufj^ht  for  there 
iirt'  no  objective  si^fns  indicating,'  its  existence.  In  the  post-mortem  room 
it  is  not  uncommon  to  lind  it  in  eases  in  which  its  presence  has  been  un- 
Huspected  durinj^  life. 

I'liin  is  a  variable  symptom,  not  usually  Intense,  and  in  this  form 
riuely  excited  by  pressure.  It  is  more  marked  in  the  early  stage,  and  may 
1)(>  referred  either  to  the  pra>cordia  or  to  the  rejfion  of  the  xiphoid  carti- 
lii^je.  Instances  are  recorded  of  pain  of  an  agj,'ravated  and  most  distress- 
iui,'  cliaraeter  resembling  angina.  Fever  is  usually  present,  but  it  is  not 
alwavs  easy  to  say  how  much  depends  upon  the  primary  febrile  an"(!cti()n, 
and  iiow  much  upon  the  pericarditis.  It  is  as  a  rule  not  high,  rarely 
cxiH'iMling  l()'i-o°.     In  rheunuitie  cases  hyperpyrexia  has  been  observed. 

Physical  Signs. — Inspection  is  negative ;  palpation  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rubbing  of  the  roughened  peri- 
cardial surfaces.  This  is  usually  best  marked  over  the  right  ventricle.  It 
is  not  always  to  be  felt,  even  when  the  friction  sound  on  auscultation  is 
l(Ui(l  and  clear.  Anncultation :  The  friction  sound,  duo  to  the  movement 
(if  the  pericardial  surfaces  upon  each  other,  is  one  of  the  most  distinctive 
of  physical  signs.  It  is  double,  corresponding  to  the  systole  and  diastole  ; 
imt  tlie  synchronism  with  the  heart-sounds  is  not  accurate,  and  the  to-and- 
fro  murmur  usually  outlasts  the  time  occu])ied  by  the  first  and  second 
sound.  In  rare  instances  the  friction  is  single ;  more  frequently  it  ap- 
pears to  be  triple  in  character — a  sort  of  canter  rhythm.  The  sounds  have 
!i  i)oouliar  rubbing,  grating  quality,  characteristic  when  once  recognized, 
and  rarely  simulated  by  endocardial  murmurs.  Sometimes  instead  of 
fivating  there  is  a  creaking  quality — the  Iruit  do  cuir  ;/e»/— the  new- 
leather  murmur  of  the  French.  The  pericardial  friction  appears  super- 
ficial, very  close  to  the  ear,  and  is  usually  intensified  by  pressure  with  the 
stethoscope.  It  is  best  heard  over  the  right  ventricle,  the  part  of  the  heart 
which  is  most  closely  in  contact  with  the  front  of  the  chest — that  is,  in  the 
fourth  and  fifth  interspaces  and  adjacent  portions  of  the  sternum.  There 
are  instances  in  which  the  friction  is  most  marked  at  the  base  over  the 
aorta  and  at  the  superior  reflection  of  the  pericardium.  Occasionally  it 
is  best  heard  at  the  apex.  It  may  be  limited  and  heard  over  a  very  narrow 
area,  or  it  may  be  transmitted  up  and  down  the  sternum.  There  are, 
liowever,  no  definite  lines  of  transmission  as  in  the  endocardial  murmur. 
An  important  point  is  the  variability  of  sounds,  both  in  position  and 
'luality ;  they  may  be  heard  at  one  visit  and  not  at  another.  The  maxi- 
mum of  intensity  will  be  found  to  vary  with  position. 


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584 


DISEASES  OF  THE   CIRCULATORY  SYSTEJI. 


Diagnosis. — There  is  rarely  any  difficulty  in  determiniug  the  pros- 
ence  of  a  dry  pericarditis,  for  the  friction  sounds  are  disfiiictivo.  The 
double  niurniur  of  aortic  incompetency  may  simulate  closely  the  to-and- 
fro  pericardial  rub.  I  recall  one  instance  at  least  in  which  this  mistake 
was  made.  The  constant  character  of  the  aortic  murmur,  the  direction 
of  transmission,  the  jjhenomena  in  the  arteries,  and  the  associated  condi- 
tions of  the  disease  should  be  sufficient  to  prevent  this  error. 

I  have  never  known  an  instance  in  which  pericarditis  Avas  mistaken  for 
endocarditis,  though  writeis  refer  to  such,  and  give  the  differential  diag- 
nosis in  the  two  affections.  The  only  possible  mistake  could  be  made  in 
those  rare  instances  of  single  soft,  systolic,  pericardial  friction. 

Pleuro-pericardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  particularly  in  cases  of  pleuro-pneumonia.  It  is  fre- 
quent, too,  in  phthisis.  It  is  best  heard  over  the  left  border  of  the  lioart, 
and  is  much  affected  by  the  respiratory  movement.  Holding  the  breath 
or  taking  a  deep  inspiration  may  annihilate  it.  The  rhythm  is  not  the  sim- 
ple to-and-fro  diastolic  and  systolic,  but  the  respiratory  rhythm  is  sn])c'r- 
added,  usually  intensifying  the  murmur  during  expiration  and  lessening 
it  on  inspiration.  In  phthisis  there  are  instances  in  which,  witli  the  fric- 
tion, a  loud  systolic  click  is  heard,  duo  to  the  compression  of  a  thin  laytr 
of  lung  and  the  expulsion  of  a  bubble  of  air  from  a  small  softening  focus 
or  from  a  bronchus. 

Course  and  Termination. — Simple  fibrinous  pericarditis  never  kills, 
but  it  occurs  so  often  in  connection  with  serious  aff'ections  that  we  have 
frequent  oiiportunities  to  see  all  stages  of  its  progress.  In  the  majority 
of  ci'-o-  'he  inflammation  subsides  and  the  thin  fibrinous  lamina?  gradually 
become  converted  into  connective  tissue,  which  unites  the  pericardial  leaves 
firmly  together.  In  other  instances  the  inflammation  progresses,  with  in- 
crease of  the  exudation,  and  the  condition  is  changed  from  a  "  dry  "  to  a 
"moist"  pericarditis,  or  the  pericarditis  with  effusion. 

In  a  few  instances— probably  always  tuberculous— the  simple  plastic 
pericarditis  becomes  chronic,  and  great  thickening  of  both  visceral  and 
parietal  layers  is  gradually  induced. 

Pericarditis  with  Effusion.— Though  commonly  a  direct  scqueuoo  of 
the  dry  or  plastic  pericarditis,  of  which  it  is  sometimes  spoken  as  the  sec- 
ond stage,  this  form  presents  special  features  and  deserves  separate  con- 
sideration. It  is  found  most  frequently  in  association  with  acute  rheuma- 
tism, tuberculosis,  and  septicaemia.,  and  sets  in  usually  with  the  symptoms 
above  described,  namely,  praecordial  pain,  with  slight  fever  or  a  distinct 
chill. 

In  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
breath,  and  increasing  pallor,  the  physician  may  find,  to  his  astonishment, 
signs  of  most  extensive  pericardial  effusion.    These  latent  cases  are  often  tu- 


PERICARDITIS. 


585 


bcrculous.  The  effusion  may  be  pero-fibrinons,  iKTmorrhai^ic,  or  pnnilent. 
Till'  iiinoiiut  varies  from  200  or  300  c.  e.  to  2  litres.  In  the  cases  of  sero- 
fibrinous exudation  the  pericardial  membranes  arc  covered  with  thick, 
creamy  fibrin,  whic^h  may  be  in  ridges  or  honeycombed,  or  may  present 
loiiiT,  villous  extensions.  The  i)arietal  hu'er  may  be  several  millimetres  in 
thickness  and  nniy  form  a  firm,  leathery  membrane.  I'he  luxMnorrluigic 
exudation  is  usually  associated  with  tuberculous,  or  with  cancerous  peri- 
carditis, or  with  the  disease  in  the  aged.  The  lym})!)  is  less  abundant, 
but  both  surfaces  are  injected  and  often  show  numerous  hamiorrhages. 
Tiiii'k,  curdy  masses  of  lymph  are  usually  found  in  the  dependent  part  of 
the  sac.  In  the  purulent  elTusion  the  fluid  has  a  creamy  consistency,  par- 
ticularly in  tuberculosis.  In  many  cases  the  effusion  is  really  sero-puru- 
lent,  a  thin,  turbid  exudation  containing  flocculi  of  fibrin. 

The  pericardial  layers  are  greatly  thickened  and  covered  with  fibrin. 
\\'\m\  the  fluid  is  pus,  they  present  a  grayish,  rough,  granular  surface. 
Sometimes  there  are  distinct  erosions  on  the  visceral  memln'aiie.  The 
heart  muscle  in  these  cases  becomes  involved  to  a  greater  or  less  extent, 
and  on  section,  the  tissue,  for  a  distance  of  from  two  to  three  millimetres, 
is  pido  and  turbid,  and  shows  evidence  of  fatty  and  granular  clumge.  En- 
docarditis coexists  fre(pieutly,  but  rarely  results  from  the  extension  of  the 
iulhunmation  through  the  wall  of  the  heart. 

Symptoms. — Even  with  copious  effusion  the  onset  and  course  may 
be  so  insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is 
aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  cither  sharp  and 
stabbing  or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region. 
It  is  more  frequent  with  effusion  than  iu  the  plastic  form.  Pressure 
at  tlie  lower  end  of  the  stjrnum  usually  Jiggravates  it.  Dyspnoea  is  a 
cointnon  and  important  symptom,  one  which,  jierhaps,  more  than  any 
iither,  excites  suspicion  of  grave  disorder  and  leads  to  careful  examiiuition 
of  heart  and  lungs.  The  patient  is  restless,  lies  upon  the  left  side  or,  as 
the  elfasion  increases,  sits  up  in  bed.  Associated  with  the  dyspnoea  is  in 
many  cases  a  peculiarly  dusky,  anxious  countonance.  The  pulse  is  rapid, 
small,  sometimes  regular,  and  may  present  the  chanu'ters  known  an  pulsus 
paradoxus,  in  which  during  each  inspiration  the  pulse-beat  becomes  very 
weak  or  is  lost.  These  symptoms  are  due,  in  great  part,  to  the  direct 
meelianical  effect  of  the  fluid  within  the  pericardium  which  embarrasses 
the  heart's  action.  Other  pressure  effects  are  distention  of  the  veins  of 
the  neck,  dysphagia,  which  may  be  a  nuxrked  symptom,  ami  irritjitive 
cough  from  compression  of  the  trachea.  Ai)honia  is  not  uncommon,  duo 
to  compression  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round 
the  aorta.  Another  important  pressure  effect  is  exercised  upon  the  left 
lung.  Ill  massive  elTusion  the  pericardial  sac  occupies  such  a  large  por- 
tion of  the  antero-lateral  region  of  the  left  side  that  the  condition  has  fre- 
quently been  mistaken  for  pleurisy.     Even  in  mo<lerate  grades  the  left 


.  .if  ;f  Z 


,i   ^j 


:4 


1  ' 


"      'I 


I  t\- 


n  ■  <ii 


586 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


lung  is  somewhat  compressed.  This  is  an  additional  element  in  the  jiro- 
duction  of  tlie  dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and 
coma  are  symptoms  in  tlie  more  severe  cases.  Delirium  and  marked  cere- 
bral symptoms  are  associated  with  tlio  hyperpyrexia  of  rheumatic  cases, 
but  apart  from  the  ordinary  delirium  tliore  may  be  poculiar  mental  symp- 
toms. The  patient  may  become  melancholic  and  show  suicidal  tendencios. 
In  other  cases  the  condition  resembles  closely  delirium  tremens.  Sibsoii, 
who  has  specially  described  this  condition,  states  that  the  majority  of  sucli 
cases  recover.  Chorea  may  also  occur,  as  was  jiointed  out  by  l?ri(dit. 
Epilepsy  is  a  rare  complication  which  has  occurred,  as  in  pleurisy,  during 
paracentesis. 

Physical  Signs. — Inspection. — In  children  the  pra^cordia  bulges  ami 
with  copi(nis  exudation  tlio  antero-lateral  region  of  the  left  chest  becomes 
enlarged.  The  intercostal  spaces  are  prominent  and  there  may  be  marked 
cedema  of  the  wall.  Perforation  externally  through  a  space  is  very  rare. 
Owing  to  the  compression  of  the  lung,  the  ex})ansion  of  tlio  left  side  is 
greatly  diminished.  Tlie  diaphragm  and  left  lobe  of  the  liver  may  be 
puslied  down  and  may  produce  a  distinct  prominence  in  the  epigastric' 


region. 


Palpation. — A  gradual  diminution  and  final  obliteration  of  the  cardiac 
shock  is  a  striking  feature  in  jirogressivo  effusion.  The  ajiex  beat  is  often 
raised  an  interspace  and  dislocated  outward.  Alteration  in  the  position 
of  the  impulse  simultaneously  Avitli  the  position  of  tlic  patient,  a  sign 
upon  which  Oppolzer  laid  great  stress,  cannot  often  be  determined,  as  tlio 
beat  may,  and  usually  does,  disappear  entirely.  The  pericardial  friction 
may  lessen  with  the  effusion,  though  it  often  persists  at  tlie  base  when 
no  longer  palpable  over  the  right  ventricle,  or  may  be  felt  in  the  eroet 
and  not  in  the  recumbent  posture,  riuctuation  can  rarely,  if  ever,  be 
detected. 

Pcrciis.sion  gives  most  important  indications.  The  gradual  distention 
of  the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large 
area  comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased 
percussion  dulness.  The  form  of  this  dulness  is  irregularly  jiear-sliajied ; 
the  base  or  broad  surface  directed  downward  and  the  stem  or  apex  directed 
upward  toward  the  manubrium. 

Auscultation. — The  friction  sound  heard  in  the  early  stages  may  dis- 
^»pear  when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at 
the  limited  area  of  the  apex.  It  may  be  audible  in  the  erect  and  imt  in 
the  recumbent  posture.  "With  the  absorption  of  the  fluid  the  friction 
returns.  One  of  the  most  important  signs  is  the  gradual  weakening  of  the 
lieart-sounds,  which  with  the  increase  in  the  effusion  may  become  '.-o 
muffled  and  indistinct  as  to  bo  scarcely  audible.  Tlio  heart's  action  is 
usually  increased  and  the  rhythm  disturbed.  Occasionally  a  systolic  endo- 
cardial murmur  is  heard. 


.^7^^^ 


PERICARDITIS. 


587 


Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the 
loft  lung.  The  antero-lateral  margin  of  the  lower  lobo  is  pushed  aside 
luiil  in  some  instances  compressed,  so  that  percussion  in  the  axillary  region, 
ill  and  just  below  the  transverse  nipple  line,  gives  a  modified  percussion 
note,  usually  a  flat  tympany.  Variations  in  the  position  of  the  patient 
iiKiy  oluinge  materially  this  modified  percussion  area,  over  which  on  aus- 
cultation there  is  either  feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rapidity  with  which  the  effusion 
takes  place.  In  every  instance,  when  a  pericardial  friction  murmur  hius 
been  (lotocted,  the  practitioner  should  immediately  outline  with  care — 
using  the  aniline  pencil  or  nitrate  of  silver — the  upper  and  left  limits  of 
cardiac  dulness,  since  he  will  in  this  way  have  certain  positive  guides  in 
(k'termining  the  rate  and  grade  of  the  effusion.  In  many  instances  the 
exudation  is  slight  in  amount,  reaches  a  maximum  within  forty-eight 
hours,  and  then  gradually  subsides.  In  other  instances  the  accumulation 
is  iiioi'c  gradual  and  progressive,  increasing  for  several  weeks.  To  such 
cases  the  term  chronic  has  bccTi  applied.  The  rapidity  with  which  a  sero- 
lihriuous  effusion  may  be  absorbed  is  surprising.  The  possibility  of  the 
abs(irj)tion  of  purulent  exudate  is  shown  by  the  cases  in  which  the  peri- 
cardium contains  semi-solid  grayish  masses  in  all  stages  of  calcification. 
With  soro-fibrinous  effusion,  if  nu)derate  in  amount,  recovery  is  the  rule, 
with  inevitable  union,  however,  of  the  pericardial  layers.  In  some  of  the 
septic  cases  there  is  a  rapid  formation  of  pus  and  a  fatal  result  may  follow 
in  throe  or  four  days.  More  commonly,  when  death  occurs  with  large 
effiisiou,  it  is  not  until  the  second  or  third  week  and  takes  place  by  grad- 
ual astlionia. 

Prognosis. — In  the  soro-fibrinous  effusions  the  outlook  is  good,  and 
a  largo  majority  of  all  the  rheumatic  ct..ses  recover.  The  purulent  effu- 
siciiis  are,  of  course,  more  dangerous ;  the  septic  cases  are  usually  fatal, 
tuid  rooovory  is  rare  in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked 
liy  :'i  ■  -ractitioner.  Post-mortem  experience  shows  how  often  pericarditis 
■•  c'  'T-  ognized,  or  goes  on  to  resolution  and  adhesion  without  attract- 
i.  r:  ot  In  a  case  of  rheum.itism,  watched  from  the  outset,  with  the 
atteiit,  'V.  f'ivocted  daily  to  the  heart,  it  is  one  of  the  simplest  of  diseases 
todiagn;-. ,  but  when  one  is  called  to  a  case  for  the  first  time  and  finds 
lierha{),s  an  increased  area  of  precordial  dulness,  it  is  often  very  hard  to 
•leterinino  with  f'(>rtainty  whether  or  not  effusion  is  present. 

Tlio  (lilliculLy  usually  lies  in  distinguishing  between  dilatation  of  the 
lioart  and  pericardial  effusion.  Although  the  differential  signs  are  simple 
enough  on  paper,  it  is  notoriously  difficult  in  certaiji  cases,  particularly  in 
stout  persons,  to  say  which  of  the  conditions  exists.  The  points  which 
'  ae"vo  attention  are  : 

((')  Tl'.o  character  of  impulse,  which  in  dilatation,  particularly  in  thiu- 
cUesU.'d  people,  is  commonly  visible  and  wavy. 
88 


nm 


588 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


W' 


;i#l 


{b)  The  shock  of  the  cardiac  sounds  is  more  distinctly  palpaljlo  in 
dilatation. 

(c)  The  area  Oi  diilness  in  dilatation  rarely  has  the  triangular  form ; 
nor  does  it,  except  in  cases  of  mitral  Htenosis,  reach  so  high  along  the  k;ft 
sternal  margin  or  so  low  in  the  fifth  and  sixth  interspaces  without  vinibb 
or  palpable  impulse.  An  upper  limit  of  dulness  shifting  with  the  posi- 
tion speaks  strongly  for  effusion. 

{(I)  In  dilatation  the  heart-sounds  are  clearer,  often  sharp,  valvular, 
or  fcotal  in  character ;  whereas  in  effusion  the  sounds  are  distant  ami 
muffled. 

(e)  Karely  in  dilatjition  is  the  distention  sufficient  to  compress  tho 
lung  and  i)roduce  the  tympanitic  note  in  the  axillary  region. 

The  number  of  excellent  observers  who  have  acknowledged  that  thoy 
have  failed  sometimes  to  discriminate  between  these  two  conditions,  and 
who  have  indeed  performed  paracentesis  cordis  instead  of  paracentesis 
pericardii,  is  perh'>na  the  best  comment  on  the  difficulties  which  certain 
cases  present. 

Massive  (1|  to  2  L.  iudutions  have  been  confounded  Avith  a  pleu- 
ral effusion.  On  more  auin  one  occasion  the  pericardium  has  been 
tapped  uiuler  the  impression  that  the  exudate  was  pleuritic.  Tho  flat 
tympany  in  the  infrascapular  region,  the  absence  of  well-defined  nioval)le 
dulness,  and  the  feeble,  muffled  sounds  are  indicative  points.  If  tho  ease 
has  been  followed  from  day  to  day  there  is  rarely  much  difficulty ;  but  it 
is  different  when  a  case  presents  a  large  area  of  dulness  in  the  antero- 
lateral region  of  the  left  chest,  and  there  is  no  to-and-fro  pericardial 
friction  murmur.  Many  of  the  cases  have  been  regarded  as  encapsulated 
pleural  effusion. 

The  nature  of  the  fluid  cannot  positively  be  determined  without  aspi- 
ration ;  but  a  fairly  accurate  oi)inion  can  be  formed  by  the  nature  of  the 
primary  disease  and  the  general  condition  of  the  patient.  In  rheumatic 
cases  the  exudation  is  usually  sero-fibrinous ;  in  septic  and  tubereulous 
cases  it  is  often  purulent  from  the  outset ;  in  senile,  nephritic,  and  tuber- 
culous cases  the  exudation  is  sometimes  ha;morrhagio. 

Treatment.— The  patient  should  have  absolute  quiet,  mentally  and 
bodily,  so  as  to  reduce  to  a  minimum  the  heart's  action.  Drugs  given  for 
this  purpose,  such  as  aconite  or  digitalis,  are  of  doubtful  utility.  Local 
bloodletting  by  cupping  or  leeches  is  certainly  advantageous  in  robust 
subjects,  particularly  in  the  cases  of  extension  in  pleuro-pneumonia.  TIk; 
ice-bag  or  Leiter's  tube  may  be  used  to  advantage.  They  luue  the  double 
effect  of  reducing  the  heart's  action  and  retarding  the  progress  of  iuflam- 
mation.     Blisters  are  not  indicated  in  the  early  stage. 

When  effusion  is  present,  the  following  measures  to  promote  absorp- 
tion may  be  adopted :  Blisters  to  the  praecordia,  a  practice  not  so  luucli 
in  vogue  now  as  formerly.  It  is  surprising,  however,  in  some  instances, 
how  quickly  an  effusion  will  subside  on  their  application.     If  the  patient  s 


PERICARDITIS. 


589 


i;|riiigth  is  good,  a  purge  every  other  morning  may  be  given.  The  diet 
sluiuld  be  light,  dry,  and  nutritious.  In  cases  in  which  the  pulse  is  strong 
iuul  the  constitutional  disturbance  not  great,  iodide  of  potassium  may  bo 
of  service,  and  the  action  of  the  kidneys  nuiy  be  i)romoted  by  tlie  infusion 
(/[  difritulis  and  acetate  of  potash. 

When  the  elfusion  is  large,  as  soon  as  signs  of  serious  impairment  of 
the  heart  occur,  as  indicated  by  dyspncoa,  small  rapid  pulse,  dusky,  anxious 
countenance,  surgical  measures  should  be  resorted  to,  and  paracentesis,  or 
incision  of  the  pericardium,  at  once  be  performeil.  Witii  the  sero-fibrin- 
ous  exudate,  such  as  commonly  occurs  after  rheumatism,  aspiration  is 
sufliciont;  but  when  the  exudate  is  purulent  the  pericardium  should  be 
frei'ly  incised  and  freely  drained.  The  puncture  may  be  made  in  the 
fdurtli  interspace,  either  at  the  left  sternal  margin  or  2-o  cm.  (an  inch) 
from  it.  If  made  in  the  fifth  intersj)ace  it  is  well  to  puncture  an  inch 
aiul  a  half  from  the  left  sternal  margin.  In  large  effusions  the  pericar- 
dium can  also  be  readily  reached  without  danger  by  thrustiiig  the  needle 
upward  and  backward  close  to  the  costal  margin  in  the  left  costo-xiphoid 
aiifilo.  Tlie  results  of  paracentesis  of  the  pericardium  liave  so  far  not 
been  satisfactory.  With  an  earlier  operation  in  many  instances  and  a 
more  radical  one  in  others — a  free  incision  and  not  aspiration  when  the 
lluivl  is  purulent — the  percentage  of  recoveries  will  be  greatly  increased. 

Chronic  Adhesive  Pericarditis  {Adherent  Pericardium). — This  con- 
dition follows  acute  pericarditis,  and  nuiy  be  partial  or  universal.  It  is 
not  very  uncommon  to  meet  with  limited  synechia  over  the  right  ven- 
tricle. In  the  mildest  grades  of  complete  adhesion  the  amount  of  con- 
nective tissue  between  the  membranes  is  slight,  and  there  is  not  much 
tliirkcuing.  These  are  the  instances  which  follow  the  fibrinous  rheu- 
matic pericarditis.  The  most  extreme  thickening  of  the  membranes  is 
met  with  in  the  chronic  tuberculous  form,  which  has  already  been  de- 
scribed, and  which  is  much  more  common  than  indicated  in  the  litera- 
ture. After  the  absorption  of  an  extensive  purulent  or  sero-purulent 
exudate  the  inspissated  remnants  may  undergo  calcification.  This  may 
be  in  fjuite  a  limited  region,  most  frequently  over  the  auricles  or  at  the 
base  of  the  heart.  In  extreme  grades  the  organ  is  completely  invested 
by  a  calcareous  membrane,  which  in  places  may  be  from  1  to  1-5  cm.  in 
thick  ness. 

The  tti/mptains  of  adherent  pericardium  are  uncertain  and  indefinite. 
A  iiuijority  of  the  cases  are  met  with  accidentally  in  the  post-mortem 
room,  and  there  may  have  been  no  indications  whatever  during  life  of 
oardiac  disturbance.  Enlargement  of  the  heart  is  an  almost  constant  ac- 
companiment of  universal  adhesion,  and  many  of  the  cases  come  under 
observation  for  the  first  time  with  failure  of  this  hypertrophy  and  signs 
of  cardiac  insufficiency. 

The  following  are  the  important  points  in  the  diagnosis : 

(1)  Inspection. — In  children,  in  whom  the  condition  is  not  very  un- 


2   '* 

"*^1 

'::,% 


590 


DISEASES  OP  THE  CIRCULATOIIY  SYSTEM. 


common  as  a  so.|ncnco  of  rheumatism,  the  liypertrophied  lieart  causes  l)iil<r- 
ing  of  the  chest  wall.  The  area  of  cardiac  impulse  is  increased  and  may 
sometimes  be  seen  from  the  tliird  to  the  sixth  intersi)ace  and  beyond  the 
nipple  line.  The  strongest  impulse  may  bo  to  the  right  of  the  apex.  Tlio 
wavy  character  of  the  pulsation  in  tln'  third,  fourth,  and  fifth  interspacos 
is  not  peculiar  to  adherent  i)oricardium.  Not  mudi  stress  can  ]w  laid 
upon  the  fixed  position  of  the  impulse,  whicli  in  great  enlargement  of  tli(> 
heart  is  not  much  influenced  either  by  posture  or  respiration.  A  more 
important  point  is  systolic  retraction  of  the  apex  region.  AVhether  tliis 
occurs  without  adhesion  of  the  jiei-icardium  to  the  chest  wall  is  doubtful. 
It  is  often  marked,  and  is  sometimes  best  appreciated  by  the  applieufion 
of  the  hand  over  the  apex  region,  which  is  felt  to  be  drawn  in  at  the  mo- 
ment of  systole.  The  retraction  nuiy  be  most  noticeable  in  the  lower 
sternal  region  or  even  at  the  xiphoid  cartilage.  Following  this  there  is 
sometimes  a  rapid  rebound — the  diastolic  shock — which  has  been  regarded 
by  some  as  the  most  reliable  of  all  signs  of  pericardial  adhesion.  Asso- 
ciated with  this  diastolic  rebouiul  is  the  so-called  Fricdrich\'i  niyn — dias- 
tolic collapse  of  the  cervical  veins. 

(2)  Percussion  reveals  an  increase  in  the  area  of  cardiac  dulness,  par- 
ticularly upward  as  high  as  the  second  interspace.  In  a  majority  of  the 
cases  there  are  adhesions  as  well  between  the  pleura  and  pericardium— in 
ten  of  thirteen  cases  analyzed  by  Ord.  In  some  instances  the  duliu>ss  may 
reach  as  high  as  the  first  interspace.  A  sign  of  value  is  the  fixed  limit 
above  and  to  the  left  of  cardiac  dulness,  as  pointed  out  by  C.  J.  H.  Will- 
iams. "When  the  outer  layer  of  the  pericardium  is  adherent  to  the  jileura 
this  is  a  sign  of  very  definite  value,  and  the  limit  of  dulness  varies  very 
slisrhtly  on  deep  inspiration. 

(;5)  On  misruUatinn  the  phenomena  vary  extremely  with  the  condition 
of  the  chambers.  There  may  be  no  murmurs.  When  extreme  dilatation 
is  present  the  gallop  or  foetal  rhythm  occurs.  A  loud  regurgitant  mur- 
mur is  not  uncommon  at  the  apex  region,  and  the  cases  are  frequently 
mistaken  for  mitral  insuflflciency. 

(4)  The  pulsus  paradoxus  in  which  duriiig  inspiration  the  pulse- 
wave  is  small  and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic 
sign  of  either  simple  pericardial  adhesion  or  of  the  cicatricial  mediastiiio- 
pericarditis. 

Adherent  pericardium  with  extreme  dilatation  of  the  heart  may  raisin 
the  suspicion  of  pericarditis  with  efEusion,  as  the  outline  of  dulness  in  both 
is  somewhat  alike.  As  a  rule,  however,  the  basic  dulness  is  broader  in  aii- 
hesion,  and  has  not  the  pear-shaped  outline.  The  extent  and  wavy  char- 
acter of  the  impulse  is  never  so  marked  in  large  effusions,  and  the  heart- 
sounds  are  muffled. 


■;-B|' 


OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 


n.  OTHER  AFFECTIONS  OF  THE   PERICARDIUM. 


591 


1.  Hydropericardium. — Xuturully  there  are  in  the  pericardial  sac  a 
l\\v  cubic  centimetres  of  clear,  citron-colored  fluid,  which  probably  repre- 
(A'uts  a  post-mortem  transudate.  In  certain  conditions  during  life  there 
luav  be  large  secretions  of  serum  forming  what  is  known  as  dropsy  of  the 
pericardium.  It  occurs  usually  in  connection  with  general  dropsy,  due 
to  kidney  or  heart  disease ;  more  commonly  the  former.  It  rarely  of  it- 
self proves  fatal,  though  when  the  effusion  is  excessive  it  adds  to  the 
iiiiliarrassment  of  the  heart  and  the  lungs,  particularly  when  the  pleural 
cuvitics  are  the  seat  of  similar  exudation.  There  are  rare  instances  in 
whicli  effusion  into  the  pericardium  occurs  after  scarlet  fever  with  few, 
if  any,  other  dropsical  symptoms.  The  physical  signs  arc  those  already 
referred  to  in  connection  with  pericarditis  with  effusion.  It  is  frequently 
overlooked. 

In  rare  cases  the  serum  has  a  milky  character — chylo-pericardium. 

2.  HSBmo-pericardilim. — This  condition,  by  no  means  uncommon,  is 
met  with  in  aneurism  of  the  first  part  of  the  aorta,  of  the  cardiac  wall,  or 
of  the  coronary  arteries,  and  in  rupture  and  wounds  of  the  heart.  Death 
usually  follows  before  there  is  time  for  the  production  of  symptoms  other 
tluui  tliose  of  ra})id  heart-failure  due  to  compression.  Particularly  is  this 
the  case  in  aneurism.  In  rupture  of  the  heart  the  patient  may  live  for 
many  hours  or  even  days  with  symptoms  of  progressive  heart-failure, 
(lyspi\(ea,  and  the  physical  signs  of  effusion. 

As  already  mentioned,  the  inflammatory  exudate  of  tubercle  or  cancer 
is  often  blood-stained.  The  same  is  true  of  tlie  effusion  in  the  peri- 
carditis of  Bright's  disease  and  of  old  people. 

'I  Pneumo-pericardium. — Gas  is  rarely  found  in  the  pericardial  sac, 
ami  is  due,  as  a  rule,  to  perforation  from  without,  as  in  the  case  of  stab 
wounds,  or  the  result  of  perforation  from  the  lungs,  oesophagus,  or 
stomach.  Possibly,  too,  it  may  result  from  the  decomposition  of  a  puru- 
lent exudate.  As  a  result  of  perforation,  acute  pericarditis  is  always  ex- 
cited, and  the  effusion  rapidly  becomes  purulent.  The  physical  signs  are 
remarkable.  When  the  effusion  is  copious  the  fluid  and  gas  together  give 
a  movable  area  of  percussion  dulness  with  marked  tympany  in  the  region 
of  the  gas.  On  auscultation,  remarkable  splashing,  churning,  metallic 
pliononiena  are  heard  with  friction  and  possibly  feeble,  distant  heart- 
pouiuls.  Death  follows  rapidly,  even  in  thirty-six  hours,  as  in  a  case  (the 
only  one  Avhich  I  have  seen)  of  perforation  of  the  pericardium  in  cancer 
|>f  tlu!  stomach.  Except  as  a  result  of  injury,  the  condition  is  not  one  for 
which  treatment  is  available.  In  a  case  of  perforation  from  without  with 
!*iirns  of  effusion,  to  enlarge  the  wound  by  free  incision  would  be  justi- 
fiable. 


.,\ 


1 4 


^ 


1 1- If' 


*' 


^y-    iff 


592  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

II.    DISEASES  OF  THE  HEART. 

I.   ENDOCARDITIS. 

Inflammation  of  tho  lining  membrane  of  the  heart  is  nsually  conliiiod 
to  the  valves,  so  that  the  term  is  practieally  synonymous  M'ith  valvular 
endocarditis.  It  occurs  in  two  forms — acute,  characterized  by  the  })r(\s- 
ence  of  vegetations  with  loss  of  continuity  or  of  substance  in  the  valve 
tissues;  chronic,  a  slow  sclerotic  change,  resulting  in  thickening,  pucker- 
ing, and  deformity. 

Acute  Endocarditis. 

This  occurs  in  rare  instances  as  a  primary,  independent  affection ;  Init 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  j)r()- 
cesses,  so  that  in  reality  the  disease  does  not  constitute  an  etiological 
entity. 

For  convenience  of  description  we  speak  of  a  simple  or  benign,  and  u 
malignant  or  ulcerative  endocarditis,  between  which,  however,  there  is  n(> 
essential  anatomical  difference,  as  all  gradations  can  be  traced,  and  tlioy 
represent  but  different  degrees  of  intensity  of  the  same  process. 

Simple  Endocarditis. — This  is  characterized  by  the  presence  on  the 
valves  or  on  the  lining  membrane  of  the  chambers  of  minute  vegetations, 
ranging  from  1  to  4  mm.  in  size,  with  an  irregular  and  fissured  surfuee, 
giving  to  them  a  warty  or  verrucose  appearance.  Often  these  little  canli- 
flower-like  excrescences  are  attached  by  very  narrow  pedicles.  It  is  rare 
to  see  any  swelling  or  infiltration  of  the  endocardium  in  the  neighliorhood 
of  even  the  smallest  of  the  granulations',  and  although  small  capilliiry 
vessels  do  exist  at  the  edges  of  the  valves,  redness,  indicative  of  tho  injec- 
tion or  distention  of  the  vessels,  is  extremely  rare.  With  time  the  vegeta- 
tions may  increase  greatly  in  size,  but  in  what  may  be  called  simple 
endocarditis  the  size  rarely  exceeds  that  mentioned  above.  The  finer 
changes  in  the  process  consist  of  the  proliferation  of  the  subendotlielial 
connective-tissue  elements,  resulting  in  a  small-celled  infiltration.  Wluit 
part,  if  any,  the  endothelial  cells  play  in  this  is  not  accurately  known. 
The  superficial  elements  undergo  a  coagulation  necrosis,  and  fibrin  is 
deposited  from  the  blood,  often  in  layers.  Practically  a  vegetation  is  a 
small  area  of  granulation  tissue  capped  with  fibi'in.  Micro-organisms 
are  present,  entangled  in  the  granular  and  fibrillated  fibrin,  but  wheilicr 
they  constitute  an  essential  and  constant  element  in  all  cases  of  simple 
endocarditis  has  not  yet  been  decided. 

The  further  changes  in  the  vegetation  may  be  either  in  the  direction 
of  increased  proliferation  of  the  connective-tissue  elements  of  tho  valve, 
forming  an  extensive  area  of  necrosis  and  the  production  of  the  condition 
which,  from  its  more  intense  grade,  we  speak  of  as  malignant  or  ulcerative 
endocarditis;  or,  as  is  more  usual,  healing  occurs.     The  vegetation  is 


ENDOCARDITIS. 


693 


iilisorbctl,  and  there  reraaina  a  small  nodular  tliickcninp  of  the  valve.  A 
tliird  possibility  ia  the  dislocation  of  a  vogetatioii  witli  transforence  as  an 
embolus  to  a  distant  part  of  the  circulation.  It  is  to  bo  noted,  however, 
that  this  untoward  event  is  rare  in  ac;ute  cndocartlitis  associated  with 
f(  hrile  affections,  whereas  it  is  by  no  means  uncommon  in  the  simple 
cudocarditis  which  occurs  so  constantly  on  old  sclerotic  valves. 

Anatomically,  in  the  majority  of  instances  of  acute  endocarditis,  cica- 
trization of  the  granulation  tissue  takes  pluci;  in  time,  Avith  but  little 
damage  to  the  valve  beyond  slight  nodular  tliiekwiing.  The  essential 
danger  is  remote  and  results  from  the  slow  changes  in  the  valve  tissue, 
which  are  so  apt  to  follow  an  acute  inflamnuition.  Why  this  should  be 
so  cannot  at  present  be  exjilained ;  but  the  fact  remains  that  the  simple 
endocarditis,  harmless  in  itself,  such  as  we  meet  with  in  rheiunatism  or 
ill  oliorea,  lays  the  foundation  of  subsequent  organic  lesions,  owing  to  the 
initiation  of  nutritive  changes  leading  to  sclerosis  with  contraction  and 
deformity. 

Endocarditis  is  much  more  common  on  the  left  side  of  the  heart  and 
involves  the  valvular  endocardium  in  the  great  majority  of  cases.  During 
fd'tal  life  the  right  side  of  the  heart  is  often  affected.  The  chorda)  tcn- 
dinca3  are  sometimes  involved  with  the  valves,  rarely  alone.  The  mitral 
valves  are  more  often  affected  than  the  aortic.  On  the  mitral  segment 
the  vegetations  are  usually  on  the  auricular  face,  not  at  tlie  margin,  but 
at  a  distance  of  2  or  3  mm.,  forming  a  row  of  bead-like  outgrowths.  So, 
too,  on  the  aortic  segment  they  are  not  seen  on  the  free  margin,  but  just 
below,  on  the  ventricular  face,  following  the  margin  of  the  so-called  lunat- 
cd  spaces.  In  both  the  valves  this  j)eeuliar  distribution  follows,  as  Sibson 
suggests,  the  lines  of  maximum  contact. 

Etiology. — Simple  endocarditis  d'les  not  constitute  a  disease  of  it- 
self, bill  is  invariably  found  with  some  other  affection.  The  general  ex- 
perience of  the  profession  has  confirmed  the  original  observation  of  Bouil- 
laud  as  to  the  frequency  of  association  of  simple  endocarditis  with  acute 
articular  rheumatism.  Possibly  it  is  nothing  in  the  disease  itself,  but 
simply  an  altered  state  of  the  fluid  media — a  reduction  perhaps  of  the 
lethal  influences  which  they  normally  exert — permitting  the  invasion  of 
tlie  l)lood  by  certain  micro-organisms.  I'onsillitis,  which  in  some  forms 
is  regarded  as  a  rheumatic  affection,  may  be  complicated  witli  endocardi- 
tis. Of  the  spefjfic  diseases  of  childhood  it  is  not  uncommon  in  scarlet 
fever,  while  it  is  rare  in  measles  and  chicken-pox.  In  diphtheria  simple 
cndoearditis  is  rare.  It  was  not  present  in  a  single  instaiuie  of  30  autop- 
sies which  I  made  in  this  disease  at  the  Montreal  General  Hospital.  In 
small-pox  it  is  not  common.  It  is  stated  to  be  more  frequent  in  typhoid 
fever  ]}ut  was  not  present  in  Go  post-mortems  in  this  disease. 

In  pneumonia  both  simple  and  maligiumt  endocarditis  are  common. 
In  100  autopsies  in  this  disease  made  at  the  Montreal  General  Hospital 
there  were  5   instances  of    the  former.     Acute  endocarditis  is  by  no 


w^ 


594 


DISEASES  OP  TEIR  CIRCULATORY  SYSTEM. 


moans  rare  in  phtliisia.  I  have  mot  with  it  in  13  oiusos  in  210  post-iiior- 
toms. 

In  clioroa  simple  warty  vegetations  arc  found  on  tho  valves  in  a  largo 
majority  of  all  fatal  eases.  'J'hero  is  no  diseiuso  in  which,  post  moiicin. 
a(!ute  omloeanlitis  has  been  so  frccpiently  found.  And  lastly,  siiii|i|(. 
ondoearditis  is  met  with  in  diseases  associated  with  loss  of  flesh  and  pm- 
gressivo  debility,  as  cancer,  and  such  disorders  as  gout,  diabetes,  aiiil 
Hright's  disease. 

A  very  common  -form  is  that  which  occurs  on  the  sclerotic  valves  in 
old  heart-disease — the  so-called  recurring  eiulocarditis. 

Symptoms. — Neither  the  clinical  course  nor  tho  physical  signs  are  in 
any  respect  characteristic.  The  great  majority  of  tho  cases  are  latent  and 
there  is  no  indication  whatever  of  cardiac  mischief.  Experience  has  taiij,'lil 
us  that  endocarditis  is  frequently  found  post  mortem  in  persons  in  whom 
it  was  not  suspected  during  life.  There  are  certain  features,  however,  bv 
which  its  presence  is  indicated  with  a  degree  of  probability.  The  ])ati('nt, 
as  a  rule,  does  not  comi)lain  of  any  pain  or  cardiac  distress.  In  a  case  of 
acute  rheumatism,  for  example,  the  symptoms  to  excite  suspicion  would 
be  increased  rapidity  of  the  heart's  action,  perhaps  slight  irregularity,  and 
an  increase  in  tho  fever  without  aggravation  of  the  joint  troid)le.  Hows 
of  tiny  vegetations  on  the  mitral  or  on  the  aortic  segments  seem  a  tiitling 
matter  to  excite  fever  and  it  is  dirhvult  in  tiie  endocarditis  of  febrile  \m)- 
(iosses  to  say  definitely  in  every  instarce  that  an  increase  in  the  fever  de- 
pends upon  the  tndocardia'.  compliciition.  But  a  study  of  tho  recurring 
endocarditis — which  is  of  the  warty  variety,  consisting  of  minute  beads  on 
old  sclerotic  valves— shows  that  thi^:  process  may  be  associated,  for  days 
or  week  at  a  time,  with  slight  fijver  ranging  from  100°  to  1024°.  Pal- 
pitation may  be  a  marked  feature  and  is  a  symptom  upon  wliich  certain 
authors  lay  great  stress. 

The  diagnosis  of  tho  condition  rests  upon  physical  signs  which  are 
notoriously  uncertain.  Tho  presence  of  a  murmur  at  one  or  other  f^f  the 
cardiac  areas  in  a  case  of  fever  is  often  regarded  as  indicative  of  the  exist- 
ence of  endocarditis.  This  extremely  common  mistake  has  arisen  from 
the  fact  that  tho  hridt  de  souffle  or  bellows  murmur  is  common  to  endo- 
carditis and  a  number  of  other  conditions  which  have  nothing  to  do  with 
it.  At  first  there  may  be  oidy  a  slight  roughening  of  tho  first  sound. 
which  may  gradually  develoj)  into  a  distinct  murmur.  Taken  alone,  it  is, 
however,  a  very  uncertain  and  fallacious  sign. 

Malignant  Endocarditis. — Acute  endocarditis  of  a  malignant  charueter 
is  met  Avith  : 

(a)  As  a  primary  disease  of  the  lining  membrane  of  tho  heart  or  of 
its  valves. 

(b)  As  a  secondary  affection  in  acute  rheumatism,  pneumonia,  and  in 
various  specific  fevers ;  or  as  an  associated  condition  in  septic  procotiscs. 


ENDOCARDITIS. 


505 


It  is  ulso  known  by  tlio  nanx's  of  iilccnitivc,  infections,  or  (liplithcritic 
eiulocarditiy,  but  tlio  term  nialignuJit  seems  most  appropriate  to  clmrac- 
ti'iize  the  essential  clinical  features  of  the  disease. 

Etiology. — 'I'lie  existence  of  a  primary  endocunlitis  has  been  doubled ; 
hut  there  are  instances  in  which  persons  previously  in  j^ood  health,  without 
iiiiv  liistory  of  alTections  with  which  endocarditis  is  usually  associated,  have 
hcciv  attacked  with  symptoms  resemblin<jf  eevero  typhus  or  tyi^hoid.  In 
one  ease  which  I  saw  death  occurred  on  the  si.\th  day  and  no  lesions  were 
found  other  than  those  of  nuvli<,Muint  endocarditis. 

Rheumatism,  with  which  simple  endocarditis  is  frerpiently  associated, 
is  not  so  often  complicated  with  the  nudignant  form.  Thus,  in  only 
'U  of  209  cases  the  symptoms  of  severe  endocarditis  arose  in  the  progress 
of  acute  or  subacute  rheumatisjn.  In  only  3  of  the  Montreal  cases  was 
there  a  history  of  rheumatism  eithei  before  or  during  the  atta'.'ks. 

Malignant  endocarditis  is  extremely  rare  in  chorea.  Of  all  acute  dis- 
eases complicated  with  severe  endocarditis  pneumonia  probably  heads  the 
list.  This  fact,  whitdi  had  been  referred  to  by  several  of  the  older  writers, 
was  brought  out  in  a  striking  manner  by  the  figures  on  'liich  my  lectures 
were  I)ased.  In  11  of  the  '^3  Montreal  cases  the  disease  catne  on  with 
lobar  pneumonia,  while  it  developed  with  this  disease  in  T)-!  of  the  209 
cases  analyzed — indeed,  the  endocarditis  which  occurs  in  pneumonia  seems 
to  be  of  an  uinisually  malignant  type,  as  in  ItJ  uusos  of  my  100  autoi)sie8 
in  this  disease  in  which  this  le?if)n  was  present,  11  were  of  this  form. 
Meningitis  was  associated  with  endocarditis  in  25  of  tho  209  cases,  and  iu 
15  there  was  also  pneumonia. 

The  alTection  may  complicate  erysipelas,  septicnemi.i  (from  whatever 
cause),  and  puerperal  fever  and  gonorrhoea.  Malignant  endocarditis  is 
very  rare  in  tuberculosis,  typhoid  fever,  and  diphtheria. 

It  has  been  stated  by  many  writers  that  endocarditis  occurs  in  ague. 
With  the  unusual  facilities  for  the  study  of  this  disease  which  I  have  had 
in  the  past  seven  years  I  have  not  yet  met  with  an  instance.  Unquestion- 
iibly,  in  the  majority  of  these  cases,  the  intermittent  pyrexia,  which  has 
been  regarded  as  characteristic  of  the  ague,  has  depended  upon  the  endo- 
carditis. In  dysentery  cases  have  been  described.  In  small-pox  and 
scarlet  fever,  with  which  simpb  endocarditis  is  not  infrequently  compli- 
cated, the  malignant  form  is  extremely  rare. 

Morbid  Anatomy. — The  lesions  may  be  cither  vegetative,  ulcera- 
tive, or  suppurative,  and  these  forms  may  occur  alone  or  in  combii/tion. 
Even  with  vegetations  there  is  distinct  necrosis  and  loss  of  tho  endocardial 
substance.  More  frequently  there  is  ulceration,  either  superficial,  involv- 
ing only  the  endocardium,  or  deep  and  distinct,  leading  to  perforation  of 
a  valve,  of  a  septum,  or  even  of  the  heart  itself.  In  the  suppurative  form 
the  deeper  tissues  of  the  valve  appear  first  affected  and  small  abscesses  are 
found  at  the  bases  of  the  vegetations.  The  vegetations  may  present  a  re- 
markable greenish-gray  or  greenish-yellow  color,  and  when  of  long  stand- 


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596 


DISEASKS  or  THE  CIRnULATOKY  SYSTEM. 


ing,  or  oven  in  cases  which  from  tho  clinioal  history  uppour  to  be  tulL-ralily 
acuto,  tho  vogctatiotis  may  bo  crusted  witii  lime  salts. 

A  lar;^'(?  vc^j^ftiition  of  i»ali;jf!iutit  endocarditis  consists  histoloi^Mcally  (if 
a  granular  and  fibrillatod  lllirlM,  colonics  of  micro-organisms,  and  distiiiit 
granulation  tissue  at  tin*  base,  while  tlu!  subja(;ent  endocardial  Iiivith 
show  infiltration  and  proliferation.  'J'he  destru{;tion  of  tissue  results  Iniiii 
a  gradual  extension  of  tho  necrotic  processes.  Various  micro-organisms 
have  been  found  in  cojineetion  with  the  disease,  and  the  following  brief 
statement  may  be  nuule  with  reference  to  them  :  In  a  large  proportidii  of 
tho  cases  streptococci  and  staphylococci  are  found.  The  ])neunio('(i((u.s 
has  been  cultivated  from  the  vegetations  in  pneumonia.  Other  forms 
have  occasionally  been  met  with. 

'J'he  following  figures,  taken  from  my  Culstonian  lectures  at  the  V\i>\n\ 
College  of  Physicians,  give  an  a])pro.\inuite  estimate  of  the  frccpiency  witii 
which  in  209  cases  dilforent  jiarts  of  the  heart  were  affected  :  Aortir  iiml 
mitral  valves  together,  41 ;  aortic  valves  alone,  53  ;  mitral  valves  alone,  77; 
tricuspid  in  19 ;  tho  pulmonary  valves  in  15 ;  and  the  heart  wall  in  Ii3. 
In  9  instances  the  right  heart  alone  was  involved. 

Mural  endocarditis  is  seen  most  often  at  the  nppor  part  of  the  septiii.i 
of  the  left  ventricle.  Next  in  order  is  tho  endocarditis  of  the  left  auricle 
on  tho  postero-external  wall.  'J'he  ulcerative  changes  may  lead  to  perfora- 
tion of  a  valve  segmcjit,  erosioii  of  the  chordae  tcndinea\  perforation  of 
the  septum,  or  even  of  the  heart  itself.  A  common  result  of  the  ulcera- 
tion is  the  prodnction  of  valvular  aneurism.  In  three  fourths  of  the  ea.soo 
the  affected  valves  present  old  sclerotic  changes.  The  process  may  extend 
to  tho  aorta,  producing,  as  in  ono  of  my  cases,  extensive  endarteritis  with 
multiple  acute  aneurisms. 

The  associated  pathological  changes  are  partly  tliose  of  the  ])rimary 
disease  to  which  the  endocarditis  is  secondary  and  partly  those  due  to 
embolism.  In  tho  endocarditis  of  septic  processes  there  is  the  local  lesion 
— an  acute  necrosis,  a  suppurative  wound,  or  puerperal  disease.  In  many 
cases  the  lesions  are  those  of  pneumonia,  rheumatism,  or  other  febrlic  jtro- 
cesses.  The  changes  due  to  embolism  constitute  the  most  striking  feat- 
ures, but  it  is  remarkable  that  in  soine  instances,  even  with  eiuloeanlitis 
of  a  markedly  ulcerative  character,  there  may  be  no  trace  of  embolic 
processes. 

The  infarcts  may  be  few  in  number— only  ono  or  two,  perhaps,  in  the 
spleen  or  kidney — or  they  may  exist  in  hundreds  throughout  the  various 
parts  of  the  body.  They  may  present  the  ordinary  appearance  of  red  or 
white  infarcts  of  a  suppurative  character.  They  are  most  common  in  the 
spleen  and  kidneys,  though  they  may  be  numerous  in  the  brain,  and  in 
many  cases  are  very  abundant  in  the  intestines.  In  right-sided  endocar- 
ditis tliere  may  be  infarcts  in  tho  lungs.  In  many  of  the  cases  there  arc 
innumerable  miliary  abscesses.  Acute  suppurative  meningitis  was  met 
with  in  5  of  23  of  the  Montreal  cases,  and  in  over  ten  per  cent  of  the  209 


ENDOCAIlDITia 


507 


cases  analyzed  in  the  litcraturo.     Aciito  suppurativo  parotitis  also  may 
occur. 

Symptoms. — It  is  difliciilt  to  givo  a  satisfactory  (ilinical  picturo  of 
the  tliseuso  bocauso  tho  modes  of  onset  are  so  varied  and  the  synipt(jms  so 
diverse.  Arising  in  the  course  of  soino  other  disease,  tlierc  inuy  \m  simply 
an  intcnsilieation  of  the  fever  or  a  change  in  its  character.  In  a  ma- 
joritA  of  the  cases  there  an;  present  certjiin  general  features,  such  as  irregu- 
lar pyrexia,  delirium,  sweating,  gradual  failure  of  strength. 

J'lniholio  processes  may  give  sjjccial  characters,  such  as  delirium,  coma 
or  paralysis  from  involvmnent  of  the  hrain  or  its  nuimbranes,  pain  in  the 
sides  and  local  peritonitis  from  infarction  of  the  si)leen,  bloody  urine  from 
iiniilicatiim  of  the  kidneys,  impaired  vision  from  retinal  hannorrhage,  and 
suppuration,  and  oven  gangrene,  in  various  parts  from  the  distribution  of 
tlie  emboli. 

Two  special  types  of  the  disease  have  been  recogni7,ed — the  septic  or 
pyii'iiiic  and  the  typhoid.  Other  cases  closely  resemble  true  intermittent 
fever.  In  some  the  cardiac  8ymi)toms  are  most  prominent,  while  in  others 
ii;,'aiii  the  main  symjjtoms  may  be  those  of  an  acute  alfection  of  tlio  cere- 
bro-spinal  system. 

The  s<'j>(ic  type  is  met  with  usually  in  connection  with  an  external 
woiiiiil,  the  i)uerperal  process,  or  an  acute  necrosis.  There  are  rigors, 
sweats,  irregular  fevers,  and  all  of  the  signs  of  septic  infection.  The  heart 
.symptoms  may  bo  completely  masked  by  the  general  (  ndition,  and  atten- 
tion called  to  them  oidy  on  the  occurrence  of  embolism.  In  a  most  re- 
markable sub-group  of  this  type  the  disease  nuiy  simulate  a  quotidian  or  a 
tertian  ague.  The  symptoms  may  develop  in  jjcrsons  with  chronic  heart- 
disease  without  any  external  lesions.  These  cases  may  be  much  prolonged 
—for  tlirce  or  four  months,  or  even  longer,  as  in  a  case  of  Bristowe's. 
The  existence  in  some  of  these  instances  of  a  previous  genuine  malaria 
has  been  a  very  puzzling  circumstance. 

The  (i/phoid  type  is  by  far  the  most  common  and  is  characterized  by 
an  irregular  temperature,  early  prostration,  delirium,  somnolence,  and 
ccma,  relaxed  bowels,  sweating,  which  may  be  of  a  most  drenching  char- 
acter, pctecliial  and  other  rashes,  and  occasionally  parotitis.  The  heart 
symptoms  may  be  completely  overlooked,  and  in  some  intances  the  most 
careful  examination  has  failed  to  discover  a  murmur. 

Under  the  cardiac  group,  as  suggested  by  Bramwcll,  may  be  consid- 
ered those  cases  in  which  patients  with  chronic  valve  disease  are  attacked 
witli  marked  fever  and  evidence  of  recent  endocarditis.  Many  such  cases 
present  symptoms  of  the  pytemic  and  typhoid  character  and  may  run  a 
most  acute  course.  In  others  the  process  is  less  intense  and  the  course 
more  clironic,  lasting  for  weeks  or  months,  so  that  the  term  acute  is  scarce- 
ly applicable  to  them.  In  a  case  of  this  kind  under  the  care  of  Mullin, 
of  Hamilton,  the  irregular  fever  lasted  for  more  than  a  year.  The  autop- 
sy showed  extensive  vegetative  and  ulcerative  discxso  of  the  mitral  valves. 


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598 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


There  arc  cases  in  wliich  it  is  often  difficult  to  decide  ■wlictlicr 
malignanc  endocarditis  is  present  or  not.  Thus,  a  patient  with  aortio 
valve  disease  is  under  treatment  for  failing  compel i^^ation  and  begins  to 
liavc  irregular  fever  with  rcstlessncsf  and  cardiac  distress ;  embolic  plio- 
nomena  may  develop — sudden  hemiplegia,  pain  in  the  region  of  tlu- 
spleen,  or  bloody  urine,  or  perhaps  peripheral  embolism.  There  may  1)0  u 
low  delirium  and  the  case  may  run  a  tolerably  acute  course  ;  but  in  otlur 
insttmces  the  fever  subsides  ami  recovery  occurs. 

In  what  may  be  termed  the  cerebral  (jroup  of  cases  the  clinical  jiict- 
nre  may  simulate  a  meningitis,  either  basilar  or  cerebro-spinal.  There 
may  be  acute  delirium  or,  as  in  three  of  the  Montreal  cases,  the  i)atient 
may  be  brought  into  the  hospital  unconscious.  Ileineman  reports  an  in- 
stance, with  autopsy,  in  which  the  clinical  picture  was  that  of  an  acute 
cerebro-spinal  meningitis. 

Certain  special  symptoms  may  be  mentioned.  The  fever  is  not  al- 
ways of  a  remittent  type,  but  may  be  high  and  continuous.  Pctccliiiil 
rashes  are  very  common  and  render  the  similarity  very  strong  to  certain 
cases  of  typhoid  and  cerebro-spinal  fevers.  In  one  case  the  disease  wjis 
thought  to  be  h;emorrhagic  small-pox.  Erythematous  rashes  are  not  un- 
common. The  sweating  may  be  most  profuse,  even  exceeding  that  wliich 
occurs  in  j)hthisis  and  ague.  Diarrhoea  is  not  necessarily  associated  with 
embolic  lesions  in  the  intestines.  Jaundice  has  been  observed  and  cases 
are  on  record  which  were  mistaken  for  acute  yellow  atrophy. 

The  heart  symptoms  may  be  entirely  latent  and  are  not  found  unless;  a 
careful  search  be  made.  Even  on  oxamination  there  may  bo  nt)  mur- 
mur present.  Instances  are  recorded  by  careful  observers,  in  wliich  the 
examination  of  the  heart  has  been  negative.  Cases  with  chronic  valve 
disease  usually  present  no  difficulty  in  diagnosis. 

The  course  of  the  disease  is  varied,  depending  largely  upon  the  nature 
of  the  primary  trouble.  Except  in  the  disease  grafted  upon  chronic 
valvulitis  the  course  is  rarely  extended  beyond  five  or  six  weeks.  As 
already  mentioned,  there  are  instances  in  which  the  disease  is  prolonged 
for  months.  The  most  rapidly  fatal  case  on  record  is  described  by 
Eberth,  the  duration  of  which  was  scarcely  two  days. 

Diagnosis. — Tn  many  cases  the  detection  of  the  disease  is  very  ilitli- 
cult ;  in  others,  with  marked  embolic  symptoms,  it  is  easy.  From  simple 
endocarditis  it  is  readily  distinguished,  though  confusion  occasionally 
occurs  in  the  transitional  stage,  Avhen  a  simple  is  developing  into  a  malig- 
nant form.  The  constitutioiuil  symptoms  are  of  a  graver  type,  the  fever 
is  higher,  rigors  are  common,  a'.id  septic  and  typhoid  symptoms  develop. 
Perhaps  a  majority  of  the  cases  not  associated  with  puerperal  processes  or 
bone  disesise  arc  confounded  with  typhoid  fever.  A  ditferentitd  diiignoiiis 
may  even  be  impossible,  pnrVcularly  when  we  consider  that  in  ty|ili(iul 
fever  infarctions  and  parotitis  nniy  occur.  The  di^rrrluea  and  abdeniinal 
tenderness  may  also  be  present,  which  with  the  stupor  and  progressive 


.^p^' 


ENDOCARDITIS. 


599 


asthenia  make  a  picture  not  to  be  distinguished  from  this  disease.  Points 
wliicli  may  guide  us  are:  The  more  abru])t  onset  in  cndo(!ufditis,  tlio 
al)sence  of  any  reguhirity  of  tlie  pyrexia  in  the  ear^y  stage  of  the  disease, 
and  tlie  cardiac  pain.  Oppression  and  shortness  of  breath  may  be  earl" 
symptoms  in  malignant  endocarditis.  Kigors,  too,  are  not  unoommo 
Botwoon  i)yiemia  and  malignant  endocarditis  there  are  practically  no  dif- 
fcroiitial  features,  for  the  disease  really  constitutes  an  arterial  ^  j.f>)u' a 
(Wilks).  In  the  acute  cases  resembling  malignant  fevers,  the  diagnt.  ..s  is 
usually  made  of  typhus,  typhoid,  cerel)ro-s])inal  fever,  or  even  of  lia^mor- 
rhagic  small-pox.  The  intermittent  pyn>xia,  occurring  for  weeks  or 
months,  has  led  in  some  cases  to  the  diagnosis  of  malaria,  but  this  disease 
oduld  now  be  positively  excluded  by  the  blood  examination. 

The  cases  usually  terminate  fatally.  'V\w  instances  of  recovery  are 
tli(^so  more  subacute  forms,  the  so-called  recurring  endocarditis  develop- 
in<j  on  old  sclerotic  valves  in  cases  of  chronic  heart-disease. 

Treatxaent. — AVe  know  no  measures  by  Avhich  i!i  rlieumatism, 
chorea,  or  the  eruptive  fevers  the  oTiset  of  endocarditis  can  be  prevented. 
A;*  it  is  i)robable  that  many  cases  develop,  jnirticularly  in  children,  in  mild 
forms  of  these  diseases,  it  is  well  to  guard  the  patients  against  taking  cold 
ami  insist  upon  rest  and  quiet,  and  to  bear  in  mind  that  of  all  com])lica- 
tions  an  acute  endocarditis,  though  in  its  immediate  effects  harndoss,  is 
perhaps  the  most  serious.  This  statement  is  enforced  by  the  observations 
of  Sihson  that  on  a  system  of  absolute  rest  the  proportion  of  cases  of 
rhouniatism  attacked  by  endocarditis  was  less  than  of  those  who  were  not 
SI)  treated. 

It  is  dfjiibtful  whether  the  salicylates  in  rheumatism  have  an  inducnce 
in  rouucing  the  liability  to  endocarditis.  When  the  endocarditis  is  prcs- 
I'ut  ive  know  no  reme<lies  which  will  dclinitely  influence  the  valvular 
lesions.  If  there  is  much  vascular  excitement  aconite  niay  be  given  and 
an  ice-bag  placed  over  the  heart. 

The  salicylates  are  strongly  advised  by  some  writers  and  the  sulpho- 
ciu'holates  have  been  recommended  by  Sansom.  In  the  severer  cases  of 
malignant  endocarditis  the  treatment  is  practically  that  of  .sopticismia. 


TV'S     I 


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Ciiuoxic  Endocauditis. 

This  condition,  which  is  a  sclerosis  of  the  valve,  ma>  '  e  ])rimary,  but  is 
ofti'MM-  secondary  to  acute  endocarditis,  ])articularly  the  rheumatic  form. 
It  s  essentially  a  slow,  insidious  jiroce.ss  which  leac'-,  to  deformity  of  the 
VI  .ve  segment  and  is  the  foundation  of  chronic  valvular  disease. 

C'ertain  ]ioisons  appear  capable  of  initiating  the  change,  such  as  alco- 
nf>l  syphilis,  and  gout,  though  we  are  at  present  ignorant  of  the  way  in 
which  they  act.  A  very  important  factor,  particularly  in  the  case  of  tlie 
aortic  valves,  is  the  strain  of  prolonged  and  heavy  muscular  exertion.  In 
no  other  way  can  be  explained  the  occurrence  of  so  many  cases  of  solero- 


600 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Bia  of  the  aortic  valves  in  young  and  middle-aged  men  whoso  occupations 
necessitate  the  overuse  of  the  muscles. 

Morbid  Anatomy. — Vegetations  in  the  form  in  which  they  occur 
in  acute  endocarditis  are  not  present.  In  the  early  stage,  which  we 
have  frequent  opportunities  of  seeing,  the  edge  of  the  valve  is  a  little 
thickened  and  perhaps  presents  a  few  small  nodular  prominences,  which 
in  some  cases  may  represent  the  healed  vegetations  of  the  acute  process. 
In  the  aortic  valves  the  tissue  about  the  corpora  Arantii  is  first  iilTcctecl, 
producing  a  slight  thickening  with  an  increase  in  tlie  size  of  the  nodules. 
The  substance  of  the  valve  may  lose  its  translucency,  and  the  only  cluuige 
noticeable  is  a  grayish  opacity  aiul  a  slight  loss  of  its  delicate  tcnuitv. 
In  the  auriculo-ventricular  valves  these  early  changes  are  seen  just  witliin 
the  margin  and  here  it  is  not  uncommon  to  find  swellings  of  a  grayii^h- 
red,  somewhat  infiltrated  appearance,  almost  itientical  with  the  similar 
structures  on  the  intima  of  the  aorta  in  arterio-sclerosis.  Even  early  there 
may  be  seen  yellow  or  opaque-white  subintimal  fatty  areas.  As  the  sck^- 
rotic  changes  increase  the  fibrous  tissue  contracts  ami  produces  thickening 
and  deformity  of  the  segment,  the  edges  of  wliicli  become  round,  curled, 
and  incapable  of  that  delicate  apposition  necessary  for  perfect  closure.  A 
sigmoid  valve,  for  instance,  may  be  narrowed  one  fourth  or  even  one  third 
across  its  face,  inducing  the  most  extreme  grr.de  of  insuflicicncy  witliout 
any  special  deformity  and  without  any  definite  narrowing  of  the  iu'terial 
orifice.  In  the  auriculo-ventric.ilar  segments  a  simple  process  of  tiiiclveii- 
ing  and  curlmg  of  the  edges  of  the  valves,  inducing  a  failure  to  close 
without  forming  any  obstruction  to  the  normal  course  of  the  blood-flow, 
is  less  common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  par- 
ticularly in  children,  in  Avliich  the  edges  of  the  valves  are  curled  and 
thickened,  producing  extreme  insufficiency  without  any  material  narrow- 
ing of  the  orifice.  More  frequently,  as  the  disease  advances,  the  oliordie 
tendinea?  become  thickuued,  first  at  the  valvular  ends  and  then  along 
their  course.  The  edges  of  the  valves  at  their  angles  are  gradually  drawn 
together  and  there  is  a  definite  narrowing  of  tlie  orifice,  leadiug  in  the 
aorta  to  more  or  less  stenosis  and  in  the  left  auriculo-ventricular  orifice— 
the  two  most  frequently  involved — to  constriction.  Finally,  in  the  scle- 
rotic .Mid  necrotic  tissues  lime  salts  are  deposited  and  may  even  reach  tlie 
deeper  structures  of  the  fibrous  rings,  and  the  entire  valve  becomes  a 
dense  calcareous  mass  with  scarcely  a  remnant  of  normal  tissue.  Tlu' 
chorda?  tendinea?  may  gradually  become  shortened,  greatly  thickened,  and 
in  extreme  cases  the  pajiillary  muscles  are  implanted  directly  upon  tlie 
sclerotic  and  deformed  valve.  The  apices  of  the  papillary  muscles  usually 
show  marked  fibroid  change. 

In  all  stages  of  the  process  the  vegetations  of  simjjle  endocarditis  may 
be  found  and  upon  scderotic  valves  we  find  the  severer,  ulcerative  form  of 
the  disease. 

Chronic  mural  endocarditis  produces  cicatricial-like  patches  of  a  j^'ray- 


ENDOCARDITIS. 


601 


ioh-white  appearance  Avhich  are  sometimes  seen  on  the  mnsciilar  trabccu- 
Ine  of  the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  with 
nivocarditis. 

'I'lio  frequency  with  which  clironic  endocarditis  is  met  with  may  be 
gatliered  from  the  following  figures  :  In  the  statistics,  amounting  to  from 
1-2,000  to  14,000  autopsies,  reported  from  Dresden,  Wurzburg,  and  Prague 
the  percentage  ranged  from  four  to  nine.  'I'iie  relative  fretpiency  of  in- 
volvement of  the  various  valves  is  thus  given  in  the  collected  statistics  of 
Parrot:  The  mitral  orifice  was  involved  in  0:21,  the  aortic  in  380,  the  tri- 
cuspid in  4G,  and  the  pulmonary  in  11.  This  gives  57  instances  in  the 
right  to  1,001  in  the  left  heart. 

The  endocarditis  of  the  fa)tus  is  usually  of  the  sclerotic;  form  and  in- 
volves the  valves  of  the  right  more  frequently  than  those  of  the  left  side. 

The  effects  of  sclerotic  endocarditis  are  practically  those  of  chronic 
viilviiliir  disease,  and  the  general  influence  on  the  work  of  the  heart  may 
be  briefly  stated  as  follows :  The  sclerosis  induces  insuftieiency  or  ste- 
nosis, which  may  exist  separately  or  in  combination.  The  narrowing  re- 
tards iu  a  measv.io  the  normal  outflow  and  the  iusufliciency  permits  the 
blood  current  to  take  an  abnormal  course.  In  both  instances  the  elTect  is 
dilatation  of  a  chamber.  The  result  in  the  former  case  is  an  increase 
in  the  difhculty  which  the  chamber  has  in  expelling  its  contents  through 
the  uarrow  orifice;  in  the  other,  the  overfilling  of  a  chamber  by  blood 
flowing  into  it  from  an  improper  source,  as,  for  instaJice,  in  mitral  insuf- 
ficieniv,  when  the  left  auricle  receives  blood  both  from  the  pulmonary 
veins  and  from  the  left  ventricle. 

The  cardiac  mechanism  is  fully  prepared  to  moot  ordinary  grades  of 
dilatation  which  constantly  occur  during  sudden  exertion.  A  man,  for 
instance,  at  the  end  of  a  hundred-yard  race  bus  bis  right  chambers 
srreatly  dilatod  and  his  reserve  cardiac  power  w  ■<!  to  its  full  capacity. 
The  slow  progress  of  the  sclerotic  changes  brings  ai-  )Ut  a  gradu:d,  not  an 
abrupt,  iusufliciency,  and  the  moderate  dilatation  which  follov  is  at  first 
overcome  by  the  exercise  of  the  ordinary  reserve  strength  of  the  heart 
muscles.  Gradually  a  new  factor  is  introduced.  The  reserve  power  M'hich 
is  capable  of  meeting  sudden  enjergencies  in  such  a  remarkable  manner  is 
unalile  to  cope  long  with  a  permanent  and  perhaps  increasing  dilatation. 
More  work  has  to  bo  done  and,  in  accordance  with  definite  i)hysiologica! 
laws,  more  power  is  given  by  increase  of  the  muscles.  The  lieart  hyper- 
trophies and  the  effect  of  the  valve  lesion  becomes,  as  we  say,  compen- 
sate'l.    The  equilibrium  of  the  circulation  is  in  this  way  maintained. 


m  1 


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1; 

ii     : 


,4....a: 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


II.  CHRONIC  VALVULAR   DISEASE. 

Aortic  Ixcompetexcy. 

Incompetency  of  the  aortic  valves  arises  either  from  inability  of  tiio 
valve  segments  to  close  an  abnormally  large  orifice  or  more  commonlv 
from  disease  of  the  segments  themselves.  This  best-deflned  and  most 
easily  recognized  of  valvular  lesions  was  first  carefully  studied  by  Corrigan, 
whose  name  it  sometimes  1)ears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequent  in  niaJLvs 
than  in  females,  afrecting  chiefly  able-bodied,  vigorous  men  at  the  niiddlo 
period  of  life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been 
variously  given  from  thirty  to  fifty  ])er  cent. 

Among  the  important  factors  in  producing  this  condition  are:  ((() 
Congenital  malfisniatioii,  particularly  fusion  of  two  segments  —  most 
commonly  those  behind  which  the  coronary  arteries  are  given  off.  It  is 
probable  that  an  aortic  orifice  may  be  competent  with  this  bicuspid  state 
of  the  valves,  but  a  great  danger  is  the  liability  of  these  malformed  segments 
to  s(derotic  endocarditis.  Of  .seventeen  cases  which  I  have  reported  all 
presented  sclerotic  changes,  and  the  majority  of  them  had,  during  life,  the 
clinical  features  of  chronic  heart-disease, 

(h)  Acute  endocarditis.  This  does  not  produce  aortic  incompetency 
unless  the  process  passes  on  to  ulceration  and  destruction,  niuler  which 
circumstances  it  is  often  found,  and  may  cause  a  rapidly  fatal  issue.  Sim- 
ple endocardi'^'^  associated  with  the  specific  fevers  is  not  nearly  so  com- 
mon on  the  aortic  as  on  the  mitral  segments;  so  also  with  rheumatism, 
whicli  plays  a  less  important  role  here  than  in  mitral  valve  disease. 

(r)  By  far  the  most  frecpu^nt  cause  of  insuflTiciency  is  the  slow,  pro- 
gressive sclerosis  of  the  segment,  resulting  in  a  curling  of  the  edge, 
which  lessens  the  working  surface  of  the  valve.  This  may,  of  course,  fol- 
low acute  endocarditis,  but  it  is  so  often  met  with  in  strong,  able-bodied 
men  among  the  working  classes,  without  any  history  of  rheumatism  or 
special  febrile  diseases  with  which  endtjcarditis  is  commonly  associated, 
that  other  conditions  must  be  sought  for  to  explain  its  frequency.  Of 
these,  unquesti(mably  strain  is  the  most  important — not  a  sudden,  forcible 
strain,  but  a  ])ersistent  increase  of  the  normal  tension  to  which  the 
segments  are  subject  during  the  diastole  of  the  ventricle,  (^f  circum- 
stances increasing  this  tension,  heavy  ar.d  excessive  iise  of  the  nuiscles  is 
perhaps  the  most  important.  So  often  is  this  form  of  heart-di.sease  found 
in  })ersons  devoted  to  athletics  that  it  is  sometimes  called  the  "athletes 
heart."  Alcohol  is  a  second  important  factor,  and  is  stated  to  raise  run- 
siderably  the  tension  in  the  aortic  system.  A  combination  of  these  two 
causes  is  extremely  common.  A  third  clement  in  inducing  chronic  Ft  h'- 
rotic  changes  in  these  valves  is  syphilis.  Cases  are  rarely  seen  in  which 
other  factors  must  not  be  taken  into  account,  but  the  association  is  too 


CHRONIC  VALVULAR  DISEASE, 


603 


fnqucnt  to  bo  accidental.  Tliat  syphilis  is  capable  of  inducing  arterial 
sclerosis  is,  I  think,  acknowledged,  although  the  way  in  which  it  is  done  is 
]i()t  yet  clear.  It  is  interesting  to  note  with  what  frequency  this  form  of 
valve  disease  occurs  in  soldiers.  I  was  struck  with  this  fact  in  the  Phila- 
(Kli)l!ia  Hospital,  to  which  so  many  veterans  of  the  civil  war  are  admitted. 
I  uiis  in  the  habit  of  enforcing  u})ou  my  students  the  etiological  lesson  by 
a  mythological  reference  to  J3accluis  and  Vulcan,  at  whose  shrines  a  ma- 
jority of  the  cases  of  aortic  iusuflicieucy  have  worshi])ped,  and  not  a  few 
at  that  of  Venus. 

The  condition  of  tho  valves  is  such  as  has  already  been  described  in 
chronic  endocarditis.  It  may  bo  noted,  however,  how  slight  a  grade  of 
curling  may  produce  serious  incompetency.  Associated  with  the  valve 
(li-icuse  is,  in  a  majority  of  the  eases,  a  more  or  less  advanced  arterio-scle- 
rosis  of  the  arch  of  the  aorta,  one  serious  etfect  of  which  may  be  a  narrow- 
ing of  the  orifices  of  the  coronary  arteries.  The  sclerotic  changes  are 
often  combined  with  atheroma,  either  in  the  fatty  or  calcareous  stage. 
This  may  exist  at  the  attached  margin  of  tho  valves  without  inducing  in- 
sutVicicncy.  In  other  instances  insuflicieucy  nuiy  result  from  a  calcified 
spike  projecting  from  the  aortic  attachment  into  the  body  of  the  valve, 
and  so  preventing  its  proper  closure.  Some  writers  (I*eter)  have  laid 
great  stress  upon  the  extension  of  the  endarteritis  to  the  valve,  and  would 
separate  ;he  instances  of  this  kind  from  those  of  simple  valvular  endocar- 
ditis. I  must  say  that  I  have  not  been  able  t.)  recognize  clinical  dilTer- 
eiiccs  bijtween  these  two  conditions,  though  aiuitomically  we  may  separate 
the  cases  into  two  groups — those  with  aiul  thosj  Avithout  arterio-sclerosis. 

(d)  And,  lastly,  insufficiency  may  bo  induced  by  rupture  of  a  segment 
—a  very  rare  event  in  healthy  valves,  but  not  uncommon  in  disease, 
cither  from  excessi\e  strain  during  heavy  lifting  or  from  the  ordinary 
endarterial  strain  in  a  valve  eroded  and  weakened  by  ulcerative  endo- 
carditis. 

Uehdive  insufficiency  of  tho  sigmoid  valves,  due  to  dilatation  of  tho 
aortic  ring,  is  a  rare  condition.  It  is  said  to  occur  in  extensive  arterial 
sclerosis  of  the  ascending  portion  of  the  arch  with  great  dilatation  just 
above  the  valves.  I  have  myself  never  met  with  a  pure  instance  of  tho 
kind,  for  in  such  cases  I  have  always  found  the  valve  segments  involved 
v.'itli  the  arterial  coats.  In  aneurism  just  above  the  aortic  ring,  relative 
insuHicicncy  of  the  valve  may  be  present. 

it  would  appear  from  the  careful  nu'asurements  of  Beneke  that  the 
aortic  orilice,  which  at  birth  is  20  mm.,  increases  gradually  with  the 
growth  of  the  heart  until  at  one  and  twenty  it  is  about  (JO  mm.  At  this 
It  renuiins  until  the  age  of  forty,  beyond  wliich  date  there  is  a  gradual 
increase  in  tlio  size  up  to  the  age  of  eighty,  when  it  may  reach  from  (j8 
to  10  nun.  There  is  thus  at  tho  very  jieriod  of  life  in  which  sclerosis  of 
the  valve  is  most  eomnum  a  physiological  tendency  toward  the  production 
of  a  slate  of  relative  iusutficieucy. 
8U 


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604 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


The  insiiflicieuoy  may  be  combined  witb  various  grudt's  of  iiiirrowiuf^', 
but  the  majority  of  tlic  cases  of  aortic  iusuiliciency  present  no  sijfus  of 
stenosis.  On  the  other  lianil,  cases  of  aortic  stenosis  ahiiost  witliout 
exception  are  associated  with  some  j^rade,  however  sli<^ht,  of  ri'iiiiririiation. 

Tiie  direct  elTeet  of  aortic  insuHiciency  is  the  regurgitation  of  IjIooJ 
from  tlic  artery  into  the  ventricle,  causing  an  overdisti'ution  of  the  cavity 
and  a  reduction  of  the  bkmd  cohimn ;  that  is,  a  rehitive  ana-niia  in  tlm 
arterial  tree.  As  an  immediate  effect  of  the  double  blood-flow  into  tlie 
left  ventricle  dilatation  of  the  chamber  occurs,  and  linally  hypertropliy. 
In  this  way  the  valve  defect  is  compensated  and  as  with  each  ventricular 
systole  a  larger  amount  of  blood  is  propelled  into  the  arterial  system,  the 
regurgitation  of  a  certain  amount  during  diastole  does  not,  for  a  time  at 
least,  seriously  impair  the  nutriti(m  of  the  perijdieral  parts.  In  this  valve 
lesion  dilatation  and  hypertrophy  reach  their  most  extreme  limit.  The 
heaviest  hearts  on  record  are  described  in  connection  with  this  afTection. 
The  so-called  bovine  heart,  cor  bovinn?!),  may  weigh  3')  or  4t)  ounces,  or 
even,  as  in  a  case  of  Dullcs's,  48  ounces.  The  dilatation  is  usually  ex- 
treme, and  is  in  marked  contrast  to  the  condition  of  the  chamber  in  cases 
of  pure  aortiij  stijnosis.  I'he  papillary  muscles  nuiy  lie  greatly  iluttened. 
The  mitral  valves  are  usually  not  seriously  affected,  though  the  edges 
may  present  slight  sclerosis,  and  there  is  often  relative  ineompeteTuy, 
owing  to  distention  of  the  mitral  ring.  Dilatation  and  hypertro|iliy  of 
the  left  auricle  are  common,  and  secondary  enlargement  of  the  right  heart 
occurs  in  all  cases  of  long  standing.  The  myocardium  usually  ]»rcscnt.s 
changes,  fd)roid  or  fatty;  more  commonly  the  former  in  association  with 
disease  of  the  coronary  arteries.  The  arch  of  the  aorta  may  present 
extensive  arterio-sclerosis  and  dilatation.  In  rare  instances,  usually  the 
rheumatic  cases,  the  intima  is  perfectly  smooth,  and  the  arch  wilh  its 
main  branches  not  dilated.  This  condition  may  be  found  i)0st  mortem 
even  when  during  life  there  have  been  the  most  characteristic  signs  of 
enlargement  of  the  andi  ami  of  dilatation  of  the  innominate  and  right 
carotid.  I  have  even  known  the  condition  of  aneurism  to  be  diagnosed 
when  post  mortem  no  trace  of  dilatation  or  sclerosis  was  fouiul,  only  an 
extreme  grade  of  insufficiency  Avith  enormous  dilatation  and  hy})ertro|)hy. 
The  coronary  arteries  are  usually  involved  in  the  sclerosis,  and  theif 
orifices  may  be  much  narrowed.  Although  these  vessels  have  Ix'cn  shown 
by  Martin  and  Sedgwick  to  be  filled  during  the  ventricular  systole,  the 
circulation  in  them  must  be  embarrassed  in  aortic  incompetency.  Tliey 
must  miss  the  effect  of  the  blood-pressure  in  the  sinuses  of  Valsalva  dur- 
ing the  elastic  recoil  of  the  arteries,  which  surely  aids  in  kee]nng  tiie 
coronary  vessels  full.  The  arteries  of  the  body  usually  present  more  or 
less  sclerosis  consequent  upon  the  strain  which  they  undergo  during  the 
forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  per- 
sons who  have  not  presented  any  features  of  cardiac  disease. 


CHRONIC  VALVULAR  DISEASE. 


G05 


Physical  Signs. — Inspection  shown  a  wide  iuul  forcible  iirea  of  ciinliiio 
iiiiiml.so  with  tlio  ajx'X  beat  in  the  sixth  or  seventli  interspace,  and  \)i\v- 
hii[)s  as  far  out  as  the  anterior  axillary  line.  In  young  subjects  the 
jira'cordia  may  bulge.  On  jjalpation  a  thrill,  diastolic  in  time,  is  occa- 
sionally felt,  but  is  not  common.  The  impulse  is  usually  strong  and 
licaviug,  uidess  in  conditions  of  extreme  dilatation,  when  it  is  wavy  and 
iiuleiinitc.  PercHnsiun  shows  a  greater  increase  in  the  area  of  heart  dul- 
ness  than  is  found  in  any  other  valvular  lesion.  It  extends  chielly  down- 
ward and  to  the  left. 

On  auscultalioii,  there  is  heard  a  murmur  during  diastole  in  the  second 
right  interspace,  which  is  propagated  with  intensity  towarc  thf  ensiform 
cartilage  or  down  the  left  margin  of  the  sternum  toward  the  apex.  In 
the  majority  of  cases  it  is  a  soft,  long-drawn  hruit,  and  is  of  all  cardiac 
murnuirs  the  most  reliable.  It  occurs  during  the  time  of,  and  is  produced 
hv,  the  rellux  of  blood  from  the  aorta  into  the  ventricle.  In  a  large  i)ro- 
portion  of  the  cases  there  is  also  a  systolic  murmur  lieard  at  the  aortic 
region,  usually  shorter,  often  rougher  in  (piality,  and  which  may  be  ])ropa- 
gated  upward  into  the  neck.  A  common  mistake  is  to  regard  this  as 
imlicating  stenosis,  whereas  in  the  great  majority  of  instances  of  aortic 
insuOiciency  there  is  no  material  narrowing,  and  the  murmur  is  pr(Kluced 
by  roughening  of  tlie  segments  or  of  the  intimu  of  the  arch.  The  second 
sound  is  usually  obliterated,  though  in  some  instances  botli  the  murmur 
and  the  valvular  sound  may  be  distinctly  heard.  At  the  a|)ex  murmurs 
are  also  Jicard,  either  transmitted  from  the  aortic  orilice  or  produced  at 
the  mitral.  In  the  majority  of  cases  with  aortic  incitrnjietency  of  high 
grade,  the  mitral  orifice  is  dilated,  and  there  is  relative  insufficiency  of  the 
valves.  It  can  frequently  be  determined  that  the  systolic  murmur  at  the 
apex  dilTers  in  quality  from  that  at  the  base.  A  second  murmur  at  the 
a[)ex,  ])robably  produced  at  the  mitral  orifice,  is  not  infrequent.  Atten- 
tion was  called  to  this  by  the  late  Austin  Flint,  and  the  murmur  usually 
goes  by  his  name.  It  has  a  distinctly  rumbling  quality,  is  limited  in  area, 
and  is  sometimes,  though  not  always,  distinctly  presystolic  in  time.  The 
oxphmation  of  its  occurrence,  as  given  by  Flint,  is  that  in  the  extreme 
dilatation  of  the  ventricle  the  mitral  segments  cannot  during  diastole  bo 
foreo(l  buck  against  the  wall,  and,  therefore,  remaining  in  the  blood  cur- 
rout,  they  produce  a  sort  of  relative  narrowing,  and  in  consequence  a 
viliratory  murmur  not  unlike  in  quality  the  presystolic  murmur  of  mitral 
stenosis.  My  experience  as  to  the  frequency  of  this  murmur  coincides 
with  that  of  Lee.* 

The  examination  of  the  arteries  in  aortic  insufficiency  is  of  great  value. 
\isihle  pulsation  is  more  commonly  seen  in  the  perii)heral  vessels  in  this     *''^- 
tiiaii  in  any  other  condition.     The  carotids  may  be  seen  to  throb  forcibly, 
the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with  each 


•^-T.^ 


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N: 


ir 


•  American  Journal  of  the  Medical  Sciences,  1890. 


606 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


in 


heart-beat.  With  the  ophthahnoscopo  the  retinal  arteries  are  sihmi  to 
pulsate.  Not  only  is  the  pulsation  evident,  but  the  characteristic  jcrkiii" 
quality  is  apparent.  In  the  throat  the  throbhinjj  carotids  nuiy  lead  in  tlio 
diagnosis  of  aneurism.  In  many  cases  the  pulsation  can  be  seen  in  tlie 
suprasternal  notch,  and  promiiuMit,  forcibly-throbbing  vessels  beneatli  tliu 
rigl)t sterno-raastoid  muscle.  The  abdominal  aorta nuxy  lift  the epigusliium 
with  each  systole.  To  be  mentioned  with  this  is  the  capillary  pulse,  mot 
very  often  in  aortic  insulficiency,  and  best  seen  in  the  finger-nails  or  by 
drawing  a  line  upon  the  forehead,  when  the  margin  of  h\'pera3mia  on  cither 
Bide  alternately  blushes  and  pales.  In  extreme  grades  the  face  or  tho 
Imnd  may  blush  visildy  at  each  systole.  It  is  met  with  also  in  profound 
anajmia,  occasionally  in  neurasthenia,  and  in  health  in  conditions  of  great 
relaxation  of  the  perijdieral  arteries.  Pulsation  may  also  be  present  in 
the  jjcripheral  veins.  On  jialpation  the  characteristic  water-hammer  or 
Corrigan  pulse  is  felt.  On  the  nuijority  of  instances  the  pulse  wave  strik(;s 
the  finger  forcibly  with  a  quick  jerking  impulse,  and  immediately  recedes 
or  collapses.  The  (diaracters  of  this  are  someti!ne3  best  api)reciato(l  Ijy 
grasping  the  arm  above  the  wrist  and  holding  it  up.  On  auscultation 
H  double  murmur  may  bo  heard  in  the  carotids  and  subclavians  when  it 
is  present  at  the  aortic  orifice.  Occasionally  in  the  carotid  the  second 
sound  is  distinctly  audible  when  absent  at  the  aortic  cartilage.  In  the 
femoral  artery  a  double  murmur  also  may  be  heard  sometimes,  as  pointed 
out  by  Duroziez. 

Aortic  insufficiency  may  for  years  be  fully  compensated.  Persons  do 
not  necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found 
accidentally.  So  long  as  the  hypertrophy  just  equalizes  the  valvular 
defect  there  may  be  no  symptoms  and.  the  individual  may  even  take 
moderately  heavy  exercise  without  experiencing  sensations  of  distress 
about  the  heart.  The  eases  which  last  the  longest  are  those  in  whi(di  tlie 
sclerosis  follows  endocarditis  and  is  not  a  part  of  a  general  arterio-selero- 
sis.  Coexistent  lesions  of  the  mitral  valves  tend  early  to  disturb  tlie 
compensation.  It  has  scarcely  been  sufficiently  recognized  by  the  profo.-;- 
sion  at  large  that  pure  aortic  insufficiency  is  consistent  with  years  of  avm- 
age  health  and  with  a  tolerably  active  life.  I  know  several  physiciaiis  with 
aortic  insufficiency  who  have  been  able  to  carry  on  for  years  large  and 
somewhat  onerous  practices.  One  of  them  since  the  establishment  of  insuf- 
ficiency has  passed  successfully  through  two  attacks  of  acute  rheunuitisni. 
In  large  hospital  practice,  scarcely  a  month  passes  without  the  disiovory 
of  a  case  of  aortic  insufficiency  in  connection  with  some  other  affection. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of 
the  arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  in- 
volvement of  the  orifices  of  the  coronary  arteries,  the  compensation  lie- 
comes  disturbed.  In  advanced  cases  the  changes  about  the  aortic  ring 
may  be  associated  with  alterations  in  the  cardiac  nerves  and  ganglia,  ai.d 
so  introduce  an  important  factor. 


is3« 


CHRONIC  VALVULAK  DISKASE. 


G07 


IIciuliKihe,  dizziness,  flashes  (if  li},'Iit,  and  a  feeling  of  fuintnoss  on  ria- 
iiif,'  (jiiickiy  uro  among  the  earliest  symptoms.  I'ulpitation  and  cardiac 
»li.-;tres3  on  slight  exertion  are  eomnwui.  Long  hefore  any  signs  of  failing 
( ninpeusation  pain  may  become  a  mai'ked  and  tronblesome  feature.  It  is 
extremely  variable  in  its  manifestations.  It  may  be  of  a  dull,  aching  char- 
iictir  confined  to  the  priecordia.  More  frecpiently,  however,  it  is  sharp 
and  radiating,  and  is  transmitted  u[)  the  neck  and  down  the  arms,  par- 
ticularly the  left.  Attacks  of  true  angina  pectoris  are  more  frecpient  in 
this  than  in  any  other  valvular  disease.  Aiuemia  is  also  common,  much 
more  so  than  in  aortic  stenosis  (»r  in  mitral  affections. 

More  serious  symptoms,  lus  compensation  fails,  are  shortness  of  breath 
and  u'dema  of  the  feet.  'I'he  attacks  of  dyspno'a  are  liable  to  come  on  at 
night  and  the  patient  has  to  sleep  with  the  head  high  or  even  in  a  chair. 
Of  respiratory  symptoms  cough  may  develop,  due  to  the  coTigestion  of 
the  lungs  or  a'dema.  llaMnofitysis  is  less  frecpient  than  in  mitral  disease. 
I  have  r(!portcd  a  case  in  which  it  was  profuse  and  believed  to  be  due  to 
tuberculosis  of  the  lungs,  inasmuch  as  the  patient  was  admitted  in  a  state 
of  emaciation  and  profouiul  exhaustion.  (Jcneral  dropsy  is  not  common, 
Imt  U'dema  of  the  feet  may  occur  early  and  is  sometimes  duo  to  the  anai- 
itiia,  at  others  to  the  venous  stasis,  at  times  to  both.  Unless  there  is  co- 
existing disease  of  the  mitral  valve,  it  is  rare  in  pure  aortic  incompe- 
tency for  the  patient  to  die  Avith  general  anasarca.  Sudden  death  is  fre- 
quent; more  so  in  this  than  in  otlier  valvular  diseases.  As  compensation 
fails  the  patient  takes  to  bed  and  slight  irregular  fever,  associated  usually 
with  a  recurring  endocarditis,  is  not  uncommon  toward  the  close.  Em- 
bolic symptoms  are  not  infrequent — pain  in  the  splenic  region  with  en- 
largement of  the  organ,  ha>maturia,  and  m  some  cases  paralysis.  Dis- 
tressing dreams  and  disturbed  sleep  are  more  common  in  this  than  in  other 
forms  of  valvular  disease. 

Jlcre  may  appropriately  be  mentioned  the  connection  between  mental 
symptoms  and  cardiac  disease,  as  they  are  oftenest  seen  with  this  lesion. 
An  admirable  account  of  the  relations  between  insanity  and  disease  of 
the  lioart  is  to  be  found  in  Mickle's  Gulstonian  lectures  for  1888  In 
general  medical  practice  we  seldom  find  marked  mental  symptoms,  except 
toward  the  close  of  the  disease,  when  there  may  be  delirium,  hallucinations, 
ami  morbid  impulses.  It  is  to  be  remembered  that  in  many  heart  cases 
tliis  terminal  delirium  is  ura>mic.  The  irritability  and  jieevishness  some- 
times found  in  persons  the  subject  of  organic  heart-disease  cannot,  I  think, 
be  associated  with  it  in  any  special  manner.  Wo  do  meet  insanity,  break- 
ing out  in  patients  with  aortic  and  mitral  disease,  in  the  stage  of  compen- 
sation, which  api)ears  to  be  related  definitely  to  the  cardiac  lesion.  It  is 
inviMiitant  to  bear  this  in  mind,  for  cases  occasionally  display  suicidal 
teiuK'iicios.  I  have  twice  had  patients  throw  themselves  from  the  window 
of  the  ward. 


!!' 


608 


DISEASES  OF  THE  CIRCULATORY   SYSTEM. 


■■t  i 


Aortic  Stenosi.s. 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  common  us 
insurticicnoy.  The  two  conditions,  as  already  stated,  may  occur  together, 
jiowever,  and  probahly  in  almost  every  ease  of  stenosis  there  is  some;  leakii;,'c. 

Etiology  and  Morbid  Anatomy.— In  the  milder  grades  tluiv  i.s 
adhesion  between  the  segments,  wlii(di  are  so  stitTened  that  during  systole 
they  cannot  be  pressed  back  against  the  aortic  wall.  The  process  of  co- 
hesion between  the  segments  may  go  on  without  great  thickening,  and 
produce  a  condition  in  which  tho  orifice  is  guarded  by  a  comi)arativrIy 
thin  membrane,  on  the  aortic  face  of  which  may  be  seen  the  i)riniilivi' 
raphes  8ej)aratiug  tho  sinuses  of  Valsalva.  In  some  instances  this  moiii- 
brane  is  so  thin  and  j)rescnts  so  few  traces  of  atheronuitous  or  sclerotic 
changes  that  the  condition  looks  as  if  it  had  originated  during  fo'tal  life. 
More  commonly  the  valve  segments  are  thickened  and  rigid,  and  have  iv 
cartilaginous  hardness.  In  advaiujed  cases  they  may  be  represented  by 
stiff,  calcified  masses  obstructing  the  orifice,  through  whi(;h  a  circular  or 
slit-like  passage  can  be  seen.  The  older  the  patient  the  more  likely  it  'n 
that  the  valves  will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  tho  aortic  orifice  when  with 
normal  valves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated. 
A  stenosis  due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous 
changes  without  lesion  of  the  valves  is  referred  to  by  some  authors.  I  have 
never  met  with  an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result 
of  endocarditis  in  the  mitro-sigmoidean  sinus,  usually  occurs  as  the  re- 
sult of  a  fcetal  eiulocarditis.  In  comparison  with  aortic  insnliiciency,  ste- 
nosis is  a  rare  disease.  It  is  usually  met  with  at  a  more  advanced  period 
of  life  than  insufficiency,  and  the  most  typical  cases  of  it  are  found  asso- 
ciated with  extensive  calcareous  changes  in  the  arterial  system  in  old  men. 

When  gradually  produced  and  when  there  is  not  much  insufliciency 
the  dilatation  of  the  left  ventricle  may  be  slight,  though  I  think  that 
in  all  cases  it  does  occur.  The  walls  of  the  ventricle  become  hyi)ortro- 
phied,  and  we  see  in  this  condition  the  most  ty})ical  instances  of  what  is 
called  concentric  hypertrophy,  in  which,  without  much,  if  aiiy,  enlarge- 
ment of  the  cavity,  the  walls  are  greatly  thickened,  in  contradistinctidn 
to  the  so-called  cccentrio  hypertrophy,  in  v/hich  the  chamber  is  groatly 
dilated  as  well  as  hypertrophied.  There  may  be  no  changes  in  the  other 
cardiac  cavities  if  compensation  is  well  maintained;  but  with  its  failiuT 
come  dilatation,  impeded  auricular  discharge,  pulmonary  congestion,  and 
increased  work  for  the  right  heart.  The  arterial  changes  are,  as  a  rule, 
not  so  nuirked  as  in  aortic  insufficiency,  for  the  walls  have  not  to  with- 
stand the  impulse  of  a  greatly  increased  blood-wave  with  each  systole.  0" 
the  contrary,  the  amount  of  blood  propelled  through  the  narrow  oi'fice 
may  be  smaller  than  normal,  though  when  compensation  is  fully  estab- 
lished the  pulse-wave  may  bo  of  medium  volume. 


1  ii ,-." 


.■1 


CHRONIC  VALVULAU   DISKaSE. 


6U9 


Symptoms.  Physical  Signs. — hispvcliun  msiy  fail  to  nncal  any 
iina  of  cardiac  iiiipulsi-.  J'artu'iilarly  is  tlii.s  tlio  case  in  oM  men  with 
ri;,M(l  chest  walls  and  larj^e  t'niithys('matou.s  lunj;.s.  I'ndcr  thcst'  circiiin- 
ritant'os  thoro  may  he  a  liij^h  grade;  of  hypertroijliy  without  any  visible;  ini- 
piilsc.  Evfii  when  tho  apox  heat  is  visihlo  it  may  hi',  a.s  'i'raulH'  pointed 
(lilt,  IVohlo  and  indcliniti'.  In  many  cases  the  apex  is  seen  disjilaced  dowu- 
wai'd  and  outward,  and  the  impulse  looks  stron}^  and  forcible. 

J'dljxition  reveals  in  many  cases  a  thrill  at  tho  base  of  the  heart  of 
maximum  force  in  the  aortic  re<;jion.  With  no  other  condition  do  we 
meet  with  thrills  of  greater  intensity,  'J'he  apex  beat  may  nctt  be  paljjable 
iiiiilor  the  conditions  above  mentioned,  or  there  nuiy  be  a  slow,  heaving, 
forcible  im}»ulse. 

Percussion  never  gives  tho  same  wide  area  of  dulness  as  in  uorlic  in- 
i^uniciency.  Tho  extent  of  it  depends  largely  on  the  state  of  the  lungs, 
whether  emidiysematous  or  not. 

Auscultation. — A  systolic  murmur  of  maxinuun  intensity  at  the  aortic 
cartilage,  and  proj)agated  into  the  great  vessels,  is  present  in  aortic  ste- 
nosis, but  is  by  no  means  pathognomonic.  One  of  the  last  l.'ssons  learned 
by  the  student  of  jjhysical  diagnosis  is  to  recognize  the  fact  tliat  thi;;  sys- 
tolic murmur  is  oidy  in  comparatively  rare  cases  ])r()dueo(l  by  decided 
narrowing  of  the  aortic  orifice.  Koughening  of  tlu;  valves,  or  li.e  intinia 
of  the  aorta,  and  hiemic  states  are  much  more  frequent  causes.  In  aortic 
stenosis  the  murmur  often  has  a  much  harsher  quality,  is  louder,  and  h 
ni(jro  frcipiently  musical  than  in  the  coiulitions  just  nu'iitioned.  When 
I'onipensation  fails  and  the  ventricle  is  dilated  and  feelile  tho  murmur 
may  he  soft  and  distant.  The  second  sound  is  rarely  henid  at  tlio  aortic 
cartilage,  owing  to  the  thickening  and  stitTness  of  the  valve.  A  diajt'^lio 
murnuu"  is  not  uncommon,  but  in  many  cases  it  cannot  he  heard.  Tlic 
pulse  in  pure  aortic  stenosis  is  small,  usually  oi  good  tensicm,  re.fiilar, 
and  i)erhaps  slower  than  normal. 

The  condition  may  be  latent  for  an  indefinite  ]>eriod,  as  lon'j  j'.s  tho 
liypertrophy  is  maintained.  Early  symptoms  are  those  d'.ie  to  defeelivo 
blood-supply  to  the  brain,  dizziness,  and  fainting.  Palpitation,  pi'iu 
about  tho  heart,  and  anginal  symptoms  are  not  so  niiirlced  as  in  insufll- 
cieuey.  With  degeneration  of  the  heart-muscle  and  dilatation  r;d.itive 
insunieioncy  of  the  mitral  valve  is  established,  and  the  patient  may  present 
nil  the  features  of  engorgement  in  the  lesser  and  systemic  circr.hitions, 
with  dyspncea,  cough,  rusty  expectoration,  and  tho  signs  of  a.nasarca  in  the 
lower  part  of  the  body.  ]\[any  of  the  cases  in  old  people,  witliout  present- 
ing any  dropsy,  have  symptoms  pointing  rather  to  general  arterial  disease. 
Choyne-Stokes  breathing  is  not  unconunon  with  or  Avithont  signs  of 
ura>ini;i. 

Diagnosis. — With  an  intensely  rough  or  musical  murmur  of  inuxi::uim 
intensity  at  the  aortic  region  and  signs  of  hyi)ertrophy  of  tho  left  ventricle, 
a  thrill  and  a  hard,  slow  pulse  of  moderate  volume  and  fairly  good  tension, 


if 

■ 

i 

■  'it; 

IHBt?«^ff' 

i 

BtlK 

WilH 

i 

n 

610 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


a  (lincniosls  of  !if)rtic  stenosis  oan  ho  nmdo  witli  Rorno  dc/^rco  of  prohaliilitv, 
particularly  if  the  suhjcct  is  an  old  man.  Mistakos  are  roirinion,  Iniw- 
over,  and  a  roii<,'hon{ul  or  calcified  valve  sogniont,  or,  in  sonio  instances. 
a  very  roughened  and  prominent  calcified  plate  in  the  aorta,  iiml 
liypertrophy  associated  with  renal  disease,  may  iiroduco  simihir  syniji- 
toms. 

Let  mo  repeat  that  a  murmur  of  maximum  intensity  at  the  ai/itic 
cartilage  is  of  no  imjiortanco  in  itself  as  a  diagnostic  sign  of  stenosis, 
Uoughening  of  the  valve,  sclerosis  of  tlie  intinui  of  the  arch,  and  aniviiiia 
arc  conditions  more  frorpuMitly  associated  with  a  systolic  murmur  in  this 
region.  Seldom  is  there  diOiculty  in  distinguishing  the  murmur  (liic  to 
amemia,  since  it  is  rarely  so  intense  and  is  not  associated  with  tin  ill  m- 
with  marked  hyjjertrophy  of  the  left  ventricle.  In  aortic  insunicicucv  :i 
systolic;  murmur  is  usually  present,  hut  has  neither  the  intensity  nop  the 
musical  (|uality,  nor  is  it  accompanied  with  a  thrill.  With  roiiglu'iiini; 
and  dilatation  of  the  ascending  aorta  the  murmur  may  be  very  harsh  or 
musical ;  hut  the  existenco  of  a  second  sound,  accentuated  and  ringing  in 
quality,  is  usually  suflicicut  to  difTerentiato  this  condition. 


'44 


,,n 


R  A 


illTUAL   InCOMPETKXCV. 

etiology. — Insufficiency  of  the  mitral  valve  results  from:  (a) 
Changes  in  the  segments  whereby  they  are  contracted  and  shortened. 
usually  combined  with  changes  in  the  chordae  tendinea?,  or  with  more  in- 
less  narrowing  of  the  orilice.  {b)  As  a  residt  of  changes  in  the  museiilar 
walls  of  the  ventricle,  either  dilatation,  so  that  the  valve  segments  fail  to 
close  an  enlarged  orifice,  or  changes  in. the  muscular  substance,  so  that 
the  segments  are  imperfectly  ooapted  during  the  systole — muscular  in- 
competency. The  common  lesions  producing  insufliciency  result  from 
endocarditis,  which  causes  a  gradual  thickening  at  the  edges  of  the  valves, 
contraction  of  the  chordas  tendinetP,  and  union  of  the  edges  of  the  sejf- 
ments,  so  that  in  a  majority  of  the  instances  there  is  not  only  iusutfi- 
ciency,  but  some  grade  of  narrowing  as  well.  Except  in  children,  wo 
rarely  see  the  mitral  leaflets  curled  and  puckered  without  narrowinj:  of 
the  orifice.  Calcareous  plates  at  the  base  of  the  valve  may  prevent  ])er- 
fect  closure  of  one  of  the  segments.  In  long-standing  cases  the  entire 
mitral  stnutures  arc  converted  into  a  firm  calcareous  ring.  From  this 
valvular  insullieioncy  the  other  condition  of  muscuhr  incompetency  mn?t 
be  carefully  distinguished.  It  is  met  with  in  all  conditions  of  extreme 
dilatation  of  the  left  ventricle,  and  also  in  weakening  of  the  muscles  in 
prolonged  fevers  and  in  anncmia. 

Morbid  Anatomy. — The  ofTects  of  incompetency  of  the  mitral 
segment  upon  the  heart  and  circulation  are  as  follows  :  (a)  The  imperfect 
closure  alloAvs  a  certain  amount  of  blood  to  regurgitate  from  the  vontritk' 
into  the. auricle,  so  that  at  the  end  of  auricular  diastole  this  chamber  con- 


^^jil-'-' 


CIIUONU;   VALVULAU  DIS^LVSK. 


611 


t.iiiiH  not  only  the  blood  wliidi  it  Inn  rcfcivofl  from  <ho  limits,  hut  nUit 
that  which  has  n>;?iir^ituli'(l  from  the  left  ventricle.  This  necessitates 
dilatation,  and,  iw  increaseil  work  Ih  thrown  upon  it  in  cxiiellinjj  the  au;.'- 
iiK'iited  contents,  hyj)ortroi)hy  as  well. 

(//)  With  each  systole  of  the  left  auricle  a  lart^er  volume  of  hlood  ii^ 
fdned  into  the  K'ft  ventricle,  which  also  dilates  and  8ul)se(|iiently  becomes 
liypertrophied. 

(r)  Durin;^  the  diastole  of  the  left  auricle,  as  blo(Ml  is  rej,'ur<ritated 
iii,o  it  from  the  left  ventricle,  the  [)ulmonary  veins  are  less  reailily  emptied. 
I'l  'onsetpience  the  ri^ht  ventricle  expels  its  contents  less  freely,  ami  in 
tiii;i  l)ocomea  dilated  and  liypertrophied. 

(d)  Finally,  the  right  auricle  also  is  involved,  its  chamber  is  cnlarj^ed, 
mill  its  walls  are  increased  in  thickness. 

(i)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation 
bi)tli  of  the  arteries  and  veins — often  in  long-stand ini,'  cases  atheromatous 
cliaiiges;  the  capillaries  art!  disti'iided,  and  ultimately  the  condition  of 
brown  induration  is  produced.  Perfect  eom{)ensation  may  be  elTected, 
cliielly  through  the  liypertrophy  of  both  ventricles,  and  the  elTect  upon 
the  iicripheral  eircidation  may  not  be  manifested  for  years,  as  a  normal 
volume  of  blood  is  discharged  from  the  left  heart  at  each  systole.  The 
tinio  comes,  however,  when,  owing  either  to  increase  in  the  grade  of  the 
incompetency  or  to  failure  of  the  compensation,  the  left  ventricle  is 
unable  to  send  out  its  normal  volume  into  the  aorta.  Then  there  is  over- 
lilliiig  of  the  left  auricle,  engorgenuMit  in  the  lesser  circulation,  embarrassed 
u'tidu  of  the  right  heart,  and  congestion  in  the  sj'stemic  veins.  For  years 
this  somewhat  congested  condition  may  be  limited  to  tlie  lessor  circulation, 
but  finally  the  right  auricle  becomes  dilated,  the  tricuspid  valves  incom- 
pi'tcnt,  and  the  systemic  veins  are  engorged.  This  gradually  leads  to  the 
t'oiuiition  of  cyanotic  induration  in  the  viscera  and,  when  extreme,  to 
(Irojjsical  effusion. 

Muscular  incompetency,  due  to  impaired  nutrition  of  the  mitral  and 
imi)illary  nniacles,  is  rarely  followed  by  such  perfect  compensation.  There 
may  ho  in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of 
t!io  left  ventricle  with  relative  incompetency  of  the  mitral  segments,  great 
dilatation  of  the  left  auricle,  and  intetise  CTigorgement  of  the  lungs,  under 
wliicli  circumstances  profuse  Incmorrhage  may  result.  In  these  cases 
tiicrt'  is  little  chance  for  the  esta1)lishment  of  com[)ensation.  In  cases 
of  hypertrophy  and  dilatation  of  the  heart,  without  valvular  lesions,  but 
iissDciatod  with  heavy  work  and  alcohol,  the  insufliciency  of  the  mitral 
valve  may  be  extreme  and  lead  to  great  ])ulmonary  congestion,  engorge- 
iiK'tit  of  the  systemic  veins,  and  a  condition  of  cardiacs  dropsy,  which 
I'aniiot  ho  distinguished  by  any  feature  from  that  of  mitral  incompetency 
due  to  lesion  (^f  the  valve  itsidf.  In  chronic  Ilright's  disease  the  hyper- 
trophy of  the  left  ventricde  may  gradually  fail,  leading,  in  the  later  .-^•lges, 
to  relative  insufficiency  of  the  mitral  valve,  and  the  production  of  a  con- 


m 

II' 


■'JnM 


M 


kmMmr-  '^ 


^i' 


%'\%. 


i-m. 


'      Hi 


m 


(If  '5^  'f 


612 


DISEASES  OF  TIIH  CIRCULATORY  SYSTEM. 


tlitioii  of  inilnionarv  and  systomic  congestion,  similar  to  that  iuduot'd  liv 
the  most  extreme  <fra(k>  of  lesion  of  the  valve  itself. 

SymptOIUS.  —  Dm-inj^  the  development  of  the  lesion,  uidess  llic  iii- 
eomiJi'teney  comes  on  acutely  in  consei|iiciu'e  of  rupture  of  the  valve 
se,i:;MU'nt  or  of  ulceration,  the  compensatory  changes  go  hand  in  hand 
with  the  delect,  and  there  are  no  sul)ji'ctivc  symptoms.  So,  also,  in  ihc 
stage  of  perfi'ct  compensation,  tiici'c  may  ln'  the  most  extreme  grade  of 
mitral  insutlici(>ncy  with  enormous  hypertrophy  of  the  heart,  vet  thu 
l)atienl  may  nut  he  aware  of  the  existenci'  of  heart  troid>le,  and  niav 
sutler  nil  inconvenience  except  perhaps  a  litth'  shortness  of  hreatli  mi 
exertion  or  cm  going  up-stairs.  It  is  only  when  from  any  cause  the  cdiii- 
j)ensation  has  not  heen  i)erl"ectly  etfeeted,  or  having  heen  so  is  hrokeii 
abruptly  or  graiiuidly,  that  tiie  patients  begin  to  be  troubled.  The  sviiip- 
toms  may  be  divided  into  Ivo  grt>ups  ; 

{(i)  The  minor  manifestations  while  compensation  is  still  good.  \\\. 
tients  with  extreme  incompetency  often  have  a  congested  appearance  (,f 
the  face,  the  li[)s  and  ears  have  a  bluish  tint,  and  the  venules  .,u  tln> 
cheeks  may  be  enlarged,  which  in  many  cases  is  very  suggestive.  In 
long-standing  cases,  ])articularly  in  children,  tlu'  fingers  may  be  clulihed. 
and  there  is  shortness  of  breath  on  exertion.  This  is  oui'  of  the  nio'-t 
constant  features  in  mitral  insullicit'ucy,  and  may  exist  for  years,  even 
wluMi  tlie  compcnsatidu  is  perfect.  Owing  to  the  sonu'what  coni^csttMl 
condition  of  tin-  lungs  these  patients  have  a  tiMidi-ncy  to  attacks  nf 
bron(diitis  cr  ha-nutptysis.  There  m;;y  also  be  palpitation  of  tlic 
heart.  As  a  rule,  however,  in  well-balanced  lesions  in  adults,  tlii- 
}teriod  of  full  compensation  or  latent  stage  is  not  associatcil  witii  syiii|)- 
tonis  which  call  the  attention  of  the  i)atient  to  an  all'cction  of  tli' 
lietirt. 

(h)  Sooner  or  latt  r  comes  a  ])eriod  of  disturbed  or  broken  conipi  tis;i- 
tion,  in  which  the  most  iniense  symptoms  are  those  of  venous  iigorgt  iiu'iit. 
'J'licrc  arc  palpitation,  weak,  irregular  action  of  the  heart,  and  Mgiis  "( 
dilatutiitn.  I  >yspna'a  is  a  marked  fi'ature,  and  there  icay  be  e(:iirli- 
There  is  usiudly  a  slight  cyanv)sis,  and  even  a  jaundiced  l,nt  (o  the  skin. 
The  most  marked  symptoms,  however,  are  those  of  venous  stasis.  Tin' 
overfilling  of  the  ])uln>onarv  ves.-Jcds  accounts  in  part  for  the  dyspiui'ii. 
Theri'  is  cough,  ol'tcn  with  bloody  or  watery  expector.ition,  and  the 
alveolar  epillieliun»  contai'iing  brown  pigmen<-grains  k  abumlaut.  Ilnip- 
sieal  elfusion  usually  .sets  in,  beginning  •  i  the  i  :vi  and  extending  ti>  llie 
body  and  the  seri)us  sacs.  The  liver  is  enlargecV  and  there  are  signs  ef 
jiorlal  congestion,  gastric  irritation,  and  catarrh  of  (he  stoma(di  and  in- 
testines. The  uriiu'  i..  usual! v  scanty  and  albuminous,  and  ct)ntains  tnlie 
('lists  and  .^ometinu's  blood-corpus(des.  With  jinlicious  freatn,.iit  the 
.))Mpensation  may  be  restoreil  and  all  the  serioua  s\m|)toms  ni.i\  piis.'^ 
aw.ij.  Patients  may  have  recurring  attacks  oi  this  kind,  but  uiliniaul.v 
the  condition  is  beyond  repair  and  the  pati'.-nt  either  dies  of  a  geiu-nil 


T 

'V 


,,,vt-v»jf», 


CHRONIC  VALVULAU  DISEASE. 


013 


lln>[>^^y  or  thoro  is  pro>:^rossivo  diliilation.  of  tlio  lu'iirt,  ami  iloulh  from 
ii^vstolo.     Siuldou  death  in  these  cases  is  rnre. 

Physical  Signs. —  Iiisprrfin/i. — In  cliiKlrcn  the  j)ra'oordia  may  hiilgo 
iinil  there  may  l)e  a  hirge  area  of  viHiliU'  jjiilsation.  'Die  apex  l)eat  is  to 
till'  left  of  the  nippU',  in  some  eases  in  the  sixth  interspace,  in  the  anterior 
axillary  line.  There  may  he  a  wavy  inqnilse  in  the  eervieal  veins  whieh 
juv  (il'ten  full,  particularly  when  the  patient  is  recumlu'nt. 

Fiilpalion. — A  thrill  is  rare;  wIumi  present  it  is  felt  at  the  ajiex, 
(>i'tcn  in  a  limited  area.  The  force  of  the  impulse  imiy  depend  largely 
uniin  the  stage  in  whieh  the  ease  is  examiiu'd.  In  full  compensation  it  is 
f()nil(le  and  lioaving;  when  the  compensation  is  disturbed,  usually  wavy 
anil  i'eehle. 

I'riri'ssiou. — The  dulness  is  ii\creased,  ])articularly  in  a  lateral  direc- 
tum. There  is  no  disease  of  the  valves  which  jirodut'es,  in  long-standing 
cases,  a  more  extensive  transverse  area  of  heart  dulnes.s.  It  does  not  ex- 
tciii!  so  unu'h  upward  along  tlie  left  nuirgin  of  the  sternum  as  beyond  the 
rijit  margin  and  to  the  left  of  the  nipple  line. 

AusniUa(ii)n. — At  the  apex  there  is  a  systolic  murmur  which  wholly 
or  partly  obliterates  the  iirst  sound.  It  is  loudest  here,  and  has  a  lilowing, 
soiiietinies  nmsieal  in  character,  particularly  toward  the  luttir  part.  The 
iiiunmir  is  transmitted  to  the  axilla  ami  may  be  heard  at  the  back,  in 
sdiue  instances  over  the  (>ntire  chest.  There  are  ca.ses  in  wbieli,  as  pointed 
out  by  Naunyn,  the  murmur  is  heanl  best  along  the  left  border  of  the 
stoniiun.  Usually  in  diastole  at  the  apex  the  loudly  transmitted  second 
<iiiiii,l  may  be  heard.  Occasionally  ther:'  is  also  a  .soft,  sometimes  a 
iMtigh  or  rumbling  presystolic  murmur.  As  a  ruli>,  in  casi's  of  extreme 
inili'al  insulVu'iency  from  valvular  lesion  with  great  hypertrophy  of  both 
vriitriele.s,  there  is  heard  only  a  loud  blowing  murmur  during  .systole. 
\  laurniiir  of  mitral  iusutliciency  nuiy  vary  a  great  deal  according  to  the 
I  isitiou  of  the  patient.  It  jnay  be  ])ri'siMit  in  the  rei'umbent  and  ali- 
.<oiit  ill  the  erect  posture.  In  ea.ses  of  dilatation,  particularly  when  dropsy 
is  |U'esent,  there  may  be  heard  at  the  eusifortu  cartilage  and  in  the  lower 
sternal  region  a  soft  .systolic  murmur  due  to  tricuspid  regurgitation.  An 
important  sign  on  auscultation  is  the  aceontuuted  j)ulmonary  si'cond  souml. 
This  is  heard  to  the  left  of  the  sternum  in  the  second  intersj)ace,  or  ovir 
the  third  left  costal  cartilage. 

'I'lie  pulse  in  mitral  insuH'  lency,  during  the  period  of  full  coinpeu.sa- 
tioii.iiiay  be  full  and  regular,  o.teii  of  low  tt'iision.  Usually  with  the  Iirst 
onset  ii!"  the  symptoms  the  pul.se  becomes  irregular,  a  features  which  then 
ilomiiiates  the  ease  throughout.  There  may  l»e  no  two  beats  oi  c(|ual 
f'lrce  or  Volume.  Often  after  i'lC  di.sai)pearauce  of  ♦  le  sym[)toms  of  fail- 
ure of  coinpen.siition  the  irregidarity  of  the  pul.se  persists. 

'I'lie  three  important  jihysical  signs  then  of  mitral  regurgitation  are: 
(d)  systolic  nnirmur  of  nuiximum  inteiisity  at  the  apex,  which  is  (trop.i- 
gated  t  .  the  axilla  and  heard  ut  tho  iinglo  of  the  seupulu;  {b)  uccentuatiou 


,  s   il 


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614 


DISEASES  OP  THE  CIRCULATORY   SYSTEM. 


of  the  pulmonary  Bcoond  pouikI  ;  {c)  evidence  of  enlargement  of  the  luart. 
j)artic!ularly  the  inenuise  in  the  transverse  diameter,  dxie  to  hypertmiiliv 
of  both  right  and  left  ventrieles. 

Diagnosis. — 'I'Iutc  is  rarely  any  difliculty  in  the  diagnosis  of  niiin.I 
insullieiency.  The  physical  signs  just  referred  to  are  quite  eluiractcristic 
and  distinctive.  Two  points  are  to  be  borne  in  mind.  First,  a  niurnuir. 
systolic  in  character,  and  of  maximum  int<>nsity  at  the  apex,  and  iii(i|i;i. 
gated  even  to  the  axilla,  does  not  necessarily  indicate  incoTni)etciicv  of  the 
mitral  vidve.  There  is  heard  in  this  region  a  larger  group  of  what  arc 
termed  acci(l(^ntal  murmurs,  the  precise  nature  of  which  is  still  doulitful. 
They  are  prol)al>ly  f(»rmcd,  iiowever,  in  the  ventricle,  and  are  not  associutcij 
with  hypertrophy,  or  accentuation  of  ])idni(tnary  second  sound. 

Scc(»nd,  it  is  not  always  possible  to  say  whether  tiie  iiisunicicncv  is 
due  to  lesion  of  the  valve  segment  or  to  dilatation  of  the  mitral  ring  and 
relative  incompetency.  Here  neither  the  character  of  the  niurnnir,  the 
propagation,  tlu^  accentuation  of  the  pulmonary  second  souiul,  nor  the 
hypertrophy  iissists  in  the  dilfcrentiation.  The  history  is  souictiiiics  of 
greater  value  in  this  matter  than  tlu^  physical  examination.  The  casis 
most  likely  to  lead  to  error  are  those  of  the  so-called  idiopathic  dilatatidii 
and  liypertr(»phy  of  the  heart  (in  which  the  sy^tolic^  murmur  may  he  df 
the  greatest  intensity),  iind  the  instsmces  of  arterio-sclerosis  with  (iilatcd 
heart. 

MiTUAi.  Stkxosis. 

etiology. — Xarrowing  of  the  mitral  orifice  is  usually  the  result  of 
valvular  endocarditis  occurring  in  the  earlier  years  of  life;  very  nrol}  il 
is  congenital.  It  is  very  much  more  comnum  in  women  than  in  nicii— in 
0;3  of  'SO  cases  iu>t(Kl  by  Duckworth.  This  is  not  easy  to  cx])laiii,  but  tiiciv 
ure  at  least  two  factors  to  be  cotisidered.  Ivheunuitism  prevails  luorc  in 
girls  than  in  boys  and,  as  is  well  known,  eiulocarditis  of  the  mitral  valve 
is  more  comnu)n  in  rheumatism,  ("horea,  also,  as  suggested  by  Harlow, 
has  an  important  influence,  occurring  more  frequently  in  girls  and  dfleii 
associated  with  endocarditis.  Of  1 1(1  cases  of  chorea  which  I  examined  at 
a  period  more  than  two  years  sub.sequent  to  the  attack,  54  cases  had  sij^Mis 
of  organic  h(>art-disease,  among  which  were  17  instances  with  the  ])liysieal 
signs  of  mitral  stenosis.  Aniemia  aud  chlorosis,  which  are  jirevalent  in 
girls,  have  been  regarded  as  possible  factors.  In  a  number  of  cases,  Iiow- 
ever, no  recognizable  etiologicid  factor  can  be  discovered.  This  lias  been 
regarded  by  some  writers  as  favoring  the  view  that  many  of  the  cases  are 
of  congenital  origin  ;  but  it  is  not  improl)able  that  with  any  of  the  I'elirile 
afTections  of  childhood  endocarditis  nuiy  be  associated.  AVhooping-eoiiL'Ii, 
too,  with  its  terril)le  strain  on  the  heart-valves,  may  be  accouiitalde  tor 
certai?)  cases.  Congenital  afTections  of  the  mitral  valve  arc  n<it"iioii.-ly 
rare.  While  met  with  at  all  ages,  stenosia  Is  certainly  more  fre(|ue!il  m 
young  persons. 


m 

til 


CHRONIC  VALVULAR   DISEASE. 


6U 


Morbid  Anatomy. — In  a  mujority  of  ijistiincos  with  tho  stenosis 
tliciv  id  some  inoomp(itency.  The  iiiirrowin«5  results  from  tliickoniiig  uiid 
coutriictioii  of  tho  tissues  of  tlio  ring,  of  the  viilve  siignients,  and  of  tho 
(•h(inl;e  tondineai.  The  condition  varies  a  good  deal  according  to  tho 
ainouut  of  atheromatous  change.  Jn  many  cases  the  curtains  are  so 
wclili'il  together  and  tho  whoh;  valvular  region  so  thickened  that  tho 
orilice  is  reduced  to  a  more  chink — Corrigan's  hutton-holo  contrwction. 
Ill  (itlier  cases  the  curtains  are  not  much  thickened,  but  narrowing  has 
ri'^iiltcd  from  gradual  adliesion  at  the  edges  and  thickening  of  tho  ciionho 
tundiuea',  so  that  from  the  auricK;  it  looks  cone-like — the  so-called  funnel- 
slmped  variety  of  stenosis.  'I'he  instances  in  which  tho  valve  segments 
arc  very  slightly  deformed  but  in  which  tho  orifice  is  considerably  nar- 
ri)fft'(l,  are  regarded  by  somi;  as  possibly  of  congenital  origin.  ()c(;a- 
sioiially  tho  curtains  are  in  great  part  free  from  disease,  but  the  nar- 
rowing results  from  large  (.'alcareous  masses,  which  i)roject  ii\to  them 
from  tlie  ring.  Tiie  involvement  of  the  chorda)  tendinea;  is  usually  ex- 
trciiic,  and  the  i)apillary  muscles  may  bo  inserted  directly  ui)ou  tho 
vulvc.  In  moderate  grades  of  constrii^tion  the  orifice  will  admit  tho  tip 
of  llie  iiulex-finger ;  in  more  extreme  forms,  the  tip  of  the  little  linger; 
anil  occasionally  one  meets  with  a  8i»ecimen  in  which  the  orifice  seems 
almost  obliterated,  as  in  a  case  which  came  under  my  notice,  which  oidy 
admitU'il  11  mcMlium-sizod  Bownian's  probe. 

Till'  heart  in  mitral  stenosis  is  not  greatly  enlarged,  rarely  weighing 
more  tluin  1-1  or  15  ounces.  Occasionally,  in  an  cldijrly  person,  it  may 
.Stem  slightly  if  at  all  enlarged,  and  again  there  are  instances  in  \\hi(di 
tlic  weight  may  reach  as  much  as  ^0  ounces.  The  left  ventricle  is  usually 
small,  ami  may  look  V(>ry  small  in  comparison  with  the  right  ventri(de, 
which  forms  the  greater  portion  of  the  apex.  In  cases  in  which  with  tho 
narrowing  there  is  very  considerable  incompetency  tho  loft  vontriclo  may 
1)0  moderately  dilated  and  hypertrophied. 

Tiiese  (dianges  gradually  indu(!ed  are  associated  with  secondary  altera- 
tions of  great  importance  in  the  heart.  'I'he  left  auricle  discharges  its 
Wood  with  greater  ditUculty  and  in  (!()nsequence  dilates,  and  its  walls 
reach  three  or  four  times  their  normal  thickness.  Although  tho  auricle  is 
by  structure  unfitted  to  com])ensato  an  extreme  lesion,  the  probability  is 
that  for  some  time  during  the  gradual  production  of  stenosis,  the  incrcas- 
ini,'  muscular  power  of  the  walls  is  sutlicient  to  I'ounterbalance  the  defect. 
Kvt'iitiially  tho  tension  is  increased  in  the  pulmonary  circulation,  owing 
t'l  imiicded  outflow  from  tho  veins.  To  ovorcomo  this  tho  right  ventricle 
uml'.'rgoos  dilatation  and  hypertrophy,  and  upon  this  chamlx^r  falls  tho 
Work  of  eiiualizing  the  circidation.  Uelativ(!  incompetency  of  the  tricuspid 
and  ctiii^^cstion  of  systemic  veins  at  last  supervene. 

It  is  not  uncommon  at  tho  examiiuition  to  iiml  white  tl»rond)i  in  tho 
iippomlix  of  the  left  auricle.  Occasionally  a  large  ])art  of  tho  uuriclo  is 
occupied  by  an  anto-mortom  thrombus.     Htill  more  rarely  the  renmrkablo 


1. 


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M  If 

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llfl  vil 


If 


616 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


bill!  thrombus  is  found,  in  whicli  a  globuhir  concretion,  var3'ing  in  sizo 
from  a  Avalnut  to  a  sniitll  egg,  lies  free  in  the  auricle,  two  examples  df 
whicli  have  come  under  my  observation. 

Symptoms.— Physical  Signs.— ///.".vv^rZ/rt^.— In  children  the  lower 
sternum  and  the  lifth  and  sixth  left  costal  cartilages  are  often  prominent, 
owing  to  hypertrophy  of  the  right  ventricle.  The  ape\  beat  may  be  ili- 
defined.  Usually,  it  is  not  dislocated  far  beyond  the  nipple  line,  and  the 
chief  impulse  is  over  the  lower  sternum  and  adjacent  costal  cartihiires. 
Often  in  thin-chested  j)ersons  there  is  pulsation  in  the  third  and  fmiitli 
left  interspaces  close  to  the  sternum.  When  comjiensation  fails,  the  pni'- 
cordial  impulse  is  much  feebler,  and  in  the  veins  of  the  neck  tluie  mav 
be  marked  systolic  regurgitation. 

PoljHilion  reveals  in  a  majority  of  the  cases  a  characteristic,  well- 
defined  fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  (ir 
lifth  interspace  within  the  nipple  line.  It  is  of  a  rough,  grating  ((ualitv, 
often  ]>eculiarly  limited  in  area,  most  marked  during  expiration,  and  cm 
be  felt  to  terminate  in  a  sharp,  sudden  shock,  synchronous  with  the  im- 
pulse. 'J'his  most  characti'ristic  of  physical  signs  is  pathognomonic  of 
narrowing  of  the  mitral  orifice,  and  is  perhaps  the  only  instance  in  which 
the  diagnosis  of  a  valvular  lesion  can  be  nuide  by  palpation  alone.  The 
cardiac  impulse  is  felt  most  forcibly  in  the  lower  sternum  and  in  the 
fourtii  and  lil'th  left  interspaces.  The  impulse  is  felt  very  high  in  the  third 
and  fourth  intersj)aces,  or  in  rare  cases  even  in  the  second,  and  it  has 
been  thought  that  in  the  latter  interspace  the  impulse  is  due  to  |ail>a- 
tion  of  the  auricle.  It  is  always  the  impulse  of  the  right  ventricle;  even 
in  the  most  extreme  grades  of  mitral  stenosis,  there  is  never  such  tiltiiii: 
forward  of  the  auricle  or  its  aiipcndix  as  woulil  enable  it  to  produce  au 
impression  on  the  chest  wall. 

PercitHsion  gives  an  increase  in  the  cardiac  duliicss  to  the  right  of  the 
sternum  and  along  the  left  margin ;  not  usually  a  great  increase  heyomi 
the  iii|)])h'  line,  except  in  extreme  cases,  when  the  transverse  duliioss  nuiy 
reach  from  Tj  cm.  beyond  the  right  nuirgin  of  the  sternum  to  lU  cin. 
beyoiul  the  nipple  line. 

Auficnlfd/ion. — In  tlie  niitnd  area,  usually  to  the  inner  side  of  the 
iijH'x  i)eat  and  often  in  a  very  lindted  regicm,  is  heard  a  rougli,  vil)rat(iiv 
or  purring  murmur,  whicdi  terminates  abruj)tly  in  the  first  sound.  By 
c<)nd)ining  palpation  arid  auscultation  the  purring  murmur  is  found  U>  !"■ 
synchronous  with  the  thrill  and  the  loud  shock  with  the  first  sound.  Thi< 
is  the  })resystolic  murmur,  about  the  time  and  mode  of  production  of  whidi 
so  miuh  discussion  bsis  occurred.  I  hold  with  tho.sc  who  regard  it  as  in- 
curring during  the  auricular  systole.  In  whatever  way  produced,  it  n'- 
mains  one  of  the  most  distinctive  and  characteristic;  of  murmurs  and  its 
presence  is  positively  indicative  of  narrowing  of  the  mitral  orifice.  TIr' 
sole  exception  to  this  statement  is  the  Flint  murmur  already  rcfrrrod  to 
in  aortic  incompetency.     Once,  in  a  case  of  enormous  enlurgemcn'  of  the 


:H^ 


CHRONIC   VALVULAR   DISEASE. 


617 


f5t)loon,  with  dropsy,  in  which  the  heart  was  greatly  pushed  up,  T  lieard  a 
|iro>yst()li<!  nmnmir  of  rou^li  quality,  and  the  mitral  valves  were  found 
nii-t  morteiu  to  he  nonnal.  'i'lie  presystolie  niurniur  may  oecupy  the 
entire  period  of  tlie  diast'ijc  ;  hut  more  commonly  it  is  oidy  the  latter  half, 
corresponding  to  the  auricular  systole.  The  difference  may  sometimes  ho 
iiiih'il  hetween  llie  lirst  and  second  portions  of  the  murmur,  when  it  occu- 
])i('S  t!u>  entire  time.  Often  there  is  a  peculiar  rund)lin<r  or  echoing  qual- 
ity, which  in  some  instances  is  very  limiti'd  and  may  he  heard  oidy  over  a 
siii<rlc  hell-space  of  the  stethos<'oi)e.  A  systolic  murmur  may  he  heard 
ill  the  apex  or  along  the  left  sternal  border,  often  of  extreme  softness  aiul 
aiiiiililc  oidy  when  the  hreath  is  held.  Sometinu'S  the  systolic  murmur  is 
1(111(1  and  distinct  and  is  transmitted  to  the  axilla.  The  secoiul  sound  in 
the  second  left  inters[)ace  is  loudly  accentuated,  sometimes  redui)lii'ated. 
It  may  he  transmitted  far  to  the  left  and  he  heard  with  great  clearnes.s 
bevdud  the  apex.  In  uncomplicated  cases  of  mitral  8teiu)sis  there  are 
iisuallv  no  murnnirs  audihle  at  the  aortic  region,  at  whiidi  spot  th(^  secoiul 
sduml  is  less  intense  than  at  the  pulmonary  area.  In  the  lowi-r  sternum 
and  to  the  right  a  tricuspid  murmur  is  sometimes  heard  in  advaiice(l  cases. 
Other  jioints  to  he  noted  are  tin;  following:  The  unusually  sharp,  (dear 
first  sound  which  follows' the  presystolic  murnmr,  the  cause  of  which  is 
liv  no  means  easy  to  ex[)lain.  It  can  scarcely  he  a  valvular  sound  jiro- 
iluccil  (•hielly  at  the  mitral  oritice,  since  it  may  l)e  heard  with  great  inten- 
sity ill  cases  in  whi(di  the  valves  are  rigid  and  calcilied.  More  j»rohahly  it 
is  a  ;iiodified  sound  produced  by  the  heart-muscle  and  connected,  as  has 
btvii  suggested,  with  the  altered  conditions  of  the  (dionhe  tendinc'v  and 
jiiqiilhiry  mustdes,  the  nornvai  action  of  whi(di  must  be  interfered  with. 

These  physical  signs,  it  is  to  be  borne  in  mind,  are  (diaracteristic  only 
iif  the  stage  in  which  compensation  is  nuuntained.  Finally  there  comes  a 
pi  riod  ill  which,  with  rupture  of  compensation,  the  }>resyst<dic  murmur 
disappears  and  there  is  heard  in  the  apex  region  a  sharp  first  sound,  or 
sdinetiiiies  a  galloi)  rhythm.  The  marked  systolic  shock  may  be  present 
ahw  the  disap[)earance  of  the  thrill  and  the  (diaracteristic  murmur.  Tn- 
der  treatment,  with  gradual  recovery  of  compensation,  ])robably  with  in- 
L'lwusing  vigor  of  contraction  of  the  right  ventri(de  and  left  auriede,  the 
presystolic  murmur  reap[)ears.  In  cases  seen  at  this  stage  of  the  disease 
the  nature  of  the  valve  lesion  may  he  entirely  overlooked. 

Stenosis  of  the  mitral  valve  may  for  j'ears  bo  elhcicntly  compensateJ 
iiy  the  hypertrophy  of  the  rigid  ventri<de.  Many  persons  with  the  (diar- 
acteristic physical  signs  of  this  lesion  present  no  symptoms.  They  may 
for  years  pi'rhai)s  be  short  of  breath  on  going  up-stairs,  but  arc  able  to  ])ass 
tlirouLdi  the  ordinary  duties  of  life  without  discomfort.  The  pulse  is 
smaller  in  volume  than  normal,  but  may  be  perfecitly  regular.  A  special 
daiijfer  of  this  stage  is  the  recurring  endocarditis.  Vegetations  may  bo 
whipped  off  into  the  (drculation  and,  blocking  a  cerebral  vess(d,  may  cause 
h  ■iiiiplegia  or  aphasia,  or  both.    This,  unfortunately,  is  not  an  uncommon 


.1^ 


1  i^T 
I- 


i.  * ;  *  ["TBI 


<| 


618 


DISKASKS  OF  THE  CIRCULATOUY  SYSTEM. 


8('(]U(Mii'o  in  womon.  Patients  with  mitral  sfcoiiosis  may  survive  this  iiccj. 
(lent  for  an  itult'liiiitc!  jnTiod.  A  wdiiiati,  over  seventy  years  of  a^^e,  died 
in  om'  of  my  wards  at  the  I'liilad(dpliia  Hospital,  who  had  been  in  the 
almshonse,  hemiide;:;ie,  for  more  than  thirty  yi>ars.  Tiie  heart.  ])res(  iitcd 
an  extreme  {jrado  of  mitral  stenosis  whi(d»  had  jtrohahly  existed  at  the  lime 
of  the  hemiplepfic  attaek, 

l-'ailure  o!"  eo)n])ensation  hrinjifs  in  its  train  th<'  {^rouj)  of  svinptmiis 
whi(di  have  lu-eii  discussed  under  mitral  insullieieney.  IJrielly  enuuienihii 
they  are:  Ifapid  and  irreijular  action  of  the  heart,  shortness  of  lircalli, 
('ou<j;h,  si;,Mis  of  |)ulmonary  i'n<ff)rj,'ement,  nnd  very  frequently  ha>moptvsis. 
Attaeks  of  this  kind  may  recur  for  years.  l?ronehitis  or  a  febrile  attiick 
may  cause  shortness  of  breath  or  sliifht  blueness.  Inflammatory  alTcctidiis 
of  the  lunu;s  or  pleura  seriously  disturb  the  ri<^ht  heart,  and  these  patients 
staml  pneumonia  very  badly.  Many,  perha])sa  majority  of  eases  of  initinl 
stenosis,  do  not  have  dropsy.  The  liver  may  be  jjr'"f'''tly  eidarc;ed,  and  in 
tlie  late  sta,i,'es  ascites  is  not  uncommon,  ]>artieularly  in  children,  (icn- 
eral  anasarca  is  most  fietpiently  met  with  in  those  eases  in  which  then' 
is  secondary  narrowing  of  the  tricuspid  oritice  (Hroadbeut). 


m'§ 


■  m 


•?,*■ 


Thicuspid-Valve  Disease. 

{a)  Tricuspid  Regurgitation.— Occasionally  this  results  from  iiciite 
or  chronic  endocardiiis  with  puckering;  more  commonly  the  condition  is 
one  of  relative  insullieieney,  and  is  secondary  to  lesions  of  the  valves  »n 
the  left  side,  particularly  of  the  mitral.  It  is  met  with  also  in  all  condi- 
tions of  the  lun_i,'s  which  cause  obstruction  to  the  circulation,  such  as  cir- 
rhosis and  emphysema,  particularly  in  cond)ination  with  chronic  Imm- 
ohitis.  The  symptoms  arc  tliosc  of  (»bstruction  in  the  lesser  circulation 
with  venous  congestion  in  the  systemic  veins,  such  as  has  already  i)oi'n 
described  in  connection  with  mitral  insufliciency.  The  signs  of  this  con- 
dition are : 

(1)  Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  tlio 
transmission  of  the  pulse-wave  into  the  veins  of  the  neck.  If  the  regurjri- 
tation  is  sliglit  or  the  contraction  of  the  ventricle  is  ftcble  there  may  lie 
no  venous  i)ulsation,  but  in  other  cases  there  is  nuirkcd  systolic  ])nlsation 
in  the  cervical  veins.  That  in  the  right  jugular  is  more  foi'cililc  tluui 
that  in  the  left.  It  may  ])e  seen  both  in  the  internal  and  the  external, 
particularly  in  the  latti-r.  Marked  pulsation  in  these  veins  occurs  only 
when  the  valves  guarding  them  become  incompetent.  Slight  oscillations 
are  by  no  means  uncommon,  even  when  the  valves  are  intact.  The  ilis- 
teution  of  the  veins  is  sometimes  enornu)us,  particularly  in  tlu'  act  of 
coughing,  when  the  right  jugular  at  the  root  of  the  neck  may  stand  out, 
forming  an  extraordinarily  prominent  ovoid  mass.  Occasionally  the  re- 
gurgitant pulse-wave  may  be  widely  transmitted  and  be  seen  in  the  sub- 
clavian and  axillary  veins,  and  even  in  the  subcutaneous  veins  over  the 


H 


CimONIC  VALVULAR  DISEASE. 


019 


sluiiilder,  or,  as  in  a  case  recently  under  observation,  in  the  superficial 
iiiiiiiinuiry  veins. 

U'cgurjjitunt  jjulsation  tlirouffli  tlu^  tri('us])i(l  orifice  maybe  transmitted 
to  the  inferior  cava,  and  so  to  the  hcpatii!  veins,  causin};  a  systolic  disten- 
tidii  of  the  liver.  Tliis  is  best  appreciated  by  bimanual  pal[)ation,  placirif^ 
(iiic  hand  over  the  fifth  and  sixth  costal  cartilages  and  the  other  in  the 
hilcrul  region  of  the  liver  in  the  mid-axillary  line.  The  rhythmical  ex- 
|iiiiisile  pulsation  may  be  readily  <listin<]fuished,  as  a  rule,  from  the  systolic 
(loprcssion  of  the  liver  due  to  communicated  pulsation  from  the  left  ven- 
tricle. 

(•.')  The  second  important  symptom  of  tricuspid  rcf^jurj^itation  is  the 
oniiirence  of  a  systolic;  murmur  of  nuixirmmi  intensity  in  tlu^  lower  ster- 
miiii.  It  is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a 
('(H'xistini^  mitral  murmur  by  diirerences  in  <|uality  and  ])itcli,  and  may  be 
iit'iinl  to  the  right  as  far  as  the  axilla.  Sometimes  it  is  very  limited  in  its 
distribution. 

Together  these  two  signs  positively  indicate  tricuspid  regurgitation. 
In  iiildition,  the  percussion  usually  shows  increase  in  the  area  of  duliu'ss 
to  the  right  of  the  sternum,  and  the  impulse  in  the  lower  steriud  region  is 
foi(il)le.  In  the  great  majority  of  cases  the  symptoms  are  those  of  the 
associated  lesions.  In  cirrhosis  of  the  lung  and  in  chronic  empliysema  the 
faihirc  of  compeJisatioji  of  the  right  ventricle  with  insuHicieiu'y  of  the  tri- 
luspid  not  infrerpuMitly  leads  either  to  acute  asystole  or  to  gradual  failure 
with  cardiac  dropsy. 

{b)  Tricuspid  Stenosis. — This  interesting  condition  may  be  either  con- 
fri'iiitul  or  acquired.  The  congenital  cases  are  not  uncommon,  ami  are 
associated  usually  with  other  valvular  defects  which  cause  early  death. 
Tlio  acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  4(5 
iibscrvations,  of  which  41  were  in  women.  Leudet*  has  analyzed  117 
cases.  Of  101  of  these  in  which  the  ages  were  mentioned,  80  were  in 
women  and  '^l  in  men.  A  grji'at  nuijority  of  the  cases  were  in  adults,  only 
ciirlit  lieing  l)etween  the  ages  of  ten  aiul  twenty.  Its  rarity  as  an  isolated 
cDiulition  may  be  gathered  from  the  fact  that  of  114  autopsies,  in  11  only 
was  the  lesion  confined  to  this  valve.  In  "il  the  tricuspid,  mitral,  and 
aortic  segments  were  involved,  and  in  78  the  tricuspid  and  mitral.  Prac- 
tically the  condition  is  ahnost  always  secondary  to  lesions  of  the  left  heart. 

The  piiysical  signs  are  sometimes  characteristic.  For  instance,  a  pre- 
.systolic  thrill  has  been  noted  by  several  observers.  The  percussion  sliows 
iliihiiN-^  to  bo  increased,  particularly  to  the  right  of  the  sternum.  On  aus- 
cultation a  presystolic  murmur  has  been  determined  in  certain  cases,  and 
is  licanl  lu'st  at  the  root  of  the  ensiform  cartilage,  or  a  little  to  the  right 
'if  it.  or  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  common, 
iiiid  ill  the  late  stages,  when  dropsy  supervenes,  it  is  apt  to  be  intense. 


40 


Paris  Thesis,  1888. 


i'M 


620 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


The  IcRion  is  interesting  eliiefly  because  it  forms  one  of  the  most  seriuus 
complications  of  niitnil  stenosis. 


P 


.tjtliil: 


(■Mi-- ' lift? 


PuLMONAUY  Valve  Disease. 

Tl)ia  is  extremely  rare. 

{a)  Sfi'nonis  is  almost  invariably  a  conj^enital  anomaly.  It  oonsli lutes 
one  of  tile  most  imi)ortant  of  the  coiif^^enital  cardiac  citlVctions.  Tlid  vulvo 
segments  are  usually  united,  leaving  a  small,  narrow  orifice.  In  tlu-  adult 
cases  occasionally  occuir.  In  Case  G08  of  my  jjost-mortem  records  there 
W!is  extreme  stenosis  in  a  girl  of  eighteen,  owing  to  great  thickening  .uid 
adhesion  of  the  segments,  and  there  were  also  numerous  vegetations.  TIki 
orifice  was  only  two  millimetres  in  diameter.  The  congenita!  lesion  is 
commonly  associated  with  patency  of  the  ductus  Hotalii  and  imperfection 
of  the  ventricular  se])tum.     There  may  also  be  tricuspid  stenosis. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic 
murmur  with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second 
intercostal  space.  This  murmur  may  bo  very  like  a  murmur  of  aortic 
stenosis,  but  is  not  transmitted  into  the  vessels.  Katurally  the  piihnonurv 
second  sound  is  weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  mur- 
mur.    T'^sually  there  is  hypertrophy  of  the  right  heart. 

{l>)  Puhnonanj  fiisuJIirirHri/. — This  rare  affection  is  occasionally  duo 
to  congenital  malformation,  particularly  fusion  of  two  of  the  segnieiits. 
It  is  sometimes  present,  as  Bramwell  has  shown,  in  cases  of  nnilignaiil 
endocarditis. 

The  {)hysical  signs  are  those  of  regurgitation  into  the  right  ventricle. 
but,  as  a  rule,  it  is  impossible  to  differentiate  this  from  the  murnnir  of 
aortic  insuiliciency,  though  the  maximum  intensity  may  be  in  the  ])ulmo- 
nary  area.  In  a  recent  case,  in  wliich  two  of  the  valve  segments  were 
closely  glued  to  the  wall  of  the  pulmonary  artery  owing  to  the  ])rojcction 
of  an  aneurism,  a  diastolic  murmur  developed  under  observation,  which 
was  transmitted  loudly  down  the  sternum.  The  condition  is  extremely 
rare  and  of  little  practical  significance. 

Combined  Valvular  Lesions. 

These  are  extremely  common.  The  mitral  and  aortic  segments  may 
be  affected  together;  next  in  frequency  conuis  the  combimitioii  of  mitral 
and  tricuspid  lesions;  and  then  of  aortic,  mitral,  and  tricuspid.  Aortic 
insuttlciem^y  or  aortic  stenosis  is  more  frequently  combined  with  mitral 
incompetency  than  aortic  stenosis  with  mitral  stenosis,  or  mitral  stenosis 
with  aortic  insufficiency.  In  children  the  most  common  combination  i* 
aortic  and  mitral  insufficiency.  In  adults,  mitral  insufficiency  with  thick- 
ening of  the  aortic  valves  and  slight  narrowing  is  perhaps  the  most 
commou. 


CHRONIC   VALVULAR   DISKASK. 


en 


Tlio  diagnosis  rests  iii)on  the  churucter  of  the  murmurs  and  tlie  state 
of  ilic  cliumhcrs  us  regards  hypiTtropliy  and  dilatation. 

Prognosis  in  Valvular  Disease.— 'riuMiucstion  is  entirely  one 
of  (Hutiunt  compensation.  So  long  aw  this  is  niaintaini'd  the  patii-iit  may 
Slitter  no  inconvenienee,  and  even  with  the  most  serious  forms  of  valve 
Icsimi  the  function  of  the  heart  may  be  little,  if  at  all,  disturbed. 

I'raetitioners  who  are  not  ade])ts  iu  auscultation  and  feel  unal)le  to 
estimate  tlie  value  of  tiie  various  heart  murnuirs  sliould  remember  tiuit 
tlic  liest  judgment  of  the  conditions  may  be  gathered  from  inspection 
;uiil  palpation.  Witli  an  apex  beat  in  the  normal  situation  an<l  regular  in 
rliytlini  the  auaculUitory  phenomena  may  be  practically  tlisn-garded. 

As  Sir  Andrew  Clark  states,  a  murmur  jyer  ac  is  of  little  or  no  moment 
in  ilctcrmining  the  pro<,'nosis  in  any  given  case.  'J'here  is  a  large  group 
of  patients  who  present  no  other  symptoms  than  a  systolic  murmur  heard 
over  the  body  of  the  heart,  or  over  the  apex,  in  whom  the  left  ventricle  is 
not  liypertrophied,  the  heart  rhythm  is  normal,  and  who  nuiy  not  have 
liatl  ihcunuitism.  Indeed,  the  condition  is  acicidcntally  discovered,  often 
(luring  exiimination  for  life  insurance.  I  know  cases  of  this  kind  which 
have  persisttid  unchanged  for  more  than  fifteen  years  Among  the  condi- 
tions iMlluencing  prognosis  are : 

{(i)  Age. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
etTccti'd,  and  they  are  free  from  many  of  the  influences  which  disturb 
coinptiisation  in  adults.  The  coronary  arteries  also  are  healthy,  and 
nutrition  of  the  heart-muscle  can  bo  readily  mainttiined.  Yet,  in  spite 
of  this,  the  outlook  in  cardiac  lesions  developing  in  very  young  children 
is  usually  bad.  One  reason  is  that  the  valve  lesion  itself  is  apt  to  be 
rapidly  progrcissive,  and  the  limit  of  cardiac  reserve  force  is  in  such  cases 
early  reached.  There  seems  to  bo  proportionately  a  greater  degree  of 
hyiicrtrophy  and  dilatation.  Among  other  causes  of  the  risks  of  this 
period  are  to  bo  mentioned  insuflicient  food  in  the  poorer  classes,  the 
rccuriH  iK;e  of  rheumatic  attacks,  and  the  existence  of  pericardial  adhesions 
Till'  outlook  in  a  child  who  can  be  carefully  supervised  and  prevented 
from  (laiiuiging  himself  by  overexertion  is  naturally  better  than  in  one 
wiio  is  constjintly  overtasking  his  muscles.  The  valvular  lesions  which 
develop  at,  or  subsequent  to,  the  period  of  puberty  arc  more  likely  to  be 
ponnaneiitly  and  ofliciently  compensated.  Sudden  death  from  heart- 
disease  is  very  rare  in  children. 

{b)  Sex. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fiujt  that  they  live  quieter  lives,  partly  to  the  less  common 
iuvolveiiiont  of  the  coronary  arteries,  and  to  the  greater  frequency  of  mit- 
ral lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are,  I 
tiiink,  less  serious  than  some  writers  would  have  us  believe. 

(')  Value  affected. — The  relative  prognosis  of  the  difTerent  valve  lesions 
IS  very  dillicult  to  estimate.  Each  case  must,  therefore,  be  judged  on  its 
own  merits.    Aortic  insufficiency  is  unquestionably  the  most  serious;  yet 


'fV'i 


\i'  ii 


Mua 

'wiiji 

li  '^ 

1  ni^^ 

H 

ilhi;  ,,n.  ■ 

->        1   *  :-    - 


'■(!.? 


622 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


.':'m> 


for  years  it  nmy  bo  porfoctly  onmponsatcd.  Fuvomhle  cirruinstaiiccs  in 
aiiyca.sc  are  the  moderate  jjrade  of  hypertrophy  and  dihitatioii,  the  altsciicc 
of  all  syiiiptotiis  of  nirdiac  distresa,  and  the  ahsenre  of  extensive  artciin- 
wilerosiK  and  of  atiffina.  The  profjnosis  rests  in  reality  with  the  coiKlitiiin 
of  the  eoronary  art(tries.  Hhciiinatic  lesinjis  of  the  valvi'S,  inducin;,'  insuf- 
ficieney,  are  less  apt  to  he  associated  with  endarteritis  at  the  root  of  tlic 
aorta;  an<l  in  such  cases  the  coronary  arteries  may  escape  for  years.  I 
know  a  physician,  now  about  thirty-five  years  of  age,  who,  when  sixteen, 
had  his  first  attack  of  rheumatism,  which  involved  the  aortii'  seijfTiifnts. 
lie  has  had  two  subs(M|uent  attacks  of  rheumatisni,  l)ut  with  care  lias  liccn 
able  to  live  a  comfortable  and  fairly  active  life.  On  the  other  hand,  wIk  ii 
the  aortic  insufficiency  is  only  a  })art  of  an  extensive  arterio-sclerosis  at  tlie 
root  of  the  aorta,  the  coronary  arteries  are  almost  invariably  involved,  ami 
the  outlook  in  such  cases  is  much  more  serious.  Sudden  death  is  not  ini- 
conimon,  either  from  acute  dilatation  durinj^  some  exertion,  or,  nww  fic- 
(juently,  from  blocking  of  one  of  the  branches  of  the  coronary  ai'teries. 
The  liability  of  this  form  to  ho-  associated  with  angina  pectoris  also  adds 
to  its  severity.  Aortic  Bteiu)siH  is  a  rare  lesiim,  most  commoidy  met  with  in 
middle-aged  or  elderly  men,  and  is,  as  a  rule,  well  compensated.  Jn  nianv 
eases  it  does  not  appear  to  limit  the  duration  of  life. 

In  mitral  lesions  the  outlook  on  the  whole  is  much  more  favoralilc 
than  in  aortic  insutticiency.  Mitral  insuf!icici  v,  when  well  compoiisatrd, 
carries  with  it,  perha})s,  a  better  prognosis  lii.m  mitral  stenosis;  Imt  it 
must  be  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in 
whicli  the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent. 
There  is,  in  reality,  no  valve  lesion  so  rapidly  fatal  and  so  jioorly  coin- 
j^ensated  as  that  in  which  the  mitral  segments  are  gradually  curled  and 
puckered  until  they  form  a  narrow  strip  around  a  wide  nutral  ring-  a  ion- 
dition  specially  seen  in  children.  There  are  many  cases  of  mitral  insutli- 
oiency  in  which  the  defect  is  thoroughly  balanced  for  thirty  or  even  fnity 
years,  without  distress  or  inconvenience.  Even  with  great  hyiieiirdphy 
and  the  apex  ])eat  almost  in  the  mid-axillary  line,  there  may  be  little  nv  no 
distress,  and  the  compensation  may  be  most  efTective.  Women  may  pM.-s 
safely  through  repeated  pregnancies,  though  here  they  are  liable  to  'Kii- 
dents  associated  with  the  severe  strain.  I  have  liad  under  my  care  fnr 
many  years  a  patient  who  had  her  first  attack  of  rlieumatism  at  the  ml'''  "f 
fifteen,  when  she  already  had  a  well-marki'd  mitral  murmur.  Wlicn  >hc 
first  came  under  my  observation,  lighteen  years  ago,  she  had  siirns  ot 
liypertrophy  of  the  left  ventricle  witli  a  lomi  systolic  murmur.  She  lias 
had  no  cardiac  disturbance  whatever.  She  has  lived  a  very  active  life,  lias 
}>een  unusually  vigorou.s,  lias  borne  eleven  children,  and  has  pas.sed  tlimiiL'li 
three  subsequent  attacks  of  rheumatism. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favoraMo. 
My  own  experience  has  led  mo,  Imwever,  to  place  this  lesion  almost  on  ii 
level,  particularly  in  women,  with  the  mitral  insufficiency.     It  is  fmiivl 


CHRONIC  VALVULAR   DISRASE. 


023 


very  often  in  persons  in  perfect  health,  who  have  had  neither  palpitatio!) 
ii(»r  sij,nus  of  iieurt-faihire,  and  who  have  lived  laborious  lives.  'J'iie  fi^'ures 
iMvi'ii,  too,  by  IJroadbent  indicate  that  the  date  of  death  in  mitral  stenosis 
is  comparatively  advanced.  These  patients,  too,  jkiss  thr(iii<,'h  repented 
pn  i,niaMcics  with  safety.  'I'here  are  of  course  those  too  couiinon  accidents, 
tlic  result  of  cerel)ral  embolism,  whieii  uru  luoro  liable  to  occur  in  thiit 
tliuii  ill  other  form.s. 

Hard  and  fast  lines  eannot  be  drawn  in  the  question  of  pro;;nosis  in 
valvular  disease.  Every  cM-^e  must  be  jud;,'ed  separately,  and  all  the  cir- 
( iiiiistaiK fS  earefidly  balaiiceil.  There  is  no  ([uestion  which  re(piires 
iricatcr  experience  and  more  mature  judgment,  and  oven  the  most  ex- 
perienced are  sometimes  at  fault. 

Tlie  following  brief  summary  of  the  conditions  which  justify  a  favora- 
iilc  |in)giiosis  embodies  the  large  and  varied  clinical  experience  of  Sir 
Aiidrcw  Clark:  (lood  general  health;  just  habits  of  living;  no  excep- 
tional liability  to  rhennuitio  or  catarrhal  atl'ections ;  origin  of  the  valvular 
It'sioii  independently  of  degeneration  ;  existence  of  the  valvular  lesion 
witliout  change  for  over  three  years;  sound  ventricles,  of  moderate  fre- 
(|iiciicy  and  general  regularity  of  action ;  sound  arteries,  with  a  iu»rmal 
ainoiiiit  of  blood  and  tension  in  the  smaller  vessels;  free  course  of  blood 
through  the  cervical  veins;  and,  lastly,  freedom  from  jjulmonary,  hepatic, 
and  renal  congestion. 

Treatment  of  Valvular  Lesions.— For  this  purpose  the  valvu- 
lar lesion  may  be  divided  into  the  period  of  })rogressive  development,  with 
establishment  and  maintenance  of  hypertrophy,  and  the  jieriod  of  dis- 
turiiod  compensation. 

(")  Stage  of  Compensation. — ^redicinal  treatment  at  this  period  is  not 
noctssary  and  is  often  hurtful.  A  very  common  error  is  to  administer 
cardiac  drugs,  such  as  digitalis,  on  the  discovery  of  a  nuirmur  or  of  hyjter- 
trophy.  If  the  lesion  has  been  fouiul  accidentally,  it  may  be  best  not  to 
ti'll  the  patient,  but  rather  an  intimate  friend.  Often  it  is  necessary, 
however,  U)  be  perfectly  frank  in  order  that  the  patient  may  take  certain 
jirevcntive  measures.  lie  should  lead  a  quiet,  regulated,  orderly  life,  free 
from  excitement  and  worry.  An  ordinary  wholesome  diet  should  be 
tiikcn,  tobac(;o  should  be  interdicted,  and  stimnlants  not  allowed.  Exer- 
I'ise  should  be  regulated  entirely  by  the  feelings  of  the  jmtient.  So  long 
as  110  cardiac  distress  or  palpitation  fcdlows,  moderate  exercise  will  prove 
very  benellcial.  The  skin  should  be  kept  active  by  a  daily  bath.  II<»t 
baths  shoidd  bo  avoided  and  the  Turkish  bath  should  bo  interdicted.  In 
the  case  (»f  full-blooded,  somewhat  corpulent  individuals  an  occasional 
-■iuliiu'  purge  should  bo  taken.  Patients  with  valvular  lesions  should  not 
go  into  very  high  altitudes.  The  act  of  coition  has  .serious  risks,  particu- 
Ifuly  in  aortic  insutKciency.  Knowing  that  the  causes  which  most  surely 
and  powerfully  disturb  the  compensation  are  overexertion,  mental  worry, 
uud  nuilmitrition,  the  physician  should  give  suitable  instructions  in  each 


If  i) 

i 


(«pS| 


ill 


i»: 


F  ■'  f. 


*  '11? 


rl 


024 


niSKASKS  OP  TIIK  CIHCUIiATOIlY  SYSTKM. 


IM 


W,  i 

1 

,  1 
(  -  /  ,    ,   , 

^ffll^ 

1  ■   i 

K 

H; 

cuHo.  As  it  is  111  ways  Ix^ttcr  to  Imvn  flic  co-oiicmtidii  of  an  iiitt'!lij:(tit 
puticDt,  lie  slioiild,  as  u  rule,  l)f  told  of  the  coiKlitioii,  hut  in  tliis  iiiatl(T 
the  physician  must  ho  guided  hy  circuinstunciw,  und  there  uro  cuscs  in 
which  reticence!  is  the  wiser  policy. 

{/))  Stage  of  Broken  Compensation. — The  hrcak  inay  he  hnmediafc  anil 
final,  as  when  sudden  death  results  from  acute  dilatation  or  from  hlockin" 
of  a  hrancli  of  the  c(»ronary  artery.  Ainon;;  the  lirst  indications  arc  slmrt- 
ness  of  hreath  on  exertion  or  attacks  of  nocturnal  <lyspn(ea.  These  are 
often  associated  with  impaired  nutrition,  particularly  with  ana>mia,  ami  a 
(!ourse  of  iron  or  clianj;e  of  air  may  suHice  to  relieve  the  symptoms. 

lrrej,'ularity  of  the  action  of  the  heart  cannot  always  Ih?  lerriied  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
It  has  greater  signilicanee  in  a<irtic  lesions.  S<'rious  failur(>  of  compensa- 
tion is  indicated  hy  signs  of  dilatation  of  the  heart,  the  gallop  rhyfliin,  or 
various  forms  of  arrhythmia,  with  or  without  the  existence'  of  (lni|isy. 
Under  these  circumstances  the  following  nu-asures  are  to  he  carried  out: 

(1)  /ifst, — Disturhed  compensation  nu«y  he  completely  restored  liy  nst 
of  the  hody.  Hoth  in  Montreal  and  in  IMiiladelfdiia  it  was  a  favorite  dciii- 
onstration  in  jiractical  therajteutics  t(»  show  the  inifueTice  of  c(»riipl(tc  rest 
and  ({uiet  on  the  cardiac  dilatatiem.  In  many  cases  with  (I'deuui  of  the 
ankles,  moderate  dilatation  of  the  heart,  and  irregidarity  of  the  pulse,  the 
rest  in  hed,  a  few  doses  of  the  contpound  tincture  of  cardamoms,  and  a 
Hiiline  purge  sutTice,  within  a  week  or  ten  days,  to  restore  the  compensa- 
tion. One  patient,  in  Ward  11  of  the  Montreal  (Jeiu'ral  Hospital,  with 
aortic  insiillicieiu'y  recovered  front  four  successive  attacks  of  failing  com- 
pensation hy  tlu'se  measures  ah)ne. 

(2)  The  relief  of  the  end)arrassed  ciri-ulation. 

(a)  liji  Venpsrrtion. — In  cases  of  dilatation,  from  whatever  eaiiso, 
whether  in  mitral  or  aortic  lesions  or  distention  of  the  right  veiitrii  le  in 
emphysema,  when  signs  of  venous  cngorgenu'iit  are  marked  and  when 
there  is  ortliopmea  with  cyanosis,  tlie  ahstractioTi  of  from  twenty  to  thirty 
ouiu'es  of  hlood  is  i!idicat«'d.  This  is  the  occasion  in.wliich  tinicly  veiic- 
section  may  save  tlu^  patient's  life.  It  is  a  condition  in  whi(  h  I  have  had 
most  satisfactory  results  from  venesection.  It  is  dime  much  hett(  r  caily 
than  late.  I  have  on  several  occasions  regretted  its  postponement,  par- 
ticularly in  instances  of  acute  dilatation  aiul  cyanosis  in  oonnection  with 
emphysema.* 

(/>)  ////  Ih'ph'tion  throu<ih  the  /Inm'h.—Thii^  is  particularly  valiialile 
when  droi)sy  is  present.  Of  the  various  purges  the  salines  are  to  he  pre- 
ferred, and  nuiy  he  given  by  Matthew  Hay's  method.  Half  an  Inmr  to 
an  hour  hefore  breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of 
Epsom  salts  may  be  given  in  a  concentrated  form.    This  usually  prndiu;cs 


♦  For  illustrative  cases  from  my  wards  see  paper  by  II.  A,  Lafleur,  Mediciil  News. 
.Inly.  1801.  * 


CFIIIONIC  VALVULAH  niSKASR. 


625 


from  thrco  to  five  li(|iiiil  ovacuutioiis.  'I'lie  (H)mp()uiiil  jaliip  jtowdcr  in 
li;i  (Iniclim  (loHOH,  or  I'liitcriiim,  nmy  bo  tjinployod  for  tho  Kami'  piirpoHu. 
Km  II  \vlie!i  tlu!  piiLsi!  is  very  fci'bio  tlu'sc^  liy<iriijifo;(iH(  catliarticH  aro  woll 
Imiiiii',  utitl  tl>(>y  (Icplt'tr  till'  portal  system  rapidly  and  t'lliciriitly. 

(i)    The   I  SI'  of  licnwUcs   ivhirh   slitnidate  the   Ji('((rf\s   Actidn. — Of 

thi'sc,  by  far  tli(^  most  important  is  di^Mtalis,  which  was  introduced  into 

iiriifticc   by   Withcrinj,'.      Tho   indication   for  its  \\m   is  dilatation;   tho 

contra-indicatioii  is  a  perfectly  balanci'd  compensatory  hypertrophy,  such 

us  uc  see  in  all  forms  of  valvular  disease,     iiroken  compensation,  no  mat- 

tir  what  the  valve  lesion  may  be,  is  the  signal  for  its  use.     it  acts  upon 

the  lieart,  slowing  and  at  the  same  time  increasing  tho  forco  of  tho  iiuisu- 

limi-i.     it  acta  on  tho  peripheral  arteries,  raising  their  tension,  so  that  u 

stcadv  and  e(pud)le  How  of  blood  is  nniintained  in  the  capillaries,  which, 

lifter  all,  is  tlu^  prime  aim  and  object  of  the  circulation.     'I'lie  beneticial 

(iTccts  are  best  seen  in  cases  of  mitral  disease  with  small,  irregular  |)ulse 

and  cardiac  dropsy.     Its  offeets  aro  not  loss  striking  in  the  dilatation  of 

the  left  ventricle,  in  tho  failing  compensation  of  aortic  insutlicii-ncy  or 

iif  aitcrio-sderosis.     On  theoretical  grounds  it  has  been  urged  that  its  use 

is  nut  so  advantageous  in  aortic  insutliciency,  since  it  prolongs  the  diastole 

and  leads  to  greater  distention.     Practically,  however,  this  nciod  not  bo 

considered,  and,  when  given  witli  caro,  digitalia  is  just  us  serviceable  in 

this  as  in  any  other  condition  associated  with  i)rogressive  dilatatioi'.     It 

nmy  be  given  as  the  tincture  or  the  infusion.     In  cases  of  cardiac  dropsy, 

fmiii  whatever  cause,  fifteen  minims  of  the  tincture  or   half  an  ounce  of 

the  infusion  may  bo  given  every  three  hours  for  two  days,  after  which  tho 

(liise  may  be  reduced.     Some  prefer  tho  tincture,  others  the  infusion ;  it 

is  a  matter  of  inditferenco  if  tho  drug  is  good.     Tho  urine  of  a  jiatient 

tiiking  digitalis  shoidd"  bo  carefully  estimated  each  day.     As  a  rule,  when 

its  iictioii  is  beneficial,  there  is  within  twenty-four  hours  an  increase  in 

the  amount ;  often  tlie  flow  is  very  great.     Under  its  uso  the  dyspnam  is 

relieved,  the  dropsy  gradually  disapj»ears,  the  pulse  becomes  firmer,  fuller 

ill  volume,  and  sometimes,  if  it  has  been  very  intermittent,  regular. 

Ill  etl'ects  sometimes  follow  digitalis.  There  is  \w  such  thing  as  a 
eiunulutive  action  of  the  drug  manifested  by  sudden  symptoms.  Toxic 
olleets  are  seen  in  tho  production  of  nausea  and  vomiting,  'i'lie  pulse  bo- 
eonies  irregular  and  simdl,  and  there  may  be  two  boats  (ff  the  heart  to  one 
of  tile  pulse,  which,  as  pointed  out  by  Hroadbent,  is  found  particularly  in 
cases  of  mitral  stenosis  when  they  aro  under  tho  inlluence  of  this  drug. 
The  mine  is  reduced  in  amount.  These  symptoms  subside  on  the  with- 
iliawiil  ot  tho  digitalis,  and  aro  rarely  serious.  There  are  patients  who 
tiike  iliu'italis  uninterruptedly  for  years,  and  feel  palpitation  and  distress  if 
the  ilnig  is  omitted.  In  mitral  disease,  oven  when  it  does  good  it  does  not 
always  steady  tho  pulse.  There  are  many  oases  in  which  the  irregularity 
is  not  affected  by  the  digitalis.  When  tho  compensation  has  been  re- 
estiihlishod  tho  drug  may  be  omitted.     When  there  is  dy8pnu3a  on  exer- 


Mm 


^i  ,:'il, 


t- 


',   K 


A. 


HI  F;  Sffi 

A       J 


II     i'/ 


026 


DISEASKS  OP  TflK  CIRCULATOHY  SYSTEM. 


tion  and  canliii'/  distress,  from  live  to  ton  iiiiiiinis  three  times  a  day  inav 
he  advaiitageonsly  given  for  itroloiigid  periods,  hut  the  elfeets  should  he 
carefully  watihed.  In  cirdiuc  dropsy  djiritalis  should  he  used  at  the  out- 
set with  a  fn^'  hand.  Small  doses  should  not  he  j^dven,  l)ut  from  the  tiivt 
half-ounce  doses  of  the  iidusioii  every  three  hours,  or  from  lifUiii  to 
twenty  minims  of  the  tincture.     There  are  no  sid)stitutes  for  digitalis. 

Of  oilier  remedies  stroplwritiius  a'one  is  of  service.  (Jiven  in  iloses 
of  from  live  to  t'ight  minims  of  the  tincture,  it  acts  like  digitalis.  It  cer- 
tainly will  sonu'tinu's  steady  the  intermittent  heart  of  mitral  valve  disease 
when  digitalis  fails  to  do  so,  hut  it  is  n(.t  to  he  compared  with  this  drug 
when  drop.sy  is  present.  C'onvallaria,  citrate  of  calfeine,  and  tiihinis  rrr- 
na/is  are  warndy  recomnu-nded  as  sul)stitutes  for  digitalis,  hut  tluir  inle- 
riority  is  so  maiufcst  that  their  use  is  rarely  indicated. 

There  are  two  valuahle  adjuncts  in  the  treatment  of  valvular  <liseas(  — 
iron  and  strychiua.  When  ana'mia  is  a  marked  feature  iron  should  he 
given  in  full  doses.  In  some  instances  of  failing  compensation  iron  is  tlie 
only  medicine  needed  lo  restor*'  the  halance.  Ar.seiuc  is  occasiouallv  an 
excellent  suhslitute,  and  one  or  other  of  them  should  he  administered  in 
all  instances  of  heart-irouhle  when  pallor  is  present.  Strycdinia  is  a  heart 
toiuc  of  very  great  value.  It  nuiy  he  giv.  n  in  cond)ination  with  the  digi- 
talis in  one  or  two  drop  doses  of  the  one  per  cent  solution. 

Treatment  of  Special  Symptoms.  (^0  f^ropst/.—Thv  increased 
arterial  tension  and  activity  of  the  cai)illary  circidatioii  under  the  iiitlii- 
ence  of  digitalis  liastens  the  interstitial  lymph  tlow  and  favors  res(ir|itioii 
of  the  fluid.  The  hydragogue  cathartics,  hy  ra])idly  depleting  the  liloiid. 
jiromote  the  ahsorptioii  of  the  fluid  from  the  lymph  spaces  jiiul  the  lyni|ili 
sacs.  These  two  measures  usiuilly  sutHce  to  rid  the  patient  oi  the  dinpsy. 
In  .some  cases,  however,  it  cannot  he  rclii'ved,  and  then  Soutlicy's  tiilies 
may  he  used  or  the  legs  punctured.  If  done  with  care,  after  a  thnroiiLdi 
washing  of  the  part.s,  and  if  anti.sej)tie  ])recaution8  are  taken,  scariticalinii 
is  a  very  .serviceaidi'  measure,  and  should  he  resorted  to  more  fre(|iieiitlv 
than  it  is.  Canton-llaniu'l  handages  may  he  applied  on  l!:e  cedeinatdus 
legs. 

(/>)  Ihixpiiwa. — The  patients  are  usually  uiud)le  to  lie  down.  \  coni- 
fortahle  hcd-rest  shoidd  therefore  he  ])rovidcd — if  po.ssihlc,  oiu'  with  lalcial 
projections,  so  that  in  sleeping  the  head  can  lie  supported  as  it  falls  over. 
The  shortne.^is  of  hreath  is  associated  with  dilatation,  chronic  hrnncliilis. 
or  liydrothorax.  The  chest  should  he  carefully  exanuncd  in  all  tlitse 
oases,  as  liydrothorax  of  one  siih'  or  (»f  both  is  a  common  cause  of  .-liort- 
ness  of  hreath.  There  are  eiuses  of  mitral  regurgitation  with  recnirin^' 
hydrothorax  as  the  sole  dropsical  symptom,  which  is  relieved,  week  Ia' 
week  or  month  hy  month,  hy  tapping.  For  the  nocturnal  dyspiuea.  |'iii"- 
ticularly  when  (U)mhiiu'(l  with  restlessness,  morphia  is  invaluahlc  and  niiiv 
be  given  without  hesitation.  The  value  of  the  calming  influence  of  (ipiinii 
ill  all  ecmditions  of  cardiac  insutliciency  is  not  enough  rocogiiizeii.    There 


•^•^^V'jr 


CHRONIC  VALVULAR  DISKASE. 


G27 


lire  instiinces  of  canliiU!  ilvspiuwi  utiassocititt'd  with  dropHV,  jKirticiilarly  in 
iiii'.riil-valvc  disease,  in  which  iiitrojrlyi  Tin  is  of  jjreat  servii'u,  if  <,'iveii  in 
till' niie  |K'r  cent  sohitioii  in  increasing,' (h>scs.  It  is  especially  serviceable 
ill  the  cases  in  which  tlie  pnlse  tension  is  iii^rli. 

(r)  Ptt/pi/(ifi»n  mid  ('(inline  Hislress. —  In  instances  of  ^n-eat  hypcr- 
tn»piiy  and  in  the  throl»hin<;  which  is  so  distressiiij;  in  some  cases  (»f 
iiditic  iiisuHiciencv,  aconite  is  of  siM'vice  in  doses  of  t'nim  one  to  three 
iiiiiiiiiis  every  two  or  thre(!  hours.  An  ice-l»a<;  ovi-r  thi-  heart  or  Ijciter's 
coil  is  also  of  service  in  allayiiij;  tlu^  rapid  action  and  the  throhhiiii^.  For 
the  pains,  whi(di  are  often  so  marked  in  a(»rtic  lesions,  iodide  of  poUis,-<iuin 
in  ten  fxrain  doses,  threi'  times  a  day.  or  the  nitro.Lrlycerin  nuiy  Ihj  tried. 
Small  blisters  are  sometimes  advantiijii'ous.  It  must  be  remembered  that 
III!  iiiiport4int  cause  of  palpitation  and  canliac  distress  is  tlatulent  disten- 
lidii  of  the  colon.  a;;uinst  which  suitable  in  •..-'ures  n\ust  i)e  directed. 

(d)  hiisfrir  Siiniptuins. — The  t-ases  of  cardiac  iiisutlicieiiey  which  do 
Icidly  and  fail  to  respond  todi^ntalis  are  most  often  tho.se  in  which  nausea 
iiiiil  vomiting  are  prominent  features.  Tlu'  liver  is  often  jjreatly  eidarj^ed 
ill  these  ca.si's;  there  is  more  or  less  stasis  in  the  iu'patic  ves,sels,  and  iait 
little  can  lie  expected  of  drufis  until  the  venous  (;u;ior;,'emeiit  is  relieved. 
If  tile  v. >mitin;;  persists,  it  is  best  to  st<)p  the  food  and  ^mv*-  small  bits  of 
ii'c,  small  quantities  of  milk  and  lime  water,  and  clfervescinj^  drinks,  such 
us  Apollinaris  water  and  ehampa;;ne.  ('reosot(\  hydrocyanit^  acid,  and  i)ic 
i>\;il:ite  of  cerium  are  sometimes  useful;  but,  as  a  rule,  the  (tondition  is 
ohstiiiate  and  always  serious. 

(p)  Ciiiifih  ami  /{li'i/iop/f/sis. — The  fonncr  is  almost  a  necessary  con- 
I'Diuitaiit  of  cardiac  insulli<aency,  owin;;  to  ent(or<;enu'nt  of  the  vessels 
iiiid  more  or  le.ss  broi. '''litis.  It  is  allayed  by  measures  directed  rather  to 
tlif  liearl  than  to  the  luiiLls.  Ila-mopfysis  in  chronic  valvular  disease  is 
sdiiietimes  a  salutary  symptom.  .\n  army  snrifon,  who  was  invaliiled 
(luriiiLT  Mie  late  civil  war  on  account  of  ha-nioptysis,  supposed  to  be  due 
til  tiilH'rculosis,  has  since  that  time  had,  in  association  with  mitral  insutli- 
lii'ii-'V  aii<l  enlarixed  heart,  many  attai'ks  of  ha-iiioptysis.  He  assures  me 
that  his  condition  is  invariably  better  after  the  attack.  It  is  rarely  fatal, 
except  in  some  eased  of  acute  dilatiition,  and  sold(»m  calls  for  special  treat- 
niciit. 

(f)  Sfrrplr.^sii''ss-. — One  of  the  nmst  distressinff  features  of  valviilar 
Icsiutis,  even  in  the  statfe  of  conipeiisatioii,  is  disturbed  sleep.  I'aticiits 
limy  Wiike  suddenly  with  throbbinn-  of  the  heart,  often  in  an  attack  of 
iiii,'litmare.  Snl),se((uentiy,  when  the  conipcnsiition  has  failed,  it  is  also  a 
worryini,'  symptom.  The  sleep  is  broken,  restless,  and  frci(uently  dis- 
bv  friLrhtful  dreams.     Sometimes  a  dose  of  thi' sni 


t!irl(i'< 


of  the  spirit.s  of  chloro 


fiiriii  cr  of  ether,  ^'i  h  half  a  dra.-hni  of  spirit.s  of  camphor,  jriveii  in  a 
little  hot  whisky,  will  j^ivi'  u  (piiet  ni;fht.  The  compound  spirits  of  ether, 
n>>lTmairs  anodyne,  thouj^h  very  unpleasant  to  lake,  is  frerpiently  ii  {,'reat 
1)0(111  ill  the  .'u termed ia to  period  when  eompensation  has  partially  failed 


pi 


'? 


(HP 'I 


* 

!     J 


>l     ,  'I 

■'M 


'  .    ' r    mil 


■jil  ;, 


1  .1'^ 


!  •  ■:  "■  ■'.  i<i> 


628 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


anil  the  ]iiiti(Mits  suiTcr  fntrn  restlo:^*^  and  slccploss  ni<ihts.  Puruldcliydc. 
and  jiuiylciic  hydnite  an;  somotinics  siMTicciihk'.  rrcthuii,  sulplioniil, 
and  chloraliiinido  arc  rarely  cHicaciou.s,  and  it  is  l)»^st,  after  a  few  trials, 
particularly  if  the  paraldfliyde  does  not  answer,  to  jrive  morphia.  It  iiuiv 
bo  j?iveii  ill  coiuljination  with  atropine. 

(//)  Ii't'/iii/  Si/iii/i/(nii.s. — With  ruptnred  eompcnisation  and  loweriiii:  of 
tlie  tension  in  the  aorta,  the  nrinary  seeretion  is  jjreatly  diminished,  ami 
the  anioiiiit  may  sink  to  Hvo  or  six  ounces  in  the  day.  Dijxitalis  .md 
Btrcjilianthus,  when  cllicicnt,  usiudly  increase  the  flow.  A  brisk  puriri' 
may  lie  followed  by  aujuMiientetl  secretion.  The  cond)inatioii  in  pill  I'lirin 
of  dififitali.s,  scpiill,  and  tlu'  hlack  oxide  of  mercury,  will  soinetimes  prove 
elToetive  when  the  infusion  or  tincture  of  diLritalis  alone  lias  failcil.  Culo- 
inel  acts  well  in  some  cases,  given  in  grs.  iij  every  six  hours  for  three  (ir 
four  days. 

The  i/irf  in  chronic  valve  diseases  is  often  very  diflicult  to  rei,nil;iti'. 
With  the  dilatation  and  venous  enfrorijement  conu'  nausea  and  often  ;i 
great  distaste  for  food.  The  amount  of  licpiid  should  he  restricted,  itiid 
nulk,  beef-juice,  or  egg  albumen  given  every  three  liours.  \\  lieu  the 
serious  syinptoins  have  passed,  eggs,  scraped  meat,  tish,  ;ind  fowl  may  hi' 
allowed.  Starchy  foods,  and  all  articles  likely  to  cause  llatulency.  should 
be  forbidden.     Stimulants  are  nsuallv  necessarv,  either  wliiskv  or  braiuiv. 


U  . 


III.  HYPERTROPHY  AND  DILATATION. 

Hypertrophy  is  an  enlargement  of  the  heart  due  to  an  increased  thick- 
ness, t(»tal  or  partiid,  iii  the  muscular  walls.  Dilatation  is  iin  increase  in 
fiizt'  of  one  or  nioi'f.'  of  the  chamljcrs  with  or  without  tliickeiiiug  of  the 
walls.  The  c( :;iditions  usually  coexist,  and  could  be  more  correct ly  dc- 
Bcrilied  together  under  the  term  enlargement  of  the  lieart.  Simple  hyper- 
trophy, in  which  the  cavities  remain  of  a  normal  size  and  the  walls  arc 
increuscil,  occurs,  but  simple  dilatation,  in  which  the  cavities  are  iiierea.-^cd 
and  the  walls  remain  of  a  normal  diameter,  probaltly  does  not,  as  it  !.>< 
always  associated  with  tliiiining  or  with  thickeiung  of  the  coats.  (  oni- 
inonly  wc  have  the  forms  of  simple  hypcrtropliy,  hypertrojihy  with  liilata- 
tion,  and  dilatation  with  thinning  of  the  coats. 


lIvi'KifTiim'iiv  OF  Tin;  lIi:\i{T. 

There  are  two  forms — the  siniiile  hypertrophy,  in  wlii<'h  tlie  cavity  or 
cavities  arc  of  normal  size;  and  hypertrophy  with  dilatation  (eceeiitric 
liyjicrtrophy),  in  which  the  cavities  arc  enlarged  and  the  walls  iriirea-*(d 
in  thickness.  The  condition  formerly  spoken  of  as  eoneentric  iivpcr- 
tropliy,  in  which  tlien^  is  diminution  in  the  size  of  the  cavity  with  lliick- 
oning  of  the  walls,  is,  as  u  rule,  u  post-mortem  change. 


IIYPHRTIIOPHY   AND   DILATATION. 


099 


Tlio  onliirijomont  inuy  affont  the  entire  orpin,  ot»o  sido,  or  only  ono 
ctKiinbor.     \iitiirally,  us  the  left  vi^ntridc  docs  tlu;  cliiof  work  in  forcing 
tlic  blood  through  the  systemic  arteries,  the  change  is  most  frequently  • 
fdiiiid  in  it. 

Etiology.  —  IIypcrtro])liy  of  the  heart  follows  tlic  law  governing 
muscles,  that  within  certain  limits,  if  the  nutrition  is  l<cjii  up,  increased 
wnik  is  followed  by  increased  size — i.  e.,  hypertrophy.  Hypertrophy  of 
the  left  ventricle  alone,  or  with  general  eidargement  of  the  heart,  ia 
biMUiriit  about  by — 

(.'oiitlitions  atfcM'ting  the  heart  itself:  (1)  Disease  of  the  aortic  valve ; 
(:?)  mitral  insufliciency  ;  (;5)  general  pericardial  adhesions;  (4)  sclerotic 
niyociirditis;  (5)  disturbed  innervation,  with  overaction,  as  in  exo])hthal- 
inic  goitre,  in  long-continued  nervous  palpitation,  ajid  as  a  result  of  the 
iiclinii  of  certiiin  articles,  such  as  tea,  alcohol,  and  tobacco,  in  all  of  these 
conditions  the  work  of  the  heart  is  increased.  In  the  case  of  the  "alvo 
Icsiniis  the  increa.se  is  due  to  the  increa.se<l  intraventricular  pressu  e;  in 
the  case  of  the  adherent  pericardium  aiid  myocarditis,  to  direct  interference 
with  the  symmetrical  and  orderly  contraction  of  the  chamlHTS. 

Ciinditions  acting  upon  the  blood-vessels  :  (1)  (Jeneral  arterio-sclerosis, 
witli  or  without  reiuil  disease;  {'i)  all  states  of  increased  arterial  tetision 
iiidui  I'll  by  the  contra<!tion  of  the  smaller  arteries  under  the  influence  of 
certain  toxic  substances,  whi(di  act,  as  Hright  suggested,  by  aifecting  "the 
iiiimitc  capillary  circulation,  render  greater  action  m-cessary  to  send  the 
lilmiil  through  the  distant  subdivisions  of  the  vascular  system  " ;  (15)  pro- 
li)iii:c(i  muscular  exertion,  which  enormously  increases  the  bhuxl-pressure 
ill  the  arteries;  (4)  narrowing  of  the  aorta,  as  in  the  congenital  stenoses. 
Hypertrophy  of  the  right  ventricle  is  met  with  under  the  following 

CMllllitioilS  — 

(1)  Lesions  of  the  mitral  valve,  either  incompetence  or  stenosis,  which 
act  liy  increasing  the  resistance  in  the  pulmonary  vessels,  {'i)  Pulmonary 
Ifsiuiis,  obliteration  of  any  niiiiil)cr  of  blood-vessels  within  the  lungs,  such 
as  occurs  in  emphysi  tna  or  cirrhosis,  is  followed  by  hypertro])hy  of  the 
riirlit  vein  ride.  {'.))  Valvular  lesions  on  the  right  si(h'  occasionally  cause 
liyiicrtiopliv  ill  the  adult,  iint  infrccpieiitly  in  the  fcctiis.  (4)  (  lironie 
viilvulur  disea.se  of  the  left  h(>art  and  pericardial  adhesions  are  ,s<ioner  "r 
later  associated  with  hypertrophy  of  the  right  ventriide. 

In  the  auricles  sim|ile  hypcrtroidiy  is  never  seen:  it  is  always  dilata- 
tion uiih  liyi)ertroi)hy.  In  the  left  auricle  the  condition  develops  in  lesions 
lit  the  mitral  orilice,  jiarticularly  stenosis.  The  rigiit  auricle  hypertniphies 
when  tlicre  \a  greatly  increa,se  1  blood -pressure  in  the  lesser  circulation, 
wiietlicr  due  to  mitral  stenow-  r  j)ulmonary  lesions.  Narrowing  of  the 
tncii-ipiil  (ii'ilii'c  i-  a  less  fre(|uerit  cause. 

Morbid  Anatomy. — 'I'he  heart  of  an  a\erage-sized  man  weiirhs 
lihoiit  nine  ounces  (-.iSd  grammes) ;  that  of  a  w<mmn,  about  eight  ounces 
{'ibo  jrnunmes).     In  cases  of  general  hyj)c  \   the  heart  may  weigh 


■f 


■m 


'it- 


fir 


r.30 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


from  sixteen  to  twenty  ounces.  Weij;lits  above  twenty-five  ounces  arc  nin.. 
So  far  a.s  1  Icnow,  the  heaviest  lieart  on  record  is  one  descrilted  by  Beverly 
Koliinson,  wcixhiii^'  fifty-tiircc  ounces.  Dulles  Inis  reported  oiu-  wt'i;.'-liiiiir 
forty-eiifht  nunces.  'I'iie  incasurciiicnt  of  the  thickness  of  tiic  wall>  i^ 
next  to  wciifiiin;;,  the  best  means  of  d»'terminiiijf  tiie  hyiiertropliv.  In 
cxtreiiu!  dilatation  the  walls,  tliouj,'ii  actually  thickened,  may  look  tlun. 
When  ;•///'(/•  nxirfis  is  present,  the  cavity  nuiy  be  small  and  the  wall-  imiy 
appear  jfreatly  thickened.  The  measurements  should  not  be  made  iiniil 
the  heart  has  been  .soaked  in  water  and  th(»rou;,ddy  relaxed.  In  ilie  lilt 
ventricle  a  thickiu'ss  of  ten  lines,  or  from  twenty  to  twenty-five  millimetres, 
indicates  hypertrophy.  The  rit'lit  ventricle  is  thinner  than  the  left,  ami 
has  an  avera^'e  diameter  of  from  four  to  seven  millimetres.  Jn  hyipcr- 
troj)hy  it  may  measure  from  thirteen  to  twenty  millimetres.  The  left 
auricle  has  a  normal  thickness  of  about  three  ndllinu'trcs,  which  ma\  In- 
double(|  in  hypertrojihy.  The  wall  of  tlu'  ri;,dit  auricle  is  thinner  than 
that  of  the  left,  rarely  e.\ojedinj?  two  millimetres  in  diameter,  '{"lie  ajipeii- 
dices  of  the  jiiiricles  often  present  marked  increase  in  thickness  ami  th" 
musculi  peclinati  arc  <,'reatly  developed. 

'I'he  shape  of  the  heart  is  altered  in  hypertrophy;  with  ftreat  enlari:e- 
ment  of  the  ventricles,  the  apex  is  broa<leiu'd,  and  the  conical  .shape  i>  l(i>i. 
In  the  enormous  eidarjrcnicnt  of  aorti(!  insulllciency  this  rotumlity  nl'  the 
apex  is  very  marked.  When  the  riirht  ventricle  is  chiefly  alTectcd  it  (hiii- 
pics  the  larjfcst  share  of  the  apex.  In  mitral  stenosis  the  contrast  i.>  very 
8trikiu<4'  between  the  lar;,fe,  broad  ri^ht  ventricle,  reaching  to  the  apcv, 
and  the  small  left  chamber. 

The  hy|)crtrophicd  muscle  has  a  deep  re(l  color,  is  firm,  and  is  cut  with 
increasin/^f  rcsistanci-.  The  right  ventri(ilc,  as  Hokitaiisky  noted,  may  lia\i' 
a  peculiar  hard,  leathery  consistence.  In  simple  hypertrophy  of  the  left 
ventricle  the  papillary  muscles  and  the  (iolumna'  cariu'a'  may  be  enhni'nl. 
but  the  fornu'r  are  often  much  flattened  in  dilated  hypertrophy.  Tin; 
niusctdar  trabecida;  are  more  developed,  as  a  ride,  in  the  right  veiitriilc 
than  in  the  K'ft. 

The  increase  in  siz(>  of  (he  heart  is  probably  due  to  a  definite  iuuih  ricil 
increa.se,  resulting  from  di'vclopment  of  new  fibres. 

Symptoms.  —  Hypertrophy  is  a  conservative  process,  secondary  tn 
some  valvular  or  arterial  lesion,  and  is  not  necessarily  accom|iaiiie(l  hy 
pymjttoms.  So  admiral)le  is  the  adjusting  power  (>f  the  heart  tlia',.  t'i'i' 
e.xample,  an  advancing  stenosis  of  aortic  or  mitral  ordice  may  for  yiar- 1"' 
perfectly  ciiualizcd  by  a  progressive  hypertrophy,  and  the  subjeel  ni  tin' 
ulfection  be  happily  unconscious  of  the  existence  of  hearl-tioid>le.  Ilv|»'r- 
trophy  is  in  almost  all  cases  an  uniinxed  good;  the  .symptoms  whiih  aii-f 
are  usually  to  be  attributed  to  its  failure,  or,  aa  we  say,  to  disturbance  ef 
compensation. 

Among  the  nu)st  common  symptoms  are  unjilcasaid  feelings  nheiit  tlif 
lieart — a  sense  of  fulness  and  discomfort,  rarely  amounting  to  pain.     I  '"> 


i 


IIYPKIITIIOIMIV   AND   DILATATION. 


681 


ni;iv  1)0  very  iiotiecuble  when  the  patient  is  recumbent  on  the  left  side. 
Artiiiil  jKiiii  is  rare,  except  in  the  irritable  heart  from  tobacco  or  in  neiir- 
iistliciiics.  I'ulpitation  may  not  occur,  nor  do  patients  always  have  sen- 
siii'iiis  from  tlw  violent  .shocks  of  a  {ifreatly  hypertropliied  orj^an.  There 
ari'  instances  in  which  very  unea.sy  feelint^s  arise  from  a  moderately  exa.ii- 
<.f('niti'd  })ulsation.  The  general  condition  has  much  to  do  with  this.  In 
licultli  we  are  not  conscious  of  the  heart's  pulsation-s  but  one  of  the  first 
imliciitions  of  exhaustion  from  exces,sea  or  overstndy  is  the  consciousiwss 
lit'  the  heart's  action,  not  neces.sarily  witli  ]>alpitation.  ]lea<laches,  fhish- 
iiiirs  of  the  face,  noises  in  the  ears,  and  Hashes  of  light  may  be  j)resent. 

Certain  untoward  etfects  of  long-continued  hypertrophy  of  the  left 
vciitriile  must  be  mejitioned,  chief  among  which  is  the  production  of 
;iil.  rio-sclerosis.  Particularly  is  this  the  case  when  the  hypertrophy  re- 
siihs  from  increased  peripheral  resistance.  'I'hc  heightened  Itlood -pressure 
(expressed  by  the  word  strain)  in  Lhe  arteries  gradually  induces  an  emlar- 
teritis  and  a  stilT,  inelastic  state  of  tho.se  ves.sels  most  exposed  to  it — viz., 
ihi  anrtii  and  its  primary  divisions.  In  overcoming  the  peripheral  ob- 
stnirtinn  the  hypertrophy  "ruins  the  arteries  as  a  se(|uential  result" 
(K  >thergill).  P-olonged  muscular  exertion  also  acts  injuriously  in  this 
way. 

Another  danger  is  rupture  of  tlui  blood-ves.sels,  particularly  those  of  the 
Imiiii.  In  general  arterial  degeneration  associated  with  contracted  kidneys 
iiiiil  hypertropliied  left  heart  apoplexy  is  common.  Indeed,  in  the  majority 
(if  cases  of  cerebral  Inetuorrhage  there  is  sclerosis  of  the  smaller  vessels, 
often  with  the  development  of  miliary  aneurisnia,  and  the  rupture  nuiy  be 
iiuisi'ij  hy  the  forcible  action  of  the  heart. 

Physical  Signs. —  hisprction  nuiy  show  bulging  of  the  piwconlia,  )>ro- 
ildciii;,'  in  eliiidreii  nuirked  asymmetry  of  tlu'  chest.  It  nuiy  occur  with- 
out pericardial  a<lhesioiis,  which  Schroetter  thinks  are  invariably  associated 
witii  this  eonditi(tn.  The  intercostal  spaces  are  wiileiied,  and  the  area  of 
visilile  inij'ulse  is  much  increased.  On  pnJ/t/tfi<ni  the  impulse  is  forcilile 
aiiti  liciiving,  and  with  each  .systole  the  hand  or  the  ear  applied  over  the 
lii-ait  MKiv  be  visil)ly  raised.  A  slow,  heaving  impulse  is  one  of  tlu;  best 
si'^'iis  lit"  simph^  hypertrophy.  With  'arge  dilated  hypertrophy  the  forcible 
inipiiKe  is  often  more  sudden  aiul  abrupt.  A  second,  weaker  impulse  can 
•^iiiiiilimes  Ite  felt,  due  perhaps  to  a  rebound  from  the  aortic  valves  ((iowers). 
I'll'  heat  may  he  felt,  in  the  sixtli,  seventli,  or  eiglith  interspace  from  one 
ti>  .  ,,.r  inches  outside  the  nipple.  This  downward  dislocation  of  thti 
•'P'''*  '>  iiM  important  sign  in  hypertrophy  of  the  left  ventricle.  In  moder- 
'•'.<'  fT''  'es,  such  as  are  seen  in  chronic  liright's  disease,  the  impulse  Tuay  ho 
'•I  'li    MVlh  interspa<'e  in  the  nipple  line,  f)r  a  little  outside  of  it. 

l''i'r,issi(ni  reveals  increased  duliu's.s,  which  in  the  ])arasternal  line 
may  Isgin  at  the  third  rib  or  in  the  second  interspace,  and  transversely 
't>:  ■■  \t(M\d  from  half  an  inch  to  two  inches  beyond  the  nipple  line  and 
hi;  «'iu.il  distance  beyond  the  middle  line  of  the  sternum.     The  dull  area 


■JMf  "'"ITi'''*'^" 

''1\ 

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G32 


DISKASKS  OF  THE  CIIICULATOIIY  SYSTEM. 


•"  mm- 


'•  ;<1 


ft*^  pip 


is  inoro  ovoid  tlmn  in  lumltli.  When  cavefully  (U'liinitcd  the  colossal 
hyportropliy  of  aortic  valve  disease  may  give  an  area  of  dulness  trom  seven 
to  ei<^ht  inches  in  transverse  extent,  in  moderate  j^rades  a  ti'aiis\eise 
dulness  of  four  inches  is  not  uncommon. 

On  auscuUatioa  the  sounds,  when  the  valves  are  healthy,  mav  |pivseiit 
no  special  chanjifes,  but  the  first  scmnd  is  often  prolonjicd  and  dull. 
When  there  it!  dilatation  as  well,  it  may  he  very  clear  and  sharp.  Redu- 
plication is  common  in  the  hypertrophy  of  renal  disease.  A  pccidiar  clink 
— the  liiitcniriif  iiti'htUiquc  of  Bouillaud — may  be  heard  just  to  the  ri;.'ht 
of  the  apex  beat.  The  .second  sound  is  clear  and  loud,  sometimes  rinu'in;; 
in  character  or  rciluplicated.  With  valvular  lesions,  the  sounds,  of  course, 
are  much  altered,  and  are  replaced  or  accompanied  by  nuirnuirs. 

In  simple  hypertrophy  not  dejjendent  on  valvular  lesions,  the  pulse 
is  usually  regular,  full,  strong,  and  of  high  tension.  It  may  he  in- 
crea.sed  in  rapi<lity,  but  is  often  nornud.  \\\  e(ventri(!  hypertrophy  the 
pulsi'  is  full,  but  softer,  and  usually  more  rapid.  One  of  the  earliest  signs 
of  failure  and  dilatation  is  irregularity  and  intermittence  of  the  pulse. 

lIypertroi»hy  of  tlut  riijlil  I'enlric/e  in  the  adult  very  rarely  follows 
valvular  disease  on  the  right  side,  but  results  from  increased  ri'sislunce  in 
the  pulmonary  circulation,  as  in  cirrhosis  of  the  lung  and  emphysema,  or 
in  stenosis  of  the  mitral  orifice.  With  i)erfe('t  (compensation,  wiiicli  fully 
nuiintains  thi;  eipiilibrium  of  the  circulation,  there  are  no  syni|)loins. 
Extra  exertion,  as  the  ascent  of  stairs  or  running,  may  cause  shortness  vi 
breath,  but  in  many  ways  hypertrophy  of  tiic  right  ventricle  is  the  in.„i, 
(Miduring  and  salutary  form  in  the  whole  (lycle  of  cardiac  alTections.  For 
long  periods  of  years  the  elTects  of  mitral  .stenosis  may  be  counterbalanced, 
ami  only  sudden  di'atli  by  accident  or  an  aiuite  disease  reveal  the  cxisieiice 
of  an  unsuspected  lesion.  In  the  hypertrophy  .secondary  ti»  emphysema 
or  cirrhosis  of  the  lung.s,  there  may  be  sensations  of  distress  in  the  cardiac 
region,  with  c(Migh  and  shortness  of  breath  ;  but  as  long  as  the  dilalatimi 
is  moderate  tlu;  symptoms  are  not  marked.  With  great  dilatation  and 
tricuspid  leakage  come  venous  engorgement,  uxleniii,  and  pulmonary 
troubles.  'I'lu!  iiuireased  pressure  in  the  lesser  circulation  leads  to  sclerosis 
of  the  pulmonary  arteries  and  the  constant  engorgement  of  the  capillaries 
leails  ultimately  to  a  deposition  of  pigment  and  increase  in  the  liliroiis 
elements  in  the  lung — the  brown  induration.  Extreme  |)ulmoMary  con- 
gestion and  a})oplexy  are  more  often  associated  with  dilatation.  Ihemop- 
tysis  may  result  from  rupture  of  vessels  during  sudden  exertion. 

I'/n/sinil  Si(/ns.  —  Mulging  of  the  lower  part  of  the  sternum  and  left 
cartilages  occurs.  The  apex  beat  is  forced  to  the  lefi,  but  is  not  so  often 
displaced  downward.  The  most  marked  impulse  nuiy  be  in  the  iin^rlf 
between  the  ensiform  cartilage  and  the  seventh  rib  or  beneath  the  carti- 
lages of  the  sixth  and  seventli  ribs.  The  pulsation  is  rather  dilTiiM'. 
not  punctuate,  particularly  if  there  it-  much  dilat;dion.  In  thin  ualKd 
chests  then-  may  be  pulsation  in  ihe  third  and  fourth  right  iulerspaies. 


HYPKIITIIOPIIY   AND  DILATATION. 


(533 


Till'  oanliiir  diiliu'ss  is  inorcasod  transvorscly  ami  toward  tlio  ri^ht;  it 
luav  oxUmuI  an  inch  or  m(»re  hoyond  the  bonh-r  of  this  stcrmmi.  On 
aii~i  iillatioii  tht"  lirst  soiii\d  at  the  lower  piirt  of  tlu>  stcnmin  is  louder  and 
fuller  than  normal,  lut  the  dill'i'renct^s  are  not  very  marked  unless  there 
is  iMiicli  dilatation,  wIkmi  the  sound  is  clearer  and  sharper.  Accenluation 
iind  redu|)lication  of  the  second  sound  are  heard  in  the  pulmonary  artery 
(III  iiccount  of  the  increased  tension.  Thi'  pulse  at  the  wrist  is  usually  small. 
I'liUiitiou  occurs  in  the  ju;;ulars  when  there  is  tricuspid  incompetruce. 

Hypertrophy  of  the  (iKrir/rs  always  occurs  with  dilatation.  It  is  moat 
(•(iiiuiiou  in  the  left  chand)er,  which  hypertrophies  in  mitral  stenosis  and 
iiicdiiipetciu-y  and  naturally  assists  in  restorin<(  the  ])alance  of  the  cinm- 
lulidU.  'I'here  are  no  distinctive'  j)hysical  sij^ns,  ami  we  usually  can  infer 
its  presence  only  liy  the  existence  of  mitral  stciu)sis  aiul  a  presystolic  mur- 
mur. Increaseil  dulness  tnay  he  deteruiiiu'd  to  the  left  of  the  sternum, 
and  there  may  he  a  presystolic  wave  in  the  soeoiul  left  interspace. 

Hypertrophy  and  dilatation  of  the  rijijht  auricle  are  met  with  (associ- 
ated with  a  similar  condition  in  the  rif^ht  ventricle  an<l  incompetency 
(if  the  tricuspid)  in  emi)hyscma,  cirrhosi.s  of  the  lun<^,  chronic  bronchitis, 
atiil  mitral  disease.  In  comparison  with  the  left  auricle  the  greater  de- 
volopnieut  and  hypertrophy  of  the  appendix  and  its  musculi  pectinati  is 
very  striking;.  The  latter  nuiy  l)e  distributed  over  the  anterior  wall  of 
the  sinus  to  a  fireater  extent  tlian  in  health.  Thert^  are  iiicn'ased  (luliu\s8 
in  the  third  and  fourth  inters|»aces,  j)ulsation  sometimes  presystolic  in 
rliylluu,  sijrns  of  venous  enf;or<;enu'nt,  jui^ular  pulsation,  and  other  evi- 
iliMices  of  dilatation  of  the  ri,u;ht  heart. 

Diagnosis.  —  Amonji  coiulitions  to  be  distinpiished  are: 
(1)  Neurotic  paljjitation,  from  whatever  cause,  even  when  very  forci- 
ble, hius  not  the  heavin<(  impulse  of  genuine  hypertrophy.  Kidargeinent 
(if  the  (ir;;an  may,  however,  follow  prolonged  overaction,  as  in  tlu^  smoker's 
lu'ait.  tlie  irrit:d)le  heart  of  neurasthenics,  aiul  ii\  exophthalmic  goitre,  but 
it  is  usiudly  slight. 

(i)  The  increased  area  of  dulness  may  be  due  to  a  variety  of  causes, 
some  of  which  may  clo.sely  sinnilate  hypertrophy,  such  as  pericardial  effu- 
sion, aneurism,  mediastiiuti  growths,  or  displaceiiu'ut  of  the  heart  from 
})r('s<iire,  or  the  existence  of  malfornnition  of  the  chest.  Witli  the  exer- 
I'ise  (if  ordinary  care,  however,  the  diagnosis  can  usually  be  made.  'I'here 
iiic  tun  opposite  conditions  which  fre({uently  give  trouble.  With  the  left 
luiii;  contracted  from  pleurisy,  phthisis,  or  cirrhosis,  a  large  surface  of  the 
heart  is  exposed  ;  the  pulsation  may  be  extcmsive  and  forcible,  and  nuiy  at 
tii>t  .-iu'lit  resemble  hypertrophy.  In  this  conditioi\  tbei'c  is  dislocaiioti 
iipwanl  and  to  the  left.  The  cxistcn(;e  of  pulmonary  or  pleuritic  disease 
and  the  (ixatio-.i  of  the  lung  on  deep  inspiration  will  sullict-  to  pn^vent 
iiii:<takc^.  .\  le.ss  extensive  exposure  of  the  heart  may  occur  without  any 
disoasi'  in  very  narrow-chested  pi^r.sons  with  ill-developed  lungs;  here, 
though  the  urea  of  iluliiesa  may  be  much  increased,  the  iu)rnud  position 


'*  ; 


■    •  h    - 


v.: 


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1 

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If 


084 


PISEASRS  OP  THE  CIUCULATORY  SYSTEM. 


of  tho  appx,  tlio  absence  of  forrible,  heaving  impulse,  and  of  any  oljvioii.s 
cause  of  hypertrophy  will  afford  satisfactory  criteria  for  a  <lia<jnosis.  Tlir 
reverse  condition  exists  in  some  cases  in  which  eniphysenia  masks  mmlir- 
ato  cardiac  hypertrophy.  'I'he  ana  of  didncss  may  he  normal,  or  even 
diiniiushed,  and  the  pulse  and  charai'tor  of  tliti  sounds  will  hi'lp  in  the 
diairnosis;  hut  it  is  siunctinics  a  dillicnlt  matter. 

Prognosis.  —  'I'lie  course  of  any  case  of  cardiac  hypi-rtrophy  Piay  ho 
divided  into  three  stajjcs  : 

{(t)  The  period  of  development,  which  varies  with  the  nature  of  tlio 
primary  lesion.  For  example,  in  rupture  of  an  aortic  valve,  during'  a  stnl- 
tlen  exertion,  it  may  re(piire  months  before  the  hypertrophy  be(;oni(s  fully 
developed  ;  or,  indeed,  it  may  never  do  so,  and  death  may  follow  from  an 
uncompensated  dilatation.  On  the  other  hand,  in  sclerotic  alTectioiis  t>f 
the  valves,  with  stenosis  or  i?icorni)etency,  the  hy])ertro])hy  develops  stcji 
by  step  with  the  lesion,  and  may  continue  to  counterbalance  the  jirogress- 
ive  and  increasing  impairment  (»f  the  valve. 

{/))  The  period  of  full  comptMisation — the  latent  stage — din-ing  wliich 
the  heart's  vigor  meets  the  retpiirements  of  the  circulation.  This  pcridd 
may  last  an  indelinite  time,  and  a  patient  may  never  be  made  aware  hy 
any  symptoms  that  he  has  a  valvular  lesion. 

(r)  The  ])eriod  of  brokv'H  compensation,  which  may  come  on  suddenly 
during  very  severe  exertion.  Death  may  result  from  acute  dilatatidii; 
but  more  eommoidy  it  takes  i)la<'0  slowly  an<l  results  from  degeneratiun 
and  weakening  of  the  heart-muscle. 

The  breaking  or  rupture  of  cardiac  compensation  may  be  induced  liy 
many  causes,  among  which  the  most  imi)ortant  are:  (1)  Failure  of  the 
general  nutrition.  In  many  instances-  of  heart-disease,  exposure,  poor 
food,  and  alcohol  combine  to  bring  about  disturbance  of  a  well-halanceil 
heart  lesion.  Acute  illnesses,  particularly  the  fevers,  may  induce  gt'iienil 
debility  an<l  with  it  weakening  of  the  heart-muscle.  (2)  Disturbance  of 
the  local  nutrition  of  the  heart,  owing  to  gradual  sclerosis  of  the  coronary 
arteries,  is  a  common  cause.  (;{)  NCry  severe  muscular  exertion,  wliieli  may 
disturb  a  compensation,  jierfect  for  years,  and  induce  death  in  a  few  days 
('i'raube).  (1)  Mental  emotions.  Severe  grief  or  fright  nuiy  bring  on 
failure  of  compensatitm. 

The  ])rognosis  is  largely,  as  already  stated,  a  matter  of  niaiiitained 
compensation.  Once  established,  the  hypertrophy  rarely,  if  ever,  disap- 
pears, inasmuch  as  the  cause  usually  i)ersists.  Occasionally,  j)erliaps,  the 
hypertrophy  associated  w'lh  neurotic  jjalpitation  from  tobacco,  or  dtlur 
causes,  or  the  hypertrophy  following  muscular  over-exertion,  may  ilis- 
appear. 


HYPKIITIIOIMIY   AM)   DILATATION. 


685 


DiLATATio>f  or  Tin;  Hkaut. 

Two  varieties  are  recnj^nized,  (lilatati<ni  with  tiii(koiiiii;r  hikI  <liiata- 
timi  witli  tliinniiij;.  'Die  t'unner  is  tlio  most  comiiiuii,  aiitt  cnrri'sijonds  to 
tlic  ililateti  or  eeeeiitric!  liyitertropiiy. 

Etiolog^y. — Two  important  eauses  eomltine  to  produce  dilatalioii — 
iiKKiiscd  pressuro  witliiii  tho  cavities  and  impaired  resistance,  due  to 
wcakeiiin}^  of  the  muscular  wall — whi<'li  may  act  simply,  hut  arc  ot'tcu 
(■(iiiilpiued.  A  weakened  wall  may  yield  to  a  norimil  distcndinjf  force,  or 
,1  imruuil  wall  may  yield  under  u  hei^ditened  hlood-pressurc. 

(1)  Heij^hteiu'd  endocardiac  pri'ssure  results  either  from  ;in  increased 
(Hiaiitity  of  hlood  to  he  moved  or  an  ohstade  to  l»e  overcome,  and  is  tho 
iiKist  fre(|uent  t-ause.  Jt  does  not  luseessarily  hrinj^  ahout  dilatation  ;  sim- 
ple hypertrophy  may  follow,  as  in  the  early  |)eriod  (d'  aortic  stenosis,  and 
ill  the  hypertrophy  of  the  left  ventricle  in  Brijrht's  disease. 

A  leajority  of  the  important  causes  of  increased  endocardiac  pressure 
have  already  heen  discussed  undi-r  hypertrophy.  One  or  two  may  be  eou- 
sidci'cd  more  in  detail. 

The  size  of  the  cardiac  chand»ers  varies  in  health.  With  slow  action 
(if  liie  heart  the  dilatation  is  complete  and  fidlcr  than  it  is  witli  rapid 
aetimi.  Physicdoj^ically,  the  limits  of  dilatation  are  ri'ache(l  when  the 
eliiuiilier  does  not  em|)ty  itself  durinj^  the  systole.  This  may  oecMir  as  an 
acute,  transii-nt  coiuiition  ii\  severe  exertion — durinir,  for  example,  the 
ascent  (tf  a  mountain.  There  may  he  ;;reat  dilatation  of  the  ri^dit  heart, 
as  shown  hy  the  increased  epij^'astricr  pulsation,  and  even  increase  in  tho 
caidiai'  diduess.  The  safety-valve  action  of  the  tricuspid  valves  may  here 
come  into  lilay,  relievinfi;  tlse  lnn<;s  hy  jiermitlinir  re;rnr^ilation  into 
the  auricle.  With  rest  the  condition  is  rcm<ived,  hut  if  it  has  heen  ex- 
tivnie.  the  lu'art  may  sulfer  u  strain  from  which  it  may  recover  slowly,  or, 
iiulced,  the  individual  nuiy  never  he  ahle  a<jain  to  undertake  severe  exer- 
tiiMi.  In  the  process  of  traininj;,  the  f;etlin<;  wind,  as  it  is  calle(l,  is 
lar^'cly  a  ixradual  increase  in  the  capahility  <d'  the  heart,  pai'ticularly  of 
the  riLTJit  cluimhers.  A  defxree  of  exi-rtion  can  he  safely  maintaiiu'il  in 
lull  tiaiuiiif;  which  would  he  (|uite  impossilile  under  other  circumstance.s, 
Itiraiise  hy  a  <j;radual  process  of  what  we  may  call  physical  education  tho 
heart  has  streufftheiu'd  its  reserve  force — wideiu'd  enormously  its  limits  of 
liiiysinlnriciil  woi'k.  Kuduraucr'  in  prolonircMl  contests  is  measured  hy  tho 
caiialiiliiies  of  the  heart,  and  its  t'ssence  consists  in  heiii;^  able  to  meet  llio 
••oiitiiiiiuus  tendency  to  overstep  the  limits  of  dilatation. 

\\''  have  IK)  positive  knowledije  of  the  nature  of  the  chan<;es  in  tho 
licart  uhii'h  occur  in  this  process,  hut  it  must  he  in  the  direction  of 
increased  nuiseular  and  nervous  eiu'r<jy.  The  lar^re  lu'art  of  atlik'tcs  nuiy 
lit'  tiiif  to  tho  prolon^'ed  use  of  their  muscles,  hut  no  nuin  hecomes  a 
{Treat  iiimi'T  or  oarsman  who  has  not  naturally  a  eapahle  if  not  a  lar<ro 
''eart.      Muster    Me(jratli,    the   celebrated    grevhouiul,    ami    Eclipse,   th" 

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DISKASKS  OF  TIIK  CIIICULATOUY  SYSTKM. 


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Taoe-liorso,  botli  famous  for  t'ii(luratu;e  rutluT  tliiiii  speed,  had  very  larjre 
liearts. 

Excessive  dilatation  durinff  sevore  museular  otTort  results  iu  lii;irt- 
Rtrain  A  man,  perhaps  in  poor  eouditiou,  rails  upon  his  heart  I'nr  cMia 
work  duriuf^  th(*  aseeiit  of  a  hi;;li  mountain,  and  is  at  once  seizcil  wiih 
pain  about  tlu'  heart  and  a  sense  of  distress  in  the  epij^astriiim.  lie 
hreuthes  rapidly  for  some  tinu^,  is  "putTed,"  as  wo  say,  hut  the  syiMptnm.s 
pjws  otT  after  a  ni<;ht'M  quiet.  An  attempt  to  re|)(uit  tlu'  exercise  is  |'o|. 
lowed  hy  another  attack,  or,  iiuleed,  an  attack  of  cardiac  dyspmi  a  mav 
(!ome  on  while  ho  is  at  rest.  For  nu)nths  siu-h  a  man  may  Ih'  unliltcil  for 
Bovore  exertion,  or  he  may  he  jK'rnuinently  incaitacifated.  In  sonic  way  he 
bus  overstraiiu'd  bis  heart  ami  become  "  brokon-windetl."  Kxadly  what 
bus  taken  place  in  these  hearts  wo  cannot  say,  but  their  reserve  rnrce  is 
lost,  and  with  it  the  power  of  meetin<;  the  denuviids  exacted  in  inamlain- 
ing  the  circulation  durinj;  severe  exertion.  The  "  heart-siiock  "  of  Latliain 
includes  cases  of  this  iiature — sudden  ciu'diac  breakdown  durinjr  cxcrtidn, 
not  due  to  ruptun;  of  a  valve.  It  seems  probable  that  sudden  dialli  in 
men  durinii;  louf^-continued  elTorts,  as  in  a  race,  is  sornetinu's  (hic  td  (ivci- 
disteiition  and  paralysis  of  the  heart. 

Examples  of  dilatation  occur  in  all  forms  of  valve  lesions.  In  aortic 
ineompetetu^y  blood  enters  tho  left  ventricle  durin<?  diastole  frnm  tlic 
unguarded  aorta  and  from  the  left  auricle,  and  the  (pumtity  oi'  lijund  at 
tho  termination  of  diastole  subjects  the  walls  to  an  extrenu'  dciriic  nf 
pressure,  under  which  they  inevitably  yield.  In  time  they  au},Mii(iit  in 
thi(!kness,  and  present  tlu^  typical  eccentric  hypertrophy  of  this  cnnditidii. 

In  mitral  insulliciency  blood  whicdi  should  have  been  driven  inin  the 
aort;i  is  forced  into  and  dilates  the  auricle  from  whicli  it  came,  iiiul  then 
in  the  diastole  of  tho  ventricle  a  large  amount  is  returiu-il  from  tlic  auri- 
clo,  and  with  increased  force.  In  mitral  stejiosis  the  left  aiiiii  Ic  !■<  the 
scat  of  greatly  increa.sed  tension  during  diastole,  and  dilates  as  well  as 
hypertrophies;  tho  distention,  too,  may  bo  enormous.  J)ilatati(in  of  the 
right  ventricle  is  ])roduced  l)y  a  nundier  of  conditions,  which  wtic  cun- 
sidered  under  hypertrophy.  All  circumstances,  such  as  mitral  sicimsis, 
emphysema,  etc.,  which  permanently  iiu'rease  tho  tension  of  the  lilcnd  in 
the  pultnonary  vessels,  will  cause  its  dilatation. 

(•■i)  Impaired  nutrition  (»f  tho  heart-walls  nuiy  lead  to  a  diniiniilimi  of 
the  resisting  power  so  that  dilatation  readily  occurs. 

Tho  loss  of  tone  due  to  parenchymatous  degeneration  or  niyocanliti:* 
in  fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  \vro<:- 
nized  cause  of  death  in  scarlatinal  dropsy  ((loodliart),  and  may  («•(  nr  in 
rheumatic  f(!Ver,  typhus,  typhoid,  erysipelas,  etc.  The  cIianL'"?'  i"  l'"' 
heart-mtJ.scle  which  accompany  acute  endocarditis  or  pericarditis  may  Kmi 
to  dilatation,  especially  in  the  latter  di.seaso.  In  anamiia,  Icukuiiiia,  n'"' 
chlorosis  the  dilatation  may  be  considerable.  In  sclerosis  of  the  walls,  the 
yieldii\g  is  always  where  this  process  is  most  advanced,  as  at  the  Id't  iipox. 


IlYI'Kin'UOl'IIY   AND   DILATATION. 


037 


ruder  iiiiy  of  tlu'sc  circuinstiiiu'i'S  lli(>  wivllrf  iiiiiy  yield  with  luiriiml  i)l()od- 
im'ssiiro. 

IV'rictirdiiil  adlicsioiis  arc  ii  ruurto  of  dilatation,  and  wo  poncrully  tiiid 
ill  niHi'.A  with  cxtcnsivf  and  firm  union  consich-raMo  hyiicrtntphy  and  dihi- 
t;iti(in.  'I'hcrc  is  nsually  here  sonic  impairnicnt  as  well  of  the  suitcrlicial 
liiMi's  of  nuisi'h'. 

Morbid  Anatomy. — The  condition  nsually  exists  witli  liypertrophy 
in  two  or  more  chamlicrs.  It  is  more  common  on  the  rij,'ht  than  on  the 
left  side.  The  most  cxtrcni"  dilatation  is  in  cases  of  aortic  incompetency, 
in  which  all  the  cavities  may  he  enormously  distended.  In  mitral  stenosis 
the  left  auricle  is  often  trchlcd  in  capacity,  and  the  rifj;ht  chamhcrs  also  are 
very  capacious,  'i'he  auricles  may  contain  from  eighteen  to  twenty  ounces 
(if  hlood.  In  chronic  lesions  of  the  lungs  the  right  chamhers  aro  chiefly 
iiiviilvcd.  In  gr(>at  distention  of  one  ventricle  the  septum  may  hulge 
toward  the  other  side.  The  atiriculo-ventricular  rings  arc  often  dilated, 
and  there  may  he  an  increase  in  the  circumference  of  an  inch  and  a  half 
or  even  two  imdie.s.  Thus,  the  tricuspid  orifice,  the  circumference  of 
which  is  ahout  four  and  u  half  inches,  may  freely  adniit  a  graduated  hcart- 
(•(iiK-  of  over  six  inches;  and  the  mitral  orifice,  which  normally  is  ahout 
tiircc  and  a  half  inches,  may  admit  the  cone  to  five  and  a  half  inches  or 
even  more.  (Jreat  dilatation  is  always  ucoompanied  M'ith  relative  in«!om- 
pcteiicy  of  the  valves,  so  that  free  regurgitation  into  the  auricles  is  per- 
niittod.  The  orifices  of  the  vena*  cava'  and  (>f  the  pulmonary  veins  may 
bo  ^Tcatly  dilated. 

The  endocardium  is  often  opaque,  particularly  that  of  the  auricles. 
Till'  muscle  suhstanco  varies  according  to  the  presence  or  ah.sence  of  de- 
gi'iu'ratioiis.  The  microscope  may  show  nuirked  fatty  or  parenchymatous 
(•liaiij,'e,  hut  in  some  instances  no  special  alteration  may  he  noticeahlc. 
Thci'c  is  much  truth  in  Niemeyer's  assertion  "  that  it  is  not  jiossihle  hy 
nu'uiis  of  the  microscope  to  recognize  all  the  alterations  of  the  muscular 
tiliiillic  which  diminish  the  functional  power  of  the  heart."  Of  the 
chiinircs  in  the  ganglia  of  the  heart  we  know  very  little.  As  centres  of 
iiintri)!  they  prohahly  have  more  to  do  with  cardiac  nUmy  and  hreakdctwn 
tliun  we  generally  admit.  Degeneration  of  them  has  been  noted  hy  Put- 
jakiii,  Ott,  and  others. 

Symptoms  and  Physical  Signs. — Dilatation  causes  weakness  of 
till'  ciinliac  walls,  diminishes  the  vigor  of  their  contractions,  and  is  thciv- 
fori'  the  reverse  of  hypertrophy.  So  long  as  compensation  !s  maintained 
the  oiilargoment  of  a  cavity  may  be  considerable.  The  limit  is  reached 
when  the  hypertrophied  walls  in  the  systole  can  no  longer  expel  all  the 
•  nntcnjs,  jiart  of  which  remain,  so  that  at  each  diastole  the  chamber  is 
ahrioriiKiily  full.  I'luis,  hi  aortic  incompetency  blood  enters  the  left  V(n- 
triclc  from  the  acrta  a;  well  as  the  auricle ;  dilatation  ensues,  and  also 
hypertrophy  as  a  (  I'-cft  effect  of  the  increased  pressure  and  increiuscd 
amoiuit  of  hlood  to  bb  moved.     Hut  if  from  any  cause  the  hypertrophy 


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638 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


weakens  and  the  ventricle  during  systole  fails  to  empty  itself  comi)]('toly, 
a  still  larger  amount  is  in  it  at  the  end  of  each  diastole,  and  the  dilrtatiou 
becomes  greater.  The  amount  remaining  after  systole  prevents  the  blddd 
from  entering  freely  from  the  auricle.  Incompetency  of  the  auriculo- 
ventricular  valves  follows,  with  dilatation  of  the  auricle  and  impeded 
blood-How  in  the  pulmonary  veins.  Dilatation  and  hy2)ertrophy  of  the 
right  heart  may  compensate  for  a  time,  but  when  this  fails  tlie  venous 
system  bei-omes  engorged  and  dropsy  may  result.  'J'he  consideration  of 
the  symptoms  of  chnniic  valvular  lesions  is  largely  that  of  dilatation  and 
its  effects.  Acute  dilatation,  such  as  we  see  in  fevers  or  in  sudden  failiiiv 
of  a  hypertrophied  heart,  is  accom])anied  by  three  chief  symi)tonis — weak, 
usually  rai)id,  imjiulse,  dyspneoa,  and  signs  of  obstructed  venous  circula- 
tion.    Caixliac  i)ain  nuiy  be  pretient,  but  is  often  absent. 

The  ]>Jii/siraI  signs  of  dilatation  are  those  of  a  weak  aiul  enlarged 
organ.  The  imi)ulse  is  diffuse,  often  undulatory,  and  is  felt  over  a  wide 
area,  and  an  apex  ])eat  or  a  point  of  maximum  intensity  may  not  exist. 
When  it  does  exist,  it  may  be  visible  and  yet  cannot  be  felt — a  valualile 
observation  made  by  Walslie.  An  extensive  area  of  impulse  with  a  quick, 
weak  maximum  apex  beat  may  be  present.  When  the  right  luait  is 
chiefly  dilated  the  left  may  be  pushed  over  so  as  to  occupy  a  much  less  ex- 
tensive area  in  front  of  the  heart,  and  the  true  apex  beat  cannot  be  felt; 
but  the  chief  impulse  is  just  below,  or  to  the  right  of,  the  xi])hoid  carti- 
lage, and  there  is  a  wavy  pulsation  in  the  fourth,  liftli,  and  sixth  inter- 
spaces to  the  left  of  the  sternum.  In  extreme  dilatation  of  the  right 
auricle  a  pulsation  may  sometimes  be  seen  in  the  third  riglit  iutersiiaee 
close  to  the  sternum,  and  with  free  tricuspid  regurgitation  this  may  he 
systolic  in  character.  Whether  the  pulsation  frecjuently  seen  in  tiio  sci.- 
ond  left  interspace  is  ever  due  to  a  dilated  left  auricle  has  not  been  deter- 
mined. I  have  sometimes  thought  it  was  presystolic  in  rhythm,  thou<,di 
it  may  be  distinctly  systolic.  Post  mortem,  it  is  rare  in  the  most  extreme 
distention  to  see  the  auricular  api)endix  so  far  forward  as  to  warrant  the 
belief  that  it  could  beat  against  the  second  interspace.  The  iirea  of  dul- 
ness  is  increased,  but  an  emphysematous  lung  or  the  fully  distended  oigaii 
in  a  state  of  brown  induration  may  cover  over  the  heart  and  greatly  limit 
the  extent.  The  directions  of  increase  were  considered  in  connection  with 
hypertrophy. 

The  first  sound  is  shorter,  sharper,  more  valvuhu*  in  character,  ami 
more  like  the  second.  As  the  dilatation  becomes  ex(tessive  it  gets  wt  akcr. 
Reduplication  is  not  common,  but  occasionally  differences  may  \)v  heard 
in  the  first  sound  over  the  right  and  left  hearts.  The  sounds  are  iVe- 
quently  obscured  by  murtnurs,  which  are  produced  by  inconii)eteni  y  ot 
the  valves  due  to  the  great  dilatation,  or  are  associated  with  the  chionji' 
valve  disease  on  which  the  condition  depends.  The  airtic  second  snuiui 
is  replaced  by  a  murmur  in  aortic  regurgitation.  The  puhnonary  sound 
id  accentuated  in  mitral  regui-gitation  and  pulmonary  congestion,  but 


HYPERTROPHY  AND  DILATATION, 


639 


Avith  extreme  dllatiition  it  may  be  much  weakened.  The  heart's  action 
is  irregular  and  intermittent,  and  the  pulse  is  small,  weak,  and  quick. 

On  auscultation  both  the  sounds  may  be  free  from  murmur.  Often 
there  is  the  condition  known  as  embryocardia  or  foetal  heart-rhythm,  in 
which  the  first  and  second  sounds  are  very  alike,  and  the  long  pause  is 
shortened.  In  other  instances  there  is  the  typical  and  characteristic 
giillop  rhythm,  rarely  found  apart  from  conditions  of  dilatation.  "With 
tht'  various  valvular  lesions  the  corresponding  murmurs  nuiy  be  heard. 
Murmurs,  however,  which  have  been  present  nuiy  disappear,  as  in  the  case 
of  mitral  stenosis.  In  other  instances  a  loud  systolic  murmur  may  be 
hoard  at  the  apex,  and  when  the  case  first  comes  under  observation  it 
miiy  be  impossible  to  say  whether  this  is  due  to  organic  mitral  lesion. 
The  iinirnuir  may  be  confined  to  the  apex  region,  or  propagated  well  to 
the  l):ick.  It  is  extremely  common  in  the  dilatation  which  follows  the 
hypertrophy  of  the  left  ventricle  in  arterio-sclerosis.  Under  treatment, 
with  the  gradual  disappearance  of  the  dilatation,  a  murmur  of  this  kind, 
even  though  most  intense,  may  completely  disappear,  showing  that  it  has 
hoen  due  to  a  relative  insufficiency,  not  to  a  valvular  lesion.  All  varieties 
of  iirrhythmia  may  occur  in  dilatation  of  the  heart.  The  pulse,  as  a  rule, 
is  small,  weak,  quick,  and  often  irregular. 

Dilatation  and  Hypertrophy  due  to  Overexertion  and  Alcohol.— There 
is  a  group  of  cases  of  dilatation  and  hypertrophy  dependent  upon  pro- 
longed overexertion,  which  rarely  comes  uiuler  observation  until  compen- 
siition  has  failed,  and  which  then  may  be  very  difficult  to  distinguish  from 
the  similar  conditions  produced  by  valvular  disease.  The  patients  are 
ahle-liodiod  men  at  the  middle  period  of  life,  and  complain  first  of  pal- 
pitation or  irregularity  of  the  action  of  the  heart,  shortness  of  breath,  and 
suhsefjuenuy  the  usual  symptoms  of  cardiac  insufficiency  develop.  On 
inquiring  into  the  history  of  these  patients  none  of  the  usual  etiological 
fiietors  Lansing  valve  disease  are  present,  but  they  have  always  been  en- 
gaged in  laborious  occup)ations  and  have  usually  been  in  the  hid)it  of 
taking  stimulants  freely.  This  is  the  affection  Avhich  has  been  s})ccially 
studied  by  McLean,  Clifford  Albutt,  Seitz,  and  others,  and  Iti  its  earlier 
condition  by  Da  Costa,  in  what  he  termed  the  irritable  heart  It  is  met 
with  very  frequently  in  soldiers.  These  cases  may  return  to  lu)spital 
three  or  four  times  with  cardiac  insufficiency,  sometimes  witli  slight  ana- 
sarca, Inemoptysis,  and  signs  of  })ulmonary  engorgement.  The  condition 
is  by  no  means  infrequent.  Bollinger  has  called  attention  to  the  common 
occurrence  of  dilatation  and  hypertrophy  in  beer-drinkers,  particularly  in 
the  workers  in  the  Oerman  breweries,  who  drink  twenty  or  more  litres  in 
the  (lay.  Striimpell,  at  his  Erlangen  clinic,  told  me  that  this  coiulition 
was  very  common  in  the  draymen  and  workers  in  the  breweries  of  that 
town,  very  few  of  whom  pass  the  forty-fifth  year  without  iiulications  of 
liypertrophy  and  dilatation  of  the  heart.  On  pr-t-mortem  examination  the 
valves  nuiy  be  quite  healthy,  the  aorta  smooth,  auTl  no  extensive  arterio- 


!  ) 


n,n^' 


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>    '   Jit 


640 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Bclerosis  or  renal  disease.  The  heart  weighs  from  eighteen  to  twenty-five 
ounces ;  the  chambers  are  diluted.  The  condition  has  been  met  witli  also 
in  animals,  and  Houghton  states  tliat  the  heart  of  the  celebrated  gny- 
liound  Master  McGrath  Aveighed  9'57  ounces,  just  threefold  in  excess  of 
tlie  normal  proportion  of  heart-weight  to  body-weight. 

Idiopathic  Dilatation, — And,  lastly,  there  are  other  cases  in  which 
dilatation  of  the  heart  occurs  without  discoverable  cause.  In  sonic  in- 
stances there  lu's  been  a  history  of  sudden  exercise  or  of  mental  enuition, 
but  in  other  cases  the  condition  seems  to  have  come  on  spontiineously. 
In  some  the  condition  is  acute  and  the  patient  has  dyspna>a,  slight  cyano- 
sis, cough,  and  great  cardiac  distress.  Death  may  occur  in  a  few  days,  or 
dropsy  may  sixpervene  and  the  case  may  become  chronic.  Delafield  has 
reported  an  interesting  series  of  cases  of  this  group. 

Treatment. — The  treatment  of  hypertrophy  and  dilatiition  lias  al- 
ready been  considered  under  the  section  on  valvular  lesions.  I  would 
only  here  emphasize  the  fact  that  with  signs  of  dilatation,  as  indicatwl  liy 
gallop  rhythm,  urgent  dyspnoea,  and  slight  lividity,  venesection  is  in 
many  cases  the  only  means  by  which  the  life  of  the  patient  may  be  siivt-d, 
and  from  twenty-five  to  thirty  ounces  of  blood  should  bo  abstracted  with- 
out delay.  Subsequently  stimulants,  such  as  ammonia  and  digitalis,  may 
be  administered,  but  tb.oy  are  accessories  only  to  the  bleeding  in  the  criti- 
cal condition  of  acute  dilatation,  which  is  so  frequently  met  with  iu 
cardiac  lesions. 


IV.    AFFECTIONS  OF  THE   MYOCARDIUM. 

1.  Lesions  due  to  Disease  of  tlie  Coronary  Arteries.— A  knowledge  of  the 
changes  produced  in  the  myocardium  by  disease  of  the  coronary  vessels 
gives  a  key  to  the  understanding  of  many  problems  in  cardiac  patliol- 
ogy.  The  terminal  branches  of  the  coronary  vessels  .are  end  arteries. 
The  blocking  of  one  of  these  vessels  by  a  thrombus  or  an  embolus  loads  to 
a  condition  which  is  known  as — 

(a)  A ncemic  necrosis,  OY  yfhite  mfarct.  This  is  most  commonly  seen 
in  the  left  ventricle  and  in  the  septimi,  in  the  territory  of  distrilmtion 
of  the  anterior  coronary  artery.  The  affected  area  has  a  yellowish- 
white  color,  sometimes  a  turbid,  parboiled  aspect,  at  others  a  grayish- 
red  tirt.  It  may  be  somewhat  wedge-shaped,  more  often  it  is  irroi^niliir 
in  contour  and  projects  above  the  surface.  Microscopically  the  cliaiiges 
are  very  characteristic.  The  nuclei  disappear  from  the  muscle  fil)ies, 
the  condition  of  fragmentation  is  present,  and  the  fibres  present  a  ho- 
mogeneous, hyaline  appearance.  In  some  instances  there  is  coiiqilete 
transformation,  and  even  to  the  naked  eye  a  firm  white  patch  of  hyaline 
degeneration  may  appear  in  the  centre  of  the  area.  Sudden  death  ix't 
infrequently  follows  the  blocking  of  one  of  the  branches  of  the  coronary 


1 


AFFECTIONS  OF  TPIE  MYOCARDIUM. 


641 


artery  and  the  production  of  this  ana;mic  necrosis.  In  medico-legal 
casfn  it  is  a  jioint  of  primary  importance  to  remember  that  this  is  one 
of  the  common  causes  of  sudden  death.  This  condition  shoukl  be  care- 
fully souglit  for,  iimsmuch  as  it  may  be  the  sole  lesion,  except  a  general, 
Konietimes  slight  arterio-sclerosis.  Kupture  of  the  heart  may  be  asso- 
ciated with  ana'mic  necrosis. 

[b)  The  second  important  effect  of  coronary-artery  disease  upon  the 
myoc^iirdium  is  seen  in  the  production  of  fibrous  myocarditis.  This  may 
result  from  the  gradual  transformation  of  areas  of  ana?mic  necrosis. 
More  conimoidy  it  is  caused  by  the  narrowing  of  a  coronary  branch  in 
a  process  of  obliterative  endarteritis.  The  sclerosis  is  most  frecjuently 
seen  at  tlie  apex  of  the  left  ventricle  and  in  the  septum,  but  it  may 
occur  in  any  portion.  In  the  septum  often  there  are  streaks  of  fibroid 
degeneration  Avhich  do  not  re.  i  the  endocardium,  and  it  may  be  neces- 
sary to  divide  the  muscle  in  order  to  see  them.  Hypertrophy  of  the  heart 
is  commonly  associated  with  this  degeneration.  It  is  the  invariable  pre- 
cursor of  aneurism  of  the  heart. 

Complete  obliteration  of  one  coronary  artery,  if  produced  suddenly,  is 
usually  fatal.  When  induced  slowly,  either  by  arterio-sclerosis  at  the  ori- 
fice of  the  artery  at  the  root  of  the  aorta  or  by  an  obliterating  endarteritis 
in  the  course  of  the  vessel,  the  circulation  may  be  carried  on  through  the 
other  vessel.  Sudden  death  is  not  uncommon,  owing  to  tliro>abosis  of  a 
vessel  which  has  become  narrowed  by  sclerosis.  In  the  most  extreme 
grade  one  coronary  artery  may  be  entirely  blocked,  with  the  produc- 
tion of  extensive  fibroid  disease,  and  a  main  branch  of  the  other  also 
may  ho  occluded.  A  large,  powerfully  built  imbecile,  aged  thirty-five,  at 
the  Ehvjn  Institution,  Pennsylvania,  who  had  for  years  enjoyed  doing  the 
heavy  work  about  the  place,  died  suddenly,  without  any  preliminary  symp- 
toms. The  heart,  which  is  in  my  collection,  weiglied  over  twenty  ounces ; 
tiie  anterior  coronary  artery  was  practically  occluded  by  obliterating  en- 
darteritis, and  of  the  posterior  artery  one  main  branch  was  occluded. 

{(■)  Septic  Infarcts. — In  pyaemia  the  smaller  brandies  of  the  coronary 
arteries  msiy  be  blocked  with  septic  emboli  and  cause  infarcts  in  the  myo- 
eardiuni  in  the  form  of  miliary  abscesses,  varying  in  size  from  a  pea  to 
a  jnu's  head.  These  may  not  cause  any  disturbance,  but  Svhen  large  they 
may  perforate  into  the  ventricle  or  into  the  pericardium,  forming  what 
has  heen  called  acute  ulcer  of  the  heart. 

'-  Acute  Interstitial  Myocarditis. — In  the  fevers  and  in  pericarditis 
the  intermuscular  connective  tissue  is  swollen  and  infiltrated  with  round 
cells  and  nuclei,  the  vessels  arc  dilated,  there  are  minute  extravasations, 
and  tl\e  muscle  fibres  may  be  granular  or  fatty,  with  indistinct  striaj  and 
nuclei.  These  instances  have  been  met  with  in  typhoid  fever,  small- 
pox, and  diphtheria.  The  muscle  substance  is  pale,  soft,  and  easily  torn, 
and  the  condition  has  been  described  either  as  inflammatory  or  degener- 
ative. 


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! 


642 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


3.  Pareiich3rmatous  Degeneration. — Tliis  is  usually  met  with  in  fovors, 
or  in  coniu'ction  with  endocarditis  or  pericarditis.  It  is  chanictriizcd 
by  a  pale,  turbid  state  of  the  cardiac  muscle,  which  is  general,  not  hicid- 
ized.  Turbidity  and.  softness  are  the  special  features.  It  is  the  sot't- 
ened  heart  of  Laennec  and  Louis.  Stokes  speaks  of  an  instance  in  wliidi 
"  so  great  was  the  softening  of  the  organ  that  when  the  heart  Avas  grasped 
by  the  great  vessels  and  held  with  the  apex  pointing  upward,  it  fell  down 
over  the  hand,  covering  it  like  a  cap  of  a  large  mushroom." 

Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  iire 
infdtrated  to  a  various  extent  with  granules  which  resist  the  action  of 
ether.  Sometimes  this  granular  change  in  the  fibres  is  extreme,  and  no 
trace  of  the  striaj  can  be  detected.  It  is  probably  the  effect  of  a  toxic 
agent,  and  is  seen  in  its  most  exquisite  form  in  the  lumbar  muscles  in 
cases  of  toxic  hfemoglobinuria  in  the  horse.  It  is  met  with  in  eases  of 
typhoid,  typhus,  small-pox,  and  other  infectious  diseases,  particidarly  when 
the  course  is  protracted.  There  is  no  definite  relation  between  it  and  the 
high  temperature. 

A  form  of  myocarditis  has  been  described,  characterized  by  fragmenta- 
tion of  the  fibres  owing  to  softening  of  the  cement  substance.  According 
to  von  Kecklinghausen  this  is  a  post-mortem  change. 

4.  Fatty  Heart. — Under  this  term  are  embraced  fatty  degeneration 
and  fatty  overgrowth. 

(a)  Fatty  degeneration  is  a  very  common  condition,  and  mild  grados 
are  met  with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of 
old  age,  of  wasting  diseases,  and  of  cachectic  states ;  in  prolonged  infec- 
tious fevers,  in  which  it  may  follow  or  accompany  the  parenrdiyniatous 
change ;  associated  with  acute  and  chronic  anaemias.  Certain  poisons,  such 
as  phosphorus,  produce  an  intense  fatty  degeneration.  Local  causes :  Peri- 
carditis is  usually  associated  with  fatty  or  parenchymatous  changes  in  the 
superficial  layers  of  the  myocardium.  Disease  of  the  coronary  arteries  is 
a  common  and  important  cause.  Lastly,  in  the  hypertrophied  ventricular 
wall  in  chronic  heart-disease  fatty  change  is  by  no  means  infre(|uent. 
This  degeneration  may  be  limited  to  the  heart  or  it  may  be  more  or  less 
general  in  the  solid  viscera.  The  diaphragm  may  also  be  involved,  oven 
when  the  other  muscles  show  no  special  changes.  There  api)eai's  to  be 
a  special  proneness  to  f.atty  degeneration  in  the  heart-muscle,  which  may 
perhaps  bo  connected  with  its  incessant  activity.  So  great  is  its  need  of 
an  abundant  oxygen  supply  that  it  feels  at  once  any  deficiency,  and  is  in 
consequence  the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  be  local  or  general.  The  left  ven- 
tricle is  most  frequently  affected.  If  the  process  is  advanced  and  general 
the  heart  looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish- 
brown  tint,  or,  as  it  is  called,  a  fiided-leaf  color.  Its  consistence  is  re- 
(Uiced  and  the  substance  tears  easily.  In  the  left  ventricle  the  papillary 
columns  and  the  muscle  beneath  the  endocardium  show  a  streaked  or 


(T'T''^" 


AFFECTIONS  OF  THE  MYOCARDIUM. 


fi43 


patohy  appcfvviince.  Microscopically,  the  fibres  are  seen  to  be  occupied  by 
iniimte  globules  distributed  in  rows  alcng  the  line  of  the  primitive  fibres 
(Wi'lch).  Til  advanced  grades  the  fibres  seem  completely  occupied  by  the 
niiiuite  globules. 

{/))  Fatty  Orerf/rowf/i. — This  is  usually  a  simple  excess  of  the  normal 
subporicardial  fat,  to  Avhieh  the  term  cor  adipoHum  was  given  by  the 
older  writers.  In  other  instances  the  fat  infiltrates  the  muscular  sub- 
stance and,  separating  the  strands,  may  reach  even  to  the  endocardium. 
In  corpuk'nt  jtersons  there  is  always  much  pericardial  fat.  It  forms  part 
of  the  general  obesity,  and  occasionally  leads  to  dangerous  or  even  fatal 
ini])airment  of  the  contractile  power  of  the  heart.  Of  Vl'Z  cases  analyzed 
by  l-'orchheimer  there  were  88  males  and  34  fenudes.  Over  eighty  per 
cent  occurred  between  the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  enveloped  in  a  thick  sheeting  of  fat  through 
wliicli  not  a  trace  of  muscle  substance  can  be  seen.  On  section,  the  fat 
ii)fillnites  the  muscle,  separating  the  fibres,  and  in  extreme  cases — particu- 
larly in  the  right  ventricle — reaches  the  eiulocardium.  In  some  places  there 
may  be  even  complete  substitution  of  fat  for  the  muscle  substance.  In 
rare  instances  the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usual- 
ly nnu'h  relax.  1  and  the  chambers  are  dilated.  Microscopically  the  mus- 
cle fil)res  may  si   .w,  in  addition  to  the  atrophy,  marked  fatty  degeneration. 

5.  Other  Degenerations  of  the  Myocardium,  {a)  Brown  Atrophy.— 
This  is  a  common  chaage  in  the  heart-muscle,  particularly  in  chronic 
valvular  lesions  and  in  the  senile  heart.  When  advanced,  the  color  of  the 
muscles  is  a  dark  red-brown,  and  the  consistence  is  usually  increased. 
The  fil)res  present  an  accumulation  of  yellow-brown  pigment  chiefly 
about  the  nuclei.  The  cement  substance  is  often  unusually  distinct,  but 
seems  more  fragile  than  in  healthy  muscle. 

[h)  Amyloid  degeneration  of  the  heart  is  occasionally  seen.  It  occurs 
in  the  intermuscular  connective  tissue  and  in  the  blood-vessels,  not  in 
the  fibres. 

('•)  The  hj'aline  transformation  of  Zenker  is  sometimes  met  with  in 
prolonged  fevers.  The  affected  fibres  are  swollen,  homogeneous,  trans- 
lucent, and  the  strine  are  very  faint  or  entirely  absent. 

('/)  Calcareous  degeneration  may  occur  in  the  myocardium,  ami  the 
muscle  fibres  may  be  infiltrated  and  yet  retain  their  appearance  as  figured 
and  flescribed  by  Coats  in  his  Text-book  of  Pathology. 

Symptoms  of  Myocardial  Disease.  —These  are  notoriously  un- 
certain, A  man  with  advanced  fibroid  myocarditis  may  drop  dead  sud- 
denly, while  doing  heavy  work,  without  having  complained  of  cardiac  dis- 
tress. On  the  other  hand,  a  patient  may  present  enfeebled,  irregular  action 
and  signs  of  dilatation ;  he  may  have  shortness  of  breath,  oedema,  and  the 
peneral  symptoms  believed  to  be  characteristic  of  cases  of  fibroid  and  fatty 
heart,  and  the  post-mortem  show  little  or  no  change  in  the  myocardium. 

Curdio-sclerosis  or  fibroid  heart  is  in  some  cases  characterized  by  a 


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644 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


feeble,  irregular,  slow  pulse,  with  dygpncjoa  on  exertion  and  occasional  at- 
tacks of  angina.  Irregularity  is  present  in  many,  ])ut  not  in  all  (jascs. 
The  pulse  may  he  very  slow,  even  ."30  or  40  per  minute.  U liinuitcly  tho 
cases  conie  under  observation  «.ith  the  symptoms  of  cardiac  insuflicicinv. 
The  arrhythmia,  which  may  have  been  present,  becomes  aggnivntcd  and, 
according  to  lliegel,  may  not  only  precede,  but  also  })crsist  after  the  car- 
diac ins'.iHiciency  has  ])assed  away.  This  certainly  docs  not  hold  in  all 
•cases,  for  a  i)atient  reiiently  under  observation  had  the  most  marked  ar- 
rhythmia, which  persisted  after  recovery  from  a  severe  attack  of  cardiac 
insutli(!iency  iu  which  he  nearly  died.  Upon  his  return,  a  few  weeks  ago, 
with  dilatation  and  arrhythmia,  we  agreed  that  the  condition  was  prob- 
ably one  of  cardio-sclerosis ;  but  the  autopsy  showed  simi)le  dilatation 
without  either  libroid  or  marked  fatty  change  in  the  heart. 

Fatty  degeneration  of  the  heart  presents  the  same  ditticulties.  Extreme 
fatty  changes,  as  in  ])ernicious  ana?mia,  may  be  consistent  with  full,  regu- 
lar  pulse  and  a  regularly  acting  heart.  In  some  of  these  cases  the  fat  does 
not  ai)i)ear  to  interfere  seriously  with  the  function  of  the  organ.  The  truth 
is  it  may  exist  iu  an  extreme  grade  without  producing  symi)t()ms,  so  long  as 
great  dilatation  of  the  chambers  does  not  occur.  The  cardiac  irregularity, 
the  dyspuosa,  palpitation,  and  small  pulse  are  in  reality  not  symptoms  of 
the  fatty  degeneration,  but  of  dilatation  which  has  supervened.  The  fatty 
arcus  senilis  is  of  no  moment  in  the  diagnosis  of  fatty  heart.  The;  heart- 
sounds  may  be  weak  and  the  action  irregular.  When  dilatation  o(;curs, 
there  is  often  the  gallop  rhythm,  shortening  of  the  long  pause,  and  a  sys- 
tolic murmur  at  the  apex.  Shortness  of  breath  on  exertion  is  an  early 
feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is  some- 
times a  tendency  to  syncope,  and  in  bath  fibroid  and  fatty  heart  there  are 
attacks  in  which  the  patient  feels  cold  and  depressed  and  the  pulse  sinks 
to  40  or  30,  or  even,  as  in  one  case  which  I  saw,  to  2G.  The  patient  may 
wake  from  sleep  in  the  early  morning  with  an  attack  of  severe  cardiac 
asthma.  Tliese  "spells  "  may  be  associated  with  nausea  and  may  alter- 
nate with  others  in  which  there  are  anginal  symptoms.  Tnese  pre  the 
cases,  too,  in  which  for  weeks  there  may  be  mental  symptoms.  The  pa- 
tient ban  delusions  and  may  even  become  maniacal.  Toward  the  close, 
Cheyne-Stokes  breathing  is  met  with  in  a  number  of  cases. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very 
obese  persons.  It  produces  no  symptoms  until  the  muscular  fibre  is  so 
weakened  that  dilatation  occui's.  These  patients  may  for  years  present  a 
feeble  but  regular  pulse;  the  heart-sounds  are  weak  and  muffled,  and  a 
murmur  may  be  heard  at  the  apex.  Attacks  of  cardiac  asthma  aie  not 
uncommon,  and  the  patient  may  suffer  from  bronchitis.  Dizziiuss  and 
pseudo-apoplectic  seizures  may  occur.  Sudden  death  may  result  from 
syncope  or  from  rupture  of  the  heart.  The  physical  examination  is  often 
difficult  because  of  the  great  increase  in  the  fat,  and  it  may  be  iuijiossible 
to  define  the  area  of  dulness. 


M»ir:n""'i' 


AFFECTIONS  OF  THE  MYOCARDIUM. 


645 


For  practical  purposes  we  may  group  the  cases  of  myocardial  disease 
a8  follows : 

(1)  Tliose  in  which  sudden  death  occurs  with  or  without  previous  in- 
dications of  lieart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in 
some  instances  with  recent  thrombus  and  white  infarcts ;  in  others,  exten- 
sive fibroid  disease ;  in  others  again,  fatty  degeneration.  In  many  cases 
tluni  is  never  any  complaint  of  cardiac  di  '*^ress,  but,  as  in  the  case  of 
Cliahiiors,  the  celebrated  Scottish  divine,  may  enjoy  unusual  vigor  of  mind 
and  l)ody. 

('i)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath 
on  exertion,  attacks  of  cardiac  asthma,  sometimes  anginal  attacks,  collapse 
rtymi'tonis  with  sweats  and  extremely  slow  pulse,  and  occasionally  marked 
iiu'iital  symptoms.  These  are  the  cases  in  which  the  condition  may  be 
strongly  suspected  and,  in  some  instances,  diagnosed.  It  is  rarely  possible 
to  make  a  distinction  between  the  fatty  and  fibroid  heart. 

(3)  Cases  in  Avhich  there  are  cardiac  insufficiency  and  symptoms  of  dila- 
tation of  the  heart.  Dropsy  is  often  present,  and  with  a  loud  murmur  at 
the  apex  it  may  be  difficult,  unless  the  case  has  been  seen  from  the  outset, 
to  determine  whether  or  not  a  valvular  lesion  is  present. 

Prognosis. — The  outlook  in  affections  of  the  myocardium  is  ex- 
troiiiely  grave.  Patients  recover,  however,  in  a  surprising  way  from  the 
most  serious  attacks,  particularly  those  of  the  second  group. 

Treatment. — Many  cases  never  come  under  treatment ;  the  first  are 
the  final  symptoms. 

Cases  with  signs  of  well-marked  cardiac  insufficiency,  as  manifested  by 
dyspno'a,  weak,  irregular,  rapid  heart,  and  oedema,  may  be  treated  on  the 
l)lau  kid  down  for  the  treatment  of  broken  compensation  in  valvular  dis- 
ease. Digitalis  may  be  given  even  if  fatty  degeneration  is  suspected,  and 
is  often  very  beneficisU. 

Miuih  more  difficult  is  the  management  of  those  cases  in  which  there 
is  marked  cardiac  arrhythmia,  with  a  feeble,  irregular,  very  slow  pulse, 
and  syncope  or  angina.  Dropsy  is  not,  as  a  rule,  present ;  the  heart- 
sounds  may  be  perfectly  clear,  and  there  are  no  signs  of  dilatation.  Di- 
gitalis, under  these  circumstances,  is  not  advisable,  particularly  when  the 
pulse  is  infrequent.  Complete  rest  in  bed,  a  carefully  regulated  diet,  and 
the  use  of  the  aromatic  spirits  of  ammonia,  sulphuric  ether,  and  stimulants 
are  indicated.  For  the  restlessness  and  distressing  feelings  of  anxiety  mor- 
phia is  invaluable.  From  an  eightieth  to  a  sixtieth  of  a  grain  of  strychnia 
may  be  given  three  times  a  day.  If,  as  is  sometimes  the  case,  the  pulse  is 
hard  and  firm,  nitroglycerin  may  be  cautiously  administered,  beginning 
with  one  minim  of  the  one  per  cent  solution  three  times  a  day  and  in- 
creased gradually. 

Ill  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plan  of  treatment  recommended  by  Oertl  is  advantageous.  It 
IS  an  invaluable  method  in  those  forms  of  heart- weakness  due  to  intern- 


6^6 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


k'-'\ 


.'lllh 


perance  in  eating  and  drinkin};  and  defective  bodily  exercise.  Tlic  O^rtl 
plan  consists  of  three  parts.  First,  the  reduction  in  the  amount  of  li(|iii(l. 
This  is  an  important  factor  in  reducing  the  fat  in  these  patients.  It  ulso 
slightly  increases  the  density  of  the  ])lo()d.  Oertl  allows  daily  about  thirt\- 
six  ounces  of  liquid,  which  includes  the  amount  taken  with  the  solid  loud. 
Free  perspiration  is  promoted  by  bathing  (if  advisable,  the  Turkish  bath), 
or  even  by  the  use  of  pilocari»ine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  Hhoiild 
consist  largely  of  jjroteids. 

Morning. — Cup  of  cotTee  or  tea,  with  a  little  milk,  about  six  ounces 
altogether,     liread,  three  ounces. 

Kiion. — Three  to  four  ouiu-es  of  soup,  seven  to  eight  ounces  of  must 
beef,  veal,  ganae,  or  poultry,  salad  or  a  light  vegetable,  a  little  flsli ;  one 
ounce  of  bread  or  farinaceous  pudding;  three  to  six  ounces  of  t'niit  for 
dessert.  No  liquids  at  this  meal,  as  a  rule,  but  in  hot  weather  six  ounces 
of  light  wine  may  be  taken. 

Af/crnoon. — Six  ounces  of  coffee  or  tea,  with  as  much  water.  As  an 
indulgence  an  ounce  of  bread. 

Evening. — One  or  two  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a 
small  slice  of  cheese,  salad,  and  fruit;  six  to  eight  ounces  of  wine  wi^li  four 
or  live  ouiu'cs  of  water  (Yeo). 

The  most  inqjortant  element  of  all  is  graduated  exercise,  7iot  on  tlie 
level,  but  up  hills  of  various  grades.  The  distance  walked  each  day  is 
marked  off  and  is  gradually  lengthened.  In  this  way  the  heart  is  sys- 
tematica- rcised  and  strengthened. 

Ther-  ;  doubt  of  the  great  value  of  this  or  like  methods  in  ajtpro- 

priate  cases.  At  several  of  the  health,  resorts  in  Germany,  particulaily 
the  Bad  Xauheim,  under  Schott,  the  results  are  striking.  Tlie  jilan  is 
rarely  advisable  in  valvular  lesions  and  should  not  be  adoj)ted  when  tiiere 
is  marked  arterio-sclerosis.  Cases  of  fatty  overgrowth  of  the  heart  are 
those  most  suitable.  The  plan  of  treatment  reduces  tlie  obesity,  and  the 
patients  are,  for  a  time  at  least,  much  more  comfortable  and  are  al)letogo 
about  and  do  their  Avork  without  cardiac  distress  or  great  shortness  of 
breath. 

Aneurism  OF  THE  Heart. 

(fl)  Aneurism  of  a  Valve  results  from  acute  endocarditis,  wliicli  pro- 
duces softening  or  erosion  and  may  lead  either  to  perforation  of  the  seg- 
ment or  to  gradual  dilatation  of  a  limited  area  under  the  iniluence  <if  the 
blood-pressure.  The  aneurisms  are  usually  spheroidal  and  project  from 
the  ventricular  face  of  a  sigmoid  valve.  They  are  much  less  common 
on  the  mitral  segments.  They  frequently  rupture  and  produce  extensive 
destruction  and  incompetency  of  the  valves. 

(b)  Aneurism  of  the  Walls. — This  comparatively  rare  condition  results 
from  the  weakening  of  the  walls  by  chronic  myocarditis,  or  occasionally 


..,-,■  -.JJ' 


m  I 


AFFECTIONS  OP  TIIK   MYOCARDIUM. 


647 


it  follows  mural  eiulooarditis,  which  more  commoTily,  however,  lends  to 
|nTl'(»riiti()ii.  Aneurism  hus  followed  a  stab-wound  of  the  heart.  The 
Ittt,  vfiitriele  near  the  apex  is  usually  the  seat,  at  the  situation  in 
wliicli  tlie  librous  dej^eneration  is  most  eommon.  Fifty-nine  of  the  OU 
cases  coUeeted  by  hvgg  were  situated  here.  In  the  early  stajj^es  the  ante- 
riiir  wall  of  the  ventricle,  near  the  septum,  sometimes  involving  the  septum 
itself,  is  sliffhtly  dilated,  the  endocardium  opa(iue,  and  the  :iiuscular  tissue 
scltrutic.  In  a  more  advanced  sta<:;e  the  dilatation  is  itron(.iinced  and 
layers  of  thrombi  occupy  the  sac.  Ultinuitely  a  lar<j:e  rounded  tumor  may 
])i()ject  from  the  ventricle  and  may  attain  a  size  equal  to  that  of  the  heart. 
Oeeiisionally  the  aneurism  is  saccuhited  and  communicates  with  the  ven- 
tricle throuj^h  a  very  small  orifice.  The  sac  nuiy  be  double,  as  in  a  cas-o 
rep'dtcd  l)y  Janeway.  In  the  museum  of  (Juy's  Hosi)ital  there  is  a  speci- 
men showing  the  wall  of  the  veutriclo  covered  with  aneurisnuil  bulgings. 
Kuiitiirc  occurred  in  7  of  the  90  cases  collected  by  Legg. 

The  sj/mpfoiti.s  jjroduced  by  aneurism  of  the  heart  are  indefinite.  Oc- 
ciisidually  there  is  marked  bulging  in  the  apex  region  atul  the  tunu)r  may 
[)erf (irate  the  chest  wall.  When  the  sac  is  large  and  produces  pressure 
upon  the  heart  itself,  there  may  be  a  marked  disproportion  between  the 
strong  cardiac  iujpulsc  and  the  feeble  pulsation  in  the  peripheral  arteries. 

lllITUUE   OF  THE   IIeAUT. 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  dcgenera- 
tii)ii  of  the  heart-muscles.  In  some  instances,  acute  softening  in  conse- 
quence of  embolisni  of  a  branch  of  the  coronary  artery,  suppurative  myo- 
eanlitis,  or  a  gummatous  growth  has  been  the  cause.  Of  100  cases  col- 
k'ctid  by  Quain,  fatty  degeneration  was  noted  iu  77.  Two  thirds  of  the 
piitieiits  wore  over  sixty  j'cars  of  age. 

The  rent  may  occur  in  any  of  the  chambers,  but  is  found  most  fre- 
quently in  the  left  ventricle  on  the  anterior  wall,  not  far  from  the  sejitum. 
The  accident  usually  takes  place  during  exertion.  There  may  be  no  pre- 
liminury  symptoms,  but  without  any  warning  the  patient  may  fall  and  die 
in  a  few  moments.  Sudden  death  occurred  iu  seventy-one  per  cent  of 
Quain's  cases.  In  other  instances  there  may  be  in  the  cardiac  region  a 
sense  of  anguish  and  suffocation,  and  life  may  be  prolonged  for  several 
hours.  Ill  a  Montreal  case  which  I  examined  the  patient  walked  up  a 
steep  hill  after  the  onset  of  the  symptoms,  and  lived  for  thirteen  hours. 
A  ease  is  on  record  in  which  the  patient  lived  for  eleven  days. 

New  GiiowTiis  axd  Parasites. 

t 

Tnljercle  and  syphilis  have  already  been  considered.  Primary  cancer 
or  sarcoma  is  extremely  rare.  Secondary  tumors  may  be  single  or  mul- 
tiple, and  are  usually  unattended  with  symptoms,  even  when  the  disease 


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648 


DISEASES  OF  THE  (IRCULATOUY  SYSTEM. 


m 


is  most  extensive.  Tn  one  case  I  found  in  the  wall  of  the  riglit  vciitri;  Ic 
a  mass  which  involved  tlie  anterior  8e<,Mnent  of  the  tricuspid  vulvc  aiul 
partly  blocked  the  orifice,  'JMie  surface  was  eroded  and  there  wire  mi. 
merous  cuneerous  einholi  in  the  j)ulmonary  artery.  In  another  instance 
the  heart  was  greatly  enlarged,  owing  to  the  ])resenee  of  iniuiiiicniljio 
masses  of  colloid  cancer  the  size  of  cherries.  The  nufdiastinal  sarconm 
may  penetrate  the  heart,  though  it  is  reniarkal)le  how  extensive  tlic  dis- 
ease of  the  mediastinal  glands  nmy  be  without  involvenu'iit  of  tli(;  heart 
or  vessels. 

(/ysts  in  the  heart  are  rare.  They  are  found  in  different  jiarts,  and 
are  filled  either  with  a  brownish  or  a  clear  fluid.  Blood-cysts  oeeasioiiiilly 
occur. 

The  parasites  will  bo  discussed  'inder  the  appropriate  section,  Imt  it 
may  be  mentioned  here  that  both  the  cyxticercus  cellulosw  and  the  echino- 
C0CCU8  cysts  occur  occasionally  in  the  heart. 

Wounds  axd  Foueign  Bodies. 

Wounds  of  the  heart  are  usually  fatal,  although  there  are  many  in- 
stances in  which  recovery  has  tak^r  dace.  Bullets  have  been  found  en- 
cysted inside  the  ventricle.  A  majority  of  the  cases  of  gunshot  wonnds, 
however,  are  necessarily  fatal.  Puncture  of  the  heart  by  a  sharp-point- 
ed body,  such  as  a  needle  or  a  stiletto,  does  not  always  prove  fatal. 
Peabody  has  reported  a  case  in  which  a  pin  was  found  embedded  in  the 
left  ventricle.  Suicide  has  been  attempted  by  passing  a  needle  or  jiin 
into  the  heart.  It  is  not,  however,  necessarily  fatal.  Moxon  mentioned  a 
case,  at  the  Clinical  Hociety  of  London,,  in  which  a  medical  student,  wliilo 
on  a  spree,  passed  a  pin  into  his  heart.  The  pericardium  was  opened,  and 
the  head  of  the  ]nn  was  found  outside  of  the  right  ventricle.  It  was 
grasped  and  an  attempt  made  to  remove  it,  but  it  was  withdrawn  into  tti(! 
heart  and,  it  is  said,  caused  the  patient  no  further  trouble.  Ilysteiiual 
girls  sometimes  swallow  pins  and  needles,  which,  passing  through  the 
oesophagus  and  stomach,  are  foxmd  in  various  parts  of  the  body.  A  re- 
markable case  is  reported  by  Allen  J.  Smith  of  a  girl  from  whom  several 
dozen  needles  and  pins  were  removed,  usually  from  subcutaneous  ahsoessos. 
Several  years  later  she  developed  symptoms  of  chronic  heart-disease.  At 
the  post-mortem  needles  were  found  in  the  tissues  of  the  adherent  peri- 
cardium, and  between  thirty  and  forty  were  embedded  in  the  thickened 
pleural  membranes  of  the  left  side. 

Puncture  of  the  heart  has  been  recommended  as  a  tluM-apentic  pro- 
cedure to  stimulate  it  to  action,  as  in  chloroform  narcosis,  and  experi- 
mental evidence  has  been  brought  forward  by  B.  A.  Watson  in  favor  of 
the  operation.  He  advises  abstraction  of  blood  in  combination  with  the 
puncture — cardiocentesis.  The  proceeding  is  not  without  risk.  IliBinor- 
rhage  may  take  place  from  the  puncture,  though  it  is  not  often  extensive. 


NEUROSES  OP  THE  HEART, 


640 


If  (III 

V 


At  t1u>  Philadelpliiu  Hospital  tho  prncoduro  wiis  tried  by  ono  of  tlio  rosi- 
(Iciit  idiysiciuns  in  a  ciiso  of  acuto  dilatation.  Tho  untt'rior  coronury  vi'in 
uii>  t'lit  ucrosh  and  co'isidcrablo  blood  was  found  in  tho  i)ericardium. 
Tiii'ic  is  danger  also  of  striking  Kronecker's  inhibition  centre. 


V.  NEUROSES  OF  THE  HEART. 

Palpitation. 

In  Ileal th  we  are  unoonseious  of  the  action  of  the  lieart.  In  some  peo- 
ple one  of  the  first  indications  of  debility  or  overwork  is  the  consciousness 
(if  tlic  cardiac  pulsations,  which  may,  however,  bo  lu'rfectly  regular  a!id 
orderly.  This  is  not  palpitiiiion.  Tlie  term  is  ])roperly  limited  to  irregu- 
lar or  forcible  action  of  the  heart  perceptible  to  the  individual. 

Etiology. — 'I'hc  ex[)ression  "pereeptiblo  to  the  individual"  covers 
the  essential  element  in  palpitation  of  the  heart.  The  mo-t  'xtremc  dis- 
turltiiiK^e  of  rhythm,  a  condition  even  of  what  is  termed  (hlh-iiim  corditi, 
may  Im*  unattended  with  subjective  sensations  of  distress,  and  there  may 
be  110  consciousness  of  disturbed  action.  On  the  o.htr  hand,  there  are 
cases  in  v/hich  C(  mplaint  is  made  of  the  most  distressing  palpitation  and 
sensations  of  turohbing,  in  which  the  physical  examination  reveals  a  regu- 
larly .-'  Mng  heart,  the  sensations  being  entirely  subjective.  We  meet  with 
this  symptom  in  a  large  group  of  cases  in  which  there  is  increased  excita- 
bility of  the  nervous  system.  Palpitation  may  be  a  marked  feature  at  the 
time  of  puberty,  at  tlie  climacteric,  and  occasionally  during  menstruation. 
It  is  a  very  common  symptom  in  hysteria  and  neurasthenia,  particularlj'  in 
the  form  of  the  latter  which  is  associated  with  dyspepsia.  Emotions, 
such  as  fright,  arc  common  causes  of  palpitation.  It  may  occur  as  u 
sequence  of  the  acute  fevers.  Females  are  more  liable  to  the  affection  than 
males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the 
heart  of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And, 
lastly,  palpitation  may  be  associated  with  organic  disease  of  the  heart, 
cither  of  the  myocardium  or  of  the  valves.  As  a  rule,  however,  it  is  a 
purely  nervous  phenomenon — seldom  associated  with  organic  disease — in 
which  the  most  violent  action  and  the  most  extreme  irregularity  may  exist 
without  that  subjective  element  of  consciousness  of  the  disturbance  which 
constitutes  the  essential  feature  of  palpitation, 

Tho  irritable  heart  described  by  Da  Costa,  which  was  so  common  among 
the  young  soldiers  during  the  civil  war,  is  a  neurosis  of  this  kind,  Tho 
chief  symptoms  were  palpitation  with  great  frec]uency  of  tho  pulse  on  ex- 
ertion, a  variable  amount  of  cardiac  pain,  and  dyspnoea.  The  factors  at 
work  in  producing  this  condition  appeared  to  be  the  mental  excitement, 
the  unwonted  muscular  exertion  associated  with  the  drill,  and  diarrhoea. 


i 


H 

if' ' 


650 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


IIP      T) 


The  condition  is  not  infrequent  in  civil  life  among  young  men,  and  it  loads 
in  some  cases  to  hypertrophy  of  the  heart. 

Sjrmptoms. — In  the  mildest  form,  such  as  occurs  during  a  dys- 
peptic attack,  ther  is  slight  fluttering  of  the  heart  and  a  sense  of  wluit 
patients  sometimes  call  "goneness."  In  more  severe  attacks  tlio  lu'iirt 
beats  violently,  its  pulsations  against  the  chest  wall  are  visible,  tlie  rapidity 
of  the  action  is  much  increascii,  the  arteries  throb  forcibly,  and  tlu'rc  is  a 
sense  of  great  distress.  In  some  instances  the  heart's  action  is  not  at  all 
quickened.  The  most  striking  cases  are  in  neurasthenic  women,  in  whom 
the  mere  entrance  of  a  person  into  the  room  will  cause  the  most  vidlciit 
action  of  the  heart  and  throbbing  of  the  peripheral  arteries.  Tho  pulse 
may  be  rapidly  increased  until  it  reaches  150  or  IGO.  A  diffuse  flushing 
of  the  skin  may  appear  at  the  same  time.  After  such  attacks,  there  may 
be  the  passage  of  a  large  quantity  of  pale  urine.  In  many  cases  of  ])alpi- 
tation,  particularly  in  young  men,  the  condition  is  at  once  relievi'd  by 
exertion.  A  patient  with  extreme  irregularity  of  the  heart  may,  after 
walking  quickly  one  hundred  yards  or  running  up-stairs,  return  with  the 
pulse  perfectly  regular.  This  is  not  infrequently  seen,  too,  in  the  irregu- 
lar action  of  the  heart  in  mitral-valve  disease. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpable,  are  on  auscultation  clear,  riuginjr, 
and  metallic,  but  not  associated  with  murmurs.  The  second  sound  at  the 
base  may  be  greatly  accentuated.  A  murmur  may  sometimes  bo  heard 
over  the  pulmonary  artery  or  even  at  the  apex  in  cases  of  rapid  action  in 
neurasthenia  or  in  severe  anaemia.  The  attacks  may  be  transient,  listing 
only  for  a  few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  in- 
stances any  attempt  at  exertion  renews  the  attack. 

The  prof/fiofiif  is  usually  good,  though  it  may  be  extremely  ditlieult  to 
remove  the  conditions  underlying  the  palpitation. 

Arrhythmia. 

An  intermission  occurs  when  one  or  more  beats  of  the  lioart  are 
dropped.  Irregularity  is  the  condition  when  the  beats  are  unequal  in  vol- 
ume and  force,  or  follow  each  other  at  unequal  distances.  Allorrhythniia 
is  a  term  which  is  also  used  to  express  deviations  from  the  nornnil  heart 
rhythm. 

The  following  varieties  of  arrhythmical  action  may  be  recognized : 

(1)  The  paradoxical  jiulse  of  Kiissnniul,  in  which  the  beats  during 
inspiration  are  more  frequent  but  less  full  than  during  expiratioii.  This 
is  found  in  weak  heart,  in  chronic  pericarditis,  and  when  iibrou-  haiuU 
encircle  the  root  of  the  aorta  ;  but  it  may  also  occur  normally  tVnin  the 
influence  of  the  respirations  upon  the  heart.  It  is  sometimes  to  he  felt  in 
sleeping  children. 

(3)  Intermittence,  in  which  there  is  simply  an  intermission  or  drop- 


NEUROSES  OF  THE  HEART. 


651 


ping  of  a  cardiac  beat.  The  term  dcficience  is  more  correctly  applied  to 
those  instances  in  which  the  absence  of  the  heart-sound  proves  that  the 
svstole  is  really  omitted.  The  systole  may  be  so  weak  as  not  to  produce  a 
pulsation,  and  yet  at  the  samo  time  a  feeble  first  sound  may  be  heard. 

(3)  The  alternate  heart-l)oat,  in  which  strong  "and  weak  pulsations 
alternate  regularly  and  which  is  expressed  in  the  peripheral  arteries  by 
alternate  full  and  feeble  pulse-beats. 

(4)  The  bigeminal  and  trigeminal  pulsations  occur  when  two  or  three 
beats  follow  each  other  in  rapid  succession,  each  group  being  separated 
from  the  following  by  a  longer  interval.  This  is  not  very  uncommon  in 
mitral  disease.  In  the  bigeminal  pulse  the  first  beat  of  the  pair  is  usually 
the  stronger.  Indeed,  in  the  condition  known  as  heart  bigeminiam  the 
seeond  systole  is  so  feeble  that  the  pulse  wave  does  not  reach  the  periph- 
eral arteries  and  the  two  systoles  are  represented  by  only  a  single  pulse- 
beat  at  the  wrist. 

(5)  Delirium  cordis,  in  which  these  various  factors  are  combined  and 
the  lioart's  action  is  wholly  irregular. 

(G)  Foital  heart  rhythm — embryocardia — described  by  Stokes,  is  a 
very  common  condition  in  which  the  long  pause  is  shortened  and  the 
characters  of  the  sounds  are  "  almost  completely  identical."  The  resem- 
blance to  the  fcEtal  heart-beat  is  very  striking.  In  the  later  staj^es  of 
fevers  and  in  exticme  dilatation  this  lorm  of  heart  rhythm  is  very  fre- 
quently heard. 

(T)  Gallop  rhythm,  in  which  the  sounds  resemble  the  footfall  of  a 
horse  at  canter,  usually  results  from  the  reduplication  of  the  second 
sound  in  a  rapidly  acting  heart.  It  is  expressed  by  the  words  "  rat- 
ta-tat."  Sometimes  it  seems  as  if  the  first  sound  was  split ;  more  com- 
monly it  is  the  second.  It  is  most  frequently  heard  in  interstitial  ne- 
phritis and  arterio-sclerosis,  but  it  is  said  to  be  met  with  also  in  healthy 
persons. 

The  causes  of  these  various  disturbances  of  rhythm  are  thus  classified 
by  G.  Biiumgarten  :  * 

(1)  Those  due  to  central — cerebral — causes,  either  organic  disease,  as 
in  ha'in(trrhage,  or  concussion  ;  more  commonly  psychical  influences. 

{i)  Reflex  influences,  such  as  produce  the  cardi  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

('])  Toxic  influences.  Tobacco,  coffee,  and  tea  are  common  causes  of 
arrhytliniia.  Various  drugs,  such  as  digitalis,  belladonna,  and  aconite, 
may  also  induce  it. 

(4)  {'hanges  in  the  heart  itself,  (a)  In  the  cardiac  ganglia.  Fatty, 
pignhntary,  and  sclerotic  changes  have  been  described  in  cases  of  this 
sort  and  may  have  an  important  influence  in  producing  disturbances  in 
the  rliythin  ;  but  as  yet  we  do  not  know  their  exact  significance.     They 

*  Transactions  of  tho  Association  of  American  Physicians,  vol.  iii. 
42 


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DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


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may  be  present  in  cases  which  have  not  presented  arrhythmia,  (b)  Mural 
changes  are  common  in  conditions  of  this  kind.  Simple  dilatation,  futtv 
degeneration,  and  sclerosis  are  most  commonly  present,  the  two  latter 
usually  associated  with  sclerosis  of  the  coronary  arteries. 

The  significance  of  arrhythmia  is  not  always  easy  to  determine.  Sim- 
ple irregular  action  of  the  heart  may  persist  for  years.  The  late  Cluin- 
cellor  Ferrier,  of  McGill  University,  a  man  of  unusual  bodily  and  moritiil 
vigor,  who  died  at  the  age  of  eighty-seven,  had  an  extremely  irregular 
pulse  for  almost  fifty  years  of  his  life.  One  or  two  other  instances  liave 
come  under  my  notice  of  persons  in  good  health,  without  arterial  or  car- 
diac disease,  in  whom  the  heart's  action  was  persistently  irregular.  The 
bigeminal  and  trigeminal  pulsations  are  found  more  frequently  in  mitral 
than  in  other  conditions.  The  delirium  cordis  is  met  with  in  the  dilata- 
tion associated  with  valvular  lesions,  particularly  toward  the  latter  stages. 
Foetal  heart  rhythm  is  rarely  found  apart  from  dilatation. 

Rapid  Heart — Tachycardia. 

The  rapid  action  may  be  perfectly  natural.  There  are  individuals 
whose  normal  heart  action  is  at  100  or  even  more  per  minute.  It  may 
be  caused  by  the  various  conditions  which  induce  palpitation ;  l)ut  the 
two  are  not  necessarily  associated.  Emotional  causes,  violent  exeroiso,  and 
fevers  all  produce  great  increase  in  the  rapidity  of  the  heart's  .iction. 
The  extremely  rapid  action  which  follows  fright  may  persist  for  days,  or 
even  weeks.  Traube  reports  an  instance  in  which,  after  violent  exercise, 
the  rapid  action  of  the  heart  continued.  Cases  are  not  uncommon  at  the 
menopause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  depends  upon  definite  changes  in  the  pneumogastrics 
or  in  the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot  in 
or  about  the  medulla  or  pressure  upon  the  vagi  has  been  associated  with 
heart  hurry.  Some  of  the  cases  of  frequent  action  of  the  heart  in  wimieii 
have  been  thought  to  be  due  to  reflex  irritation  from  ovarian  or  uterine 
disease. 

Paroxysmal  tachtjcardia  is  a  remarkable  affection,  characterized  by 
spells  of  heart  hurry,  during  which  the  action  is  greatly  increased,  the 
pulse  reaciiing  200  and  over.  The  cases  are  not  common.  The  condition 
has  been  thoroughly  studied  by  Nothnagel.  The  attack  may  be  quite 
short  and  persist  only  for  an  hour  or  so.  A  patient  at  the  Philadeliilua 
Infirmary  for  Nervous  Diseases  was  attac'Ked  every  week  or  two ;  tlie  })ulse 
would  rise  to  230  or  230,  and  there  were  such  feelings  of  distress  and  un- 
easiness that  the  patient  always  had  to  lie  down.  There  may  be,  liow  ever, 
no  subjective  disturbance,  and  in  another  case  the  patient  was  able  to 
walk  about  during  the  paroxysm  and  had  no  dyspnoea.  One  of  the  most 
remarkable  cases  is  reported  by  H.  0.  Wood.     A  physician  in  his  eighty- 


NEUROSES  OF  THE  HEART. 


653 


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seventh  year  has  had  attacks  at  intervals  since  his  thirty-seventh  year. 
The  unset  is  abrupt  and  the  pulse  rapidly  rises  to  200  a  minute.  For  more 
than  twenty  years  the  taking  of  ice-water  or  strong  coffee  would  arrest  the 
attacks.  Bouveret  has  analyzed  a  number  of  cases  of  tliis  essential  or 
idiopathic  form ;  he  flnds  that  a  permanent  cure  is  rare,  and  that  the  pa- 
tients sulfer  for  ten  or  more  years.  Four  instances  terminated  fatally  from 
lieart- failure.  Wood  suggests  that  these  cardiac  paroxysms  arc  caused 
by  discharging  lesions  affecting  the  centres  of  the  accelerator  nerves. 
l<Van(,'ois  Franck  has  shown  that  the  acceleration  of  the  heart's  action  is 
due  to  the  shortening  of  the  diastole,  and  during  the  systole  so  little  blood 
is  expelled  from  the  heart  that  the  average  amount  in  the  minute  is  not 
increased.  Moreover,  the  accelerators  appear  to  have  no  trophic  relation 
to  the  heart,  and  stimulation  of  them  is  not  accompanied  either  by  in- 
creased arterial  pressure  or  by  augmentation  of  the  work  done  by  the 
heart. 

Slow  Heart — Braciiycardia  {Bradycardia). 

Slow  action  of  the  heart  is  sometimes  normal  and  may  be  a  family 
peculiarity.  Napoleon  is  stated  to  have  had  a  pulse  of  only  40  per  minute. 
In  any  case  of  slow  pulse  it  is  important  first  to  make  sure  that  the 
number  of  heart,  and  arterial  beats  correspond.  In  many  instances  this  is 
not  the  case,  and  with  a  radial  pulse  at  40  the  cardiac  pulsations  may  be 
80,  half  tlie  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the 
pulse  wave,  should  be  taken  into  account.  A  most  exhaustive  study  of 
this  condition  has  been  made  recently  by  Kiegel,  whose  division  is  here 
followed: 

((/)  Physiological  braciiycardia.  In  the  puerperal  state  the  pulse  may 
heat  fr(»m  44  to  60  per  minute,  or  may  even  be  as  low  as  34.  It  is  seen  in 
premature  labor  as  well  as  at  term.  The  explanation  of  its  occurrence  at 
this  jjcriod  is  not  clear.  Slowness  of  the  pulse  is  associated  with  hunger. 
Brachycardia  depending  on  individual  peculiarity  is  extremely  rare. 

{h)  Pathological  brachj'cardia,  which  is  met  with  under  the  following 
conditions:  (I)  In  convalescence  from  acute  fevers.  This  is  extremely 
common,  particularly  after  pneumonia,  typhoid  fever,  acute  rheumatism, 
and  diphtheria.  It  is  most  frequently  seen  in  young  persons  and  in  cases 
wliich  liavc  run  a  normal  course.  Traube's  explanation  that  it  is  due  to 
exliaustion  is  probably  the  correct  one.  (2)  In  diseases  of  the  digestive 
system,  such  as  chronic  dyspepsia,  ulcer  or  cancer  of  the  stomach,  and 
jaundice.  The  largest  number  of  Riegel's  cases  were  of  this  group.  (3) 
In  diseases  of  the  respiratory  system.  Here  it  is  by  no  means  so  common, 
but  is  seen  not  infrequently  in  emphysema.  (4)  In  diseases  of  the  circu- 
latory system.  Excluding  all  cases  of  irregularity  of  the  heart,  brachy- 
cardia is  not  common  in  diseases  of  the  valves.  It  is  most  frequently  seen 
in  fatty  and  fibroid  changes  in  the  heart,  but  is  not  constant  in  them.  (5) 
In  diseases  of  the  urinary  organs.     It  occurs  occasionally  in  nephritis  and 


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654 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


may  be  a  feature  of  uraemia.  (0)  From  the  action  of  toxic  agents.  It 
occurs  in  ura3mia,  poisoning  by  lead,  alcohol,  and  follows  the  use  of  to- 
bacco, coilee,  and  digitalis.  (7)  In  constitutional  disorders,  such  as  iiiia>- 
mia,  chlorosis,  and  diabetes.  (8)  In  diseases  of  the  nervous  system. 
Apoplexy,  epilepsy,  the  cerebral  tumors,  affections  of  the  medulla,  ami 
diseases  and  injuries  of  the  cervical  cord  may  be  associated  with  very  slow 
pulse.  In  general  paresis,  mania,  and  melancholia  it  is  not  infrequent. 
(9)  It  occurs  occasionally  in  affections  of  the  skin  and  sexual  organs,  and 
in  sunstroke,  or  in  prolonged  exhaustion  from  any  cause. 

It  is  seen  most  frequently  in  the  convalescence  from  acute  fevers,  tliou 
in  disorders  of  the  digestive  system.  The  significance  of  this  symptom  is 
variable.  It  is  only  in  diseases  of  the  heart  or  brain  that  it  is  ominous. 
It  may  be  due  to  direct  irritation  of  the  vagi,  to  diminished  excitability  of 
the  cardiac  ganglia,  to  reflex  influences  acting  upon  the  vagus  centre,  or 
to  weakness  of  the  heart-muscle  itself.  The  pixlse-beat  rarely  sinks  be- 
low 20.  Prentice,  at  the  Association  of  American  Physicians  at  ^\'asl^- 
ington,  showed  a  patient  with  attacks  of  unconsciousness,  who  had,  ])ar- 
ticularly  during  the  attacks,  but  also  in  the  intervals,  a  pulse  as  low  as 
12  per  minute.  Such  cases  are  extremely  rare.  Cases  are  on  record  in 
which  the  pulse  has  fallen  to  8  or  9  beats  in  the  minute.  At  the  dis- 
cussion which  followed  the  exhibition  of  Prentice's  patient,  both  Jaeobi 
and  Kinnicutt  referred  to  similar  cases  associated  with  epileptic  seizures, 
in  one  of  which  the  pulse  fell  as  low  as  7  in  the  minute. 

Treatment  of  Palpitation  and  Arrhythmia. — An  important 
element  in  many  cases  is  to  get  the  patient's  mind  quieted,  and  lie  can  be 
assured  that  there  is  no  actual  danger.  The  mental  element  is  oftentimes 
very  strong.  In  palpitation,  before  using  medicines,  it  is  well  to  try  the 
effect  of  hygienic  measures.  As  a  rule,  moderate  exercise  may  bo  taken 
with  advan*^age.  Regular  hours  should  be  kept,  and  at  least  ten  liours 
out  of  the  twenty-four  should  be  spent  in  the  recumbent  posture.  A  tepid 
bath  may  be  taken  in  the  morning,  or,  if  the  patient,  is  weakly  and  nerv- 
ous, in  the  evening,  followed  by  a  thorough  rubbing.  Hot  baths  and  the 
Turkish  bath  should  be  avoided.  The  dietetic  management  is  most  im- 
portant. It  is  best  to  prohibit  absolutely  alcohol,  tea,  and  coffee.  The 
diet  should  be  light  and  the  patient  should  avoid  taking  largo  meals. 
Articles  of  food  known  to  cause  flatulency  should  not  be  used.  If  a 
smoker,  the  patient  should  give  up  tobacco.  Sexual  excitement  is  par- 
ticularly pernicious,  and  the  patient  should  be  Avarned  specially  on  this 
point.  For  the  distressing  a  .tacks  of  palpitation  which  occur  with  neur- 
asthenia, particularly  in  women,  a  rigid  Weir-Mitchell  course  is  the  most 
satisfactory.  It  is  in  these  cases  that  we  find  the  most  distressiiiir  throb- 
bing i'^  ':he  abdomen,  which  is  apt  to  come  on  after  meals,  and  is  very 
much  aggravated  by  flatulency.  The  cases  of  palpitation  due  to  excesses 
or  to  errors  in  diet  and  dyspepsia  are  readily  remedied  by  hygienic  meas- 
ures. 


NEUROSES  OP  THE  HEART. 


G55 


A  course  of  iron  is  often  useful.  Stryclmia  is  particularly  valuable, 
nnd  is  perhaps  best  f.r  ministered  as  the  tincture  of  nux  vomica  in  large 
(loscrf.  Very  little  good  is  obtained  from  the  smaller  quantities.  It  should 
be  given  freely,  20  minims  three  times  a  day. 

I  f  there  is  great  rapidity  of  action,  aconite  may  fc  !  tried  or  veratrum 
viride.  There  are  cases  associated  with  sleeplessness  and  restlessness  which 
fire  greatly  benefited  by  bromide  of  potassium.  Digitalis  is  very  rarely 
indicated,  but  in  obstinate  cases  it  may  be  tried  with  the  nux  vomica. 

Cases  of  heart  hurry  are  often  extremely  obstinate,  as  may  be  judged 
from  the  case  of  the  physician  reported  by  II.  C.  Wood,  in  whom  the  con- 
dition persisted  in  spite  of  all  measures  for  fifty  years.  The  bromides  are 
sometimes  useful ;  the  general  condition  of  neurastlienia  should  be  treated, 
and  during  the  paroxysm  an  ice-bag  may  be  placed  upon  the  heart,  or 
Loitcr's  coil,  through  which  ice-water  may  be  passed.  Electricity,  in  the 
form  of  galvanism,  is  sometimes  serviceable,  and  for  its  mental  effect  the 
Franklinic  current.  For  tlie  condition  of  slow  pulse  but  little  can  be 
done.    A  great  majority  of  the  cases  are  not  dangerous. 


Angina  Pectoris. 


Stenocardia,  or  the  bi'east-pang  described  by  Heberden,  is  not  an  inde- 
pendent affection,  but  a  symptom  associated  with  a  number  of  morbid 
eonditions  of  the  heart  and  vessels,  more  particularly  with  sclerosis  of 
the  root  of  the  aorta  and  changes  in  the  coronary  arteries.  True  angina, 
whieh  is  a  rare  disease,  is  characterized  by  paroxysms  of  agonizing  pain 
in  tlie  region  of  the  heart,  extending  into  the  arms  and  neck.  In  violent 
attacks  there  is  a  sensation  of  impending  death. 

Etiology  and  Pathology. — It  is  a  disease  of  adult  life  ana  occurs 
almost  exclusively  in  men.  Arterio-sclerosis,  hypertrophy  of  the  heart, 
increased  arterial  tension,  or  aortic  insufficiency  are  often  present,  while 
anatomical  changes  in  the  aorta,  arteries,  and  myocardium  are  almost 
constant.  No  instance  oi  true  angina  has  come  under  my  observation  in 
which  tlicre  were  not  signs  of  cardio-vascular  clianges.  The  immediate 
exciting  cause  of  an  attack  is  most  frequently  sudden  exertion  or  emo- 
tional excitement.  The  paroxysm  may  come  on  in  the  daytime,  but  in 
some  of  tlie  worst  cases  they  occur  at  night.  The  nature  of  the  affection 
is  di  ,j,,,al.    The  folloAving  views  have  been  entertained. 

(1)  Tluit  it  is  a  neuralgia  of  the  cardiac  nerves.  In  the  true  form  the 
aD;oiii/;ing  cramp-like  character  of  the  pain,  the  suddenness  of  the  onset, 
and  tlic  associated  features,  are  unlike  any  neuralgic  affection.  The  pain, 
however,  is  undoubtedly  in  the  cardiac  plexus  and  radiates  to  adjacent 
nerves.  It  is  interestiiag  to  note  in  connection  with  the  almost  constant 
sclerosis  of  the  coronary  arteries  in  angina  that  Thoma  has  found 
marked  sclerosis  of  the  temporal  artery  in  migraine  and  Dana  has  met 
with  local  thickening  of  the  arteries  in  some  cases  of  neuralgia    (2)  Heb- 


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656 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


crdeu  believed  that  it  was  a  cramp  of  the  heart  muscle  itself.  This 
Avonld  explain  the  agonizing  character  of  the  pain  and  the  suddenness  of 
the  onset  as  well  as  the  frequency  of  the  fatal  termination ;  hut  if  tlio 
cramps  were  general  in  the  heart-muscle  and  similar  to  those  which  occur 
in  the  voluntary  muscles,  death  would  invariably  ensue  with  great  rapid- 
ity. Cramp  of  certain  muscular  territories  would  explain  the  attacii. 
(3)  That  it  is  due  to  the  extreme  tension  of  the  ventricular  walls,  in 
consequence  of  an  acute  dilatjition  associated,  in  the  majority  of  cases, 
with  affection  of  the  coronary  arteries.  Traube,  who  supported  tliis  view, 
held  that  the  agonizing  pain  resulted  from  the  great  stretching  and  ten- 
sion of  the  nerves  in  the  muscular  substance.  A  modified  form  of  tiiis 
view  is  that  there  is  a  spasm  of  the  coronary  arteries  with  great  increase 
of  the  intracardiac  pressure. 

In  fatal  cases  of  angina  the  coronary  arteries  are  almost  inviirialily 
diseased,  either  in  their  main  division,  or  there  is  chronic  endarteritis  with 
great  narrowing  of  the  orifices  at  the  root  of  the  aorta.  Experimont^illy, 
occlusion  of  the  coronary  arteries  produces  blowing  of  the  heart's  action, 
gradual  dilatation,  and  death  within  a  very  few  minutes.  Cohnhoini  lias 
shown  that  in  the  dog  ligation  of  one  of  the  large  coronary  branches  ])ro- 
duces  within  a  minute  a  condition  of  arrhythmia,  and  within  two  niimites 
the  heart  ceases  in  diastole.  These  experiments,  however,  do  not  throw 
much  light  upon  the  etiology  of  angina  pectoris.  Extreme  sclerosis  of 
the  coronary  arteries  is  common,  and  a  large  majority  of  the  cases  ])respiit 
no  symptoms  of  angina.  Even  in  the  cases  of  sudden  death  due  to 
blocking  of  an  artery,  particularly  the  anterior  branch  of  the  coronary 
artery,  there  is  usually  no  great  pain  either  before  or  during  the  attack. 
The  lesions  of  the  nerves  described  by  Lanceveaux,  Hadden,  and  others 
cannot  yet  be  correlated  satisfactorily  with  the  symptoms  of  tmo  anjjina. 
Various  forms  of  true  angina  have  been  recognized,  but  the  difforeiiees,  in 
the  majority  of  instances,  are  not  sufficiently  marked  to  permit  a  separa- 
tion. Reference  may  be  made,  however,  to  the  angina  pectoris  vaxo-im- 
toria  described  by  Nothnagel.  In  this  the  attack  may  come  on  after  ex- 
posure to  cold.  There  is  general  spasm  of  the  peripheral  arteries  \\\\\\  a 
sense  of  stiffness  and  deadness  in  the  extremities,  and  pallor,  cyanosis,  and 
lowering  of  the  temperature.  The  arteries  are  small  and  coutiacted. 
There  is  sometimes  a  feeling  of  faintness  or  even  a  loss  of  consciousness. 
With  this  there  is  a  sense  of  pressure,  tension,  or  even  agonizinj^  })ain  in 
the  cardiac  region.  The  pulse,  however,  is  regular,  and  there  are  no  signs 
of  disease  of  the  heart.  The  condition  is  supposed  to  depend  u])on  .1 
wide-spread  spasm  of  the  peripheral  arteries.  I  have  never  recognized  a 
case  of  this  kind,  although  certain  of  its  features  are  not  at  all  uncommon 
in  the  pseudo-angina. 

Symptoms. — Usually  during  exertion  or  intense  mental  emotion  the 
patient  is  seized  with  an  agonizing  pain  in  the  region  of  the  heart  and  a 
sense  of  constriction,  as  if  the  heart  had  been  seized  in  a  vise.    Tlic  pams 


NEUROSES  OP  THE  HEART. 


657 


iti 


radiiito  up  the  neck  and  down  tlio  arm  and  there  may  be  numbness  of  the 
fin;,'ers  or  in  the  cardiac  region.  Tlio  face  is  usually  pallid  and  may  as- 
sume an  ashy-gray  tint,  and  not  infrequently  a  j)rofuse  sweat  breaks 
out  over  the  surface.  Dyspnoea  is  not  usually  i)resent.  The  paroxysm 
lusts  j'rom  several  seconds  t  a  minute  or  two,  during  which,  in  severe  at- 
tacks, the  patient  feels  as  if  death  were  imminent.  There  is  great  rest- 
lessness and  anxiety,  and  the  patient  nuiy  drop  dead  at  the  height  of  the 
attack  or  faint  and  pass  away  in  syncope.  The  condition  of  the  lieart 
(luring  the  attack  is  variable;  the  pulsations  may  be  uniform  and  regular. 
Tiie  i)ulso  tension,  however,  is  usually  increased,  but  it  is  surprising,  even 
ill  cases  of  extreme  severity,  liow  slightly  the  character  of  the  pulse  may 
be  altered.  After  the  attack  there  may  be  eructa-tions,  or  the  passage  of  a 
largo  quantity  of  clear  urine.  The  patient  usually  feels  exhausted,  and 
for  a  day  or  two  may  be  badly  shaken ;  in  other  instances  in  an  liour  or 
two  the  patient  feels  himself  again.  The  attacks  may  recur  at  intervals 
of  a  few  weeks,  or  perhaps  not  for  many  years.  There  are  iiulividuals  who 
have  well-marked  anginal  attacks  for  years,  and,  exce])t  during  the  par- 
oxysms, suffer  but  slight  inconvenience. 

Diagnosis. — There  are  many  grades  of  true  angina.  A  man  may 
have  slight  praecordial  pain,  a  sense  of  distress  and  uneasiness,  and  radia- 
tion of  the  pains  to  the  arm  and  neck.  Such  attacks  following  slight  ex- 
ertion, an  indiscretion  in  diet,  or  a  disturbing  emotion  may  alternate  with 
attackb  of  much  greater  severity,  or  they  may  occur  in  connection  with 
a  pulse  of  increased  tension  and  signs  of  general  arterio-sclerosis.  In  the 
miltler  grades  the  diagnosis  cannot  rest  upon  the  symptoms  of  the  attack 
itsolf,  since  they  may  be  simulated  by  the  pseudo-angina;  but  the  diag- 
nosis should  be  based  upon  the  examination  of  the  circulatory  system. 
In  true  angina,  even  in  the  milder  forms,  signs  of  arterio-sclerosis  are 
usually  present.  In  a  case  presenting  attacks  of  precordial  pain  or  pains 
in  the  cervical  or  brachial  plexuses,  if  the  aortic  second  sound  is  clear,  not 
ringing,  the  pulse  tension  low,  and  the  peripheral  arteries  soft,  the  diag- 
nosis of  true  angina  should  not  be  made.  After  all,  the  chief  difficulty, 
however,  arises  in  the  cases  of  the  hysterical  or  pseiido-an/jinn. 

This  is  a  common  affection  in  women,  but  may  occur  also  in  neuras- 
tlionic  men.  It  is  in  this  form  particulai'ly  that  we  see  vaso-motor  i)he- 
nomena.  The  patient  may  complain  of  great  coldness  of  the  hands  or 
feet,  or  a  general  feeling  of  deadness  and  stiffness,  often  with  pain  in  the 
back  of  the  head  and  neck.  The  attacks  recur  frequently,  a-nd  sometimes 
become  worse  at  each  monthly  period.  They  may  come  on  with  great 
severity  at  the  menopause.  Worry  and  disturbing  emotions  of  all  kinds 
may  at  any  time  precipitate  an  attack.  Iluchard  has  given  in  concise 
form  the  following  points  in  diagnosis  between  the  true  and  hysterical 
angina:  '  •     • 


;«V. 


m-'h 


Sir 


■ii.   .-, 

■'A  :,  '       "■'. 

Sii  ,  ;■■■  i.   ;  ■ 


Ir 


is'f;  ?5; 


658 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


TUUE   ANGINA. 


Most  coriimoii  between  the  ages 
of  forty  and  fifty  years. 

Most  common  in  men.  Attacks 
brougiit  on  by  exertion. 

Attacks  rarely  periodical  or  noc- 
turnal. 

Not  associated  with  other  symp- 
toms. 

Vaso-motor  form  rare.  Agoniz- 
ing pain  and  sensation  of  compres- 
sion by  a  vise. 

Pain  of  short  duration.  Atti- 
tude :  silence,  immobility. 

Lesions:  sclerosis  of  coronary 
artery. 

Prognosis  grave,  often  fatal. 

Arterial  medication. 


PSEUDO-ANOINA. 

At  every  age,  even  six  years. 

Most  common  in  women.  At- 
tacks spontaneous. 

Often  periodical  and  nocturnal. 

Associated  with  nervous  symp- 
toms. 

Vaso-motor  form  c  n  m  ni  o  n. 
Pain  less  severe;  sensation  (jf  dis- 
tention. 

Pain  lasts  one  or  two  lionrs. 
Agitation  and  activity. 

Neuralgia  of  nerves  and  ciirdio- 
plexus. 

Never  fatal. 

Antineuralgic  medication. 


There  are  cases  in  women  which  are  sometimes  very  puzzling;  for 
instance,  when  the  patient  presents  a  combination  of  marked  hystcriciil 
manifestations  and  attacks  of  angina  and  has  aortic  insufficiency.  In 
such  instances  the  patient  should  receive  the  benefit  of  the  doubt  and 
be  treated  for  true  angina. 

Prognosis. — Cardiac  pain  without  evidence  of  arterio-sclcrosis  or 
valve  disease  is  not  of  much  moment.  True  angina  is  almost  invariably 
associated  with  marked  cardio-vascular  lesions  in  which  the  prognosis  is 
always  grave.  With  judicious  treatment  the  attacks,  however,  may  be 
long  deferred,  and  a  few  instances  recover  completely.  The  prognosis  is 
naturally  more  serious  with  aortic  insufficiency  and  advanced  arterio- 
sclerosis. Patients  who  have  had  Avell-marked  attacks  may  live  for  many 
years,  but  much  depends  npon  the  care  with  which  they  regulate  their 
daily  life. 

Treatment. — Patients  subject  to  this  affection  should  live  a  quiet 
life,  avoiding  particularly  excitement  and  sudden  muscular  exertion. 
During  the  attack  nitrite  of  amyl  should  be  inhaled,  as  advised  by  Lauder 
Brunton.  From  two  to  five  drops  may  be  placed  upon  cotton-wool  in  a 
tumbler  or  upon  the  handkerchief.  This  is  frequently  of  great  service  in 
the  attack,  relieving  the  agonizing  pain  and  distress.  Subjects  of  tlie  dis- 
ease should  carry  the  perles  of  the  nitrite  of  amyl  Avith  them,  and  use  them 
on  the  first  indication  of  an  attack.  In  some  instances  the  nitrite  of  amy! 
is  quite  powerless,  though  given  freely.  If  within  a  minute  or  two  relief  is 
not  obtained  in  this  way,  chloroform  should  at  once  be  given.  A  few  in- 
halations act  promptly  and  give  great  relief.  Should  the  pains  continue, 
a  hypodermic  of  morphia  may  be  administered. 


!  ill 


CONGENITAL  AFFECTIONS  OP  THE  HEART. 


659 


In  the  intervals,  nitroglycerin  may  be  given  in  full  doses,  as  recom- 
mended by  Murrell,  or  the  nitrite  of  sodium  (Matthew  Hay).  The  nitro- 
glycerin should  be  nsed  for  a  long  time  and  in  increasing  doses,  beginning 
with  one  minim  three  times  a  day  of  the  one  per  cent  solution,  and  in- 
croiising  the  dose  one  minim  every  five  or  six  days  until  the  patient  com- 
pliiins  of  flushing  or  headache. 

lluchard  recommends  the  iodides,  believing  that  their  prolonged  use 
inlluences  the  arterio-sclerosis.  l\venty  grains  three  times  a  day  niay  be 
given  for  several  years,  omitting  the  medicine  for  about  ten  days  in  each 
month.  In  some  instances  this  treatment  is  certiunly  be  neticial.  Two 
men,  both  with  arterio-sclerosis,  ringing,  accentuated  aortic  sound,  and 
attacks  of  true  angiiui,  have  under  its  use  remained  praeticuilly  free  from 
attacks — one  case  for  nearly  three,  and  the  other  for  fully  four  years. 
Tliis  treatment  is,  however,  not  always  satisfactory,  and  I  have  had  several 
ciises  in  which  the  condition  has  not  been  at  all  relieved  by  it. 

For  the  pseudo-angina,  the  treatment  must  be  directed  to  the  general 
nervous  condition.  Electricity  is  sometimes  very  beneficial,  particularly 
the  Franklinic  form. 


VI.  CONGENITAL  AFFECTIONS  OF  THE  HEART. 

These  have  only  a  limited  clinical  interest,  as  in  a  large  propor- 
tion of  the  cases  the  anomaly  is  not  compatible  with  life,  and  in  others 
nothing  can  be  done  to  remedy  the  defect  or  even  to  relieve  '  lie  symp- 
toms. 

The  congenital  affections  result  from  interruption  of  the  normal  course 
of  development  or  from  infiammatory  processes^-eudocarditis ;  sometimes 
from  a  combination  of  both. 

(fi)  Of  general  anomalies  of  development  the  following  conditions  may 
be  mentioned :  Acardia,  absence  of  the  heart,  which  has  been  met  with 
in  the  monstrosity  known  by  the  same  name ;  clonhle  heart,  which  has 
occasionally  been  found  in  extreme  grades  of  fcetal  deformity;  dextro- 
cardia, in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part  of 
a  general  transposition  of  the  viscera ;  ectopia  cordis,  a  condition  asso- 
ciated with  fission  of  the  chest  wall  and  of  the  abdomen.  The  heart  may 
be  situated  in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the 
abdominal  variety  the  condition  is  very  rarely  compatible  with  extra- 
uterine life. 

{!>)  Anomalies  of  the  Cardiac  Septa. — The  septa  of  both  auricles  and 
ventricles  may  be  defective,  in  which  case  the  heart  consists  of  but  two 
chambers,  the  cor  bilocujare  or  reptilian  heart.  In  the  septum  of  the  auri- 
cles there  is  a  very  common  defect,  owing  to  the  fact  that  the  membrane 
closing  the  foramen  ovale  has  failed  at  one  point  to  become  attached  to  the 
ring,  and  leaves  a  valvular  slit  which  may  be  large  enough  to  admit  the 


%  '1 


!?« 


i  n 


«(l    a;  •  >  I         *11 


..1i\ 


?  ■ 


I'.iW^K  -^'1 


60O 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


ii  I  ;•  ■  iiiiiiiiaiMi.iLLL 


handle  of  a  soalpel.  Neitlier  this  nor  tlio  small  cribriform  perforations  of 
tho  mombram)  aro  of  any  significance. 

The  foramen  ovale  may  he  patent  without  a  trace  of  memhrane  cios- 
ing  it.  In  some  instances  this  exists  with  other  serious  defects,  siuli  as 
stenosis  of  the  pulmonary  artery,  or  imperfection  of  the  veiitriiniliir  sop- 
turn.  In  others  tho  patent  foramen  ovale  is  the  oidy  anomaly,  iiiul  in 
many  instances  it  does  not  a})pear  to  have  caused  any  emharra.ssnicnt,  us 
tho  condition  has  been  found  in  persons  who  have  died  of  various  affectidns. 
Tho  ventricular  septum  may  be  absent,  tho  condition  known  as  trilocular 
heart.  Much  more  frequently  there  is  a  small  defect  in  tho  up])cr  portion 
of  the  septum,  either  in  the  situation  of  the  mend^ranous  portion  known 
as  the  "  undefended  space  "  or  in  the  region  situated  just  anterior  to  tliis. 
The  anomaly  is  very  frequently  associated  with  narrowing  of  tho  pul- 
monary  oriticc  or  of  the  conus  arteriosus  of  the  right  ventricle. 

(c)  Anomalies  and  Lesions  of  the  Valves.— Numerical  anomalies  of  tlio 
valve  are  not  uncommon.  The  semilunar  segments  at  the  arterial  oritici's 
are  not  infrequently  increased  or  diminished  in  immber.  Supernumer- 
ary segments  are  more  frequent  in  the  pulmonary  artery  than  in  the  aorta. 
Four,  or  sometimes  live,  valves  have  been  found.  The  segments  may  ho  of 
equal  size,  but,  as  a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspid  condition.  In  my  experience,  this  is  most  frequent 
in  the  aortic  valve.  Of  twenty-one  instances  only  two  occurred  at  the 
pulmonary  orifice.  Two  of  the  valves  have  united,  and  from  the  ventricu- 
lar face  show  either  no  trace  of  division  or  else  a  slight  depression  indicat- 
ins:  Avhere  the  union  had  occurred.  From  the  aortic  side  there  is  usually 
to  be  seen  some  trace  of  division  into  two  sinuses  of  Valsidva.  There  lias 
been  a  discussion  as  to  the  origin  of  this  condition,  whether  it  is  really  an 
anomaly  or  whether  it  is  not  due  to  endocarditis,  fcetal  or  post-natal.  The 
combined  segment  is  usually  thickened,  but  the  fact  that  this  anomaly  is 
met  with  in  the  fcetus  without  a  trace  of  sclerosis  or  .endocarditis  shows 
that  it  may,  in  some  cases  at  least,  result  from  a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the 
liability  of  the  combined  valve  to  sclerotic  changes.  Except  two  fietiil 
specimens  all  of  my  ciises  showed  thickening  and  deformity,  and  in  fifteen 
of  those  which  I  have  reported  death  resulted  directly  or  indirectly  from 
the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no 
significance  ;  they  occur  in  a  considerable  proportion  of  all  bodies. 

Anomalies  of  the  auriculo-ventricular  valves  are  not  often  met  with. 

Fa3tal  endocarditis  may  occur  either  at  the  arterial  or  auriculo-ven- 
tricular orifices.  It  is  nearly  always  of  the  chronic  or  sclerotic  variety. 
Very  rarely  indeed  is  it  of  the  warty  or  verrucose  form.  There  aro  little 
nodular  bodies,  sometimes  six  or  eight  in  number,  on  the  mitral  and  tri- 
cuspid segments — the  nodules  of  Albini — which  represent  the  remains  of 


CONGENITAL   AFFRCTIONS  OF  THE  HEART. 


601 


fd'tiil  structuroa,  and  must  not  bo  niistukon  for  endociinlial  outgrowths. 
Tlio  little  roundod,  l)i'iid-liko  luvniorrhagos  of  a  deep  i)uri)lo  color,  which 
iirc  vory  common  on  the  heart  valves  of  children,  ar(3  also  not  to  he  mis- 
takoii  for  the  products  of  endocarditis.  In  fu)tal  endocarditis  the  segments 
are  usually  thickened  at  the  edges,  shrunken,  and  smooth.  In  the  mitral 
and  tricuspid  valves  the  cusps  are  found  united  and  the  chordiu  tendinea) 
uri!  thickened  and  shortened.  In  the  semilunar  valves  all  trace  of  the 
scgnieuts  has  disappeared,  leaving  u  stiff  membranous  diaphragm  perfo- 
riit(Ml  l)y  an  oval  or  rouiuletl  orifice.  It  is  sometimes  very  dilllcult  to  say 
whether  this  condition  has  resulted  from  fcetal  endocarditis  or  whether  it 
is  an  error  in  development.  In  very  many  instances  the  processes  are 
(•()inl)ined  ;  an  anomalous  valve  becomes  the  seat  of  chronic  sclerotic 
changes,  and,  according  to  liauchfuss,  endocarditis  is  more  common  on 
the  right  side  of  the  heart  only  because  the  valves  are  here  most  often  the 
seat  of  developmental  errors. 

Lesions  at  the  Pulmonary  Orifice. — Stenosis  of  this  orlfico  is  one  of  the 
ooininonost  and  most  important  of  congenital  heart  affections.     A  slow 
oiidocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the 
orifice  to  such  a  degree  that  it  only  admits  the  smallest-sized  probe.     In 
some  of  the  cases  the  smooth  membranous  condition  of  the  combined 
sognionts  is  such  that  it  would  appear  to  be  the  result  of  faulty  develop- 
ment.   In  some  instances  vegetations  develop.     The  condition  is  com- 
patiljlc  with  life  for  many  years,  and  in  a  considerable  proportion  of  the 
cases  of  heart-disease  above  the  tenth  year  this  lesion  is  present.     With  it 
tliero  may  be  defect  of  the  ventricular  septum.     Obliteration  or  atresia  of 
the  pulmonary  orifice  is  less  frequent  but  a  more  serious  condition  than 
stenosis.    It  is  of  necessity  associated  with  either  imperfection  of  the  ven- 
tricular septum  or  patency  of  the  foramen  ovale  and  persistence  of  the 
(Iiictus  arteriosus.     Stenosis  of  the  conus  arteriosus  of  the  right  ventricle 
exists  ill  a  considerable  proportion  of  the  cases  of  obstruction  at  the  pul- 
monary orifice.    At  the  outset  a  developmental  error,  it  may  bo  combined 
with  sclerotic  changes.     The  ventricular  septum  is  imperfect,  the  foramen 
ovale  is  usually  open,  and  the  ductus  arteriosus  patent.    These  three  lesions 
at  the  pulmonary  orifice  constitute  the  most  important  group  of  all  con- 
gi'iiital  cardiac  affections.     Of  181  instances  of  various  congenital  anoma- 
lies I'oUected  by  Peacock  111)  cases  came  under  this  category,  and,  accord- 
ing to  this  author,  in  eighty-six  per  cent  of  the  patients  with  congenital 
hoait-disease  living  beyond  the  twelfth  year  the  lesion  is  at  this  orifice. 

Congenital  lesions  of  the  aortic  orifice  are  not  very  frequent.  Rauch- 
fuss  his  collected  24  cases  of  stenosis  and  atresia,  and  stenosis  of  the  left 
conus  arteriosus  may  also  occur,  a  condition  which  is  not  incompatible 
with  prolonged  life.  Ten  of  the  sixteen  cases  tabulated  by  Dilg  were 
over  thirty  years  of  age. 

Symptoms  of  Congenital  Heart-disease. — Cyanosis  occurs  in 
over  ninety  per  cent  of  the  cases  and  forms  so  distinctive  a  feature  that 


*i 


I 


'.     '»       v'»  .  iM»l 


G62 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


mm 


tho  terms  "blue  diHoasc "  and  "  morbuH  cn'rulcMr, "  arc  priicficnilv 
HynonyinH  for  ooiiffoiiitul  hcart-discaso.  1'ho  lividity  in  a  inaj(»ritv  (if 
eiusps  a])peara  early,  within  the  HrHt  week  of  life,  and  may  be  geiu'ial  (ir 
confined  to  the  lips,  nose,  and  ears,  and  to  the  finj^ers  and  toes.  In  soriic 
instances  there  is  in  addition  a  j^c^ieral  dnsky  sutTusion,  and  in  tlif  most 
extreme  j^rades  the  skin  is  almost  pnrple.  It  may  vary  a  good  deal  and 
may  only  be  intense  on  exertion.  Tiio  external  tempcu'ature  i^  Idw, 
Dyspnu'a  on  exertion  and  cough  are  (;ommon  symptoms.  The  cliihhcii 
rarely  thrive  and  often  display  a  lethargy  of  both  mind  and  body.  Tlu' 
fingers  and  toes  are  (dubbed  in  a  grade  rarely  met  with  in  any  other  alTw- 
tion.  The  cause  of  the  cyanosis  has  been  much  discussed.  .M(ir::iii:tii 
referred  it  to  the  general  (!()nge8tion  of  tho  venous  system  due  to  (ilistriic- 
tion,  and  this  view  was  supported  in  a  paper,  one  of  the  ablest  that  has 
been  written  on  tho  subject,  by  Moreton  Stille.  Morrison's  recent  analysis 
of  75  eases  of  congenital  heait-disease  shows  that  closure  of  the  pultnonary 
orifice  and  paten(!y  of  the  foramen  ovale  and  tho  ventricular  seiituiii  arc 
tho  lesions  most  frequently  associated  with  cyanosis,  and  he  conchnlcs  that 
tho  deficient  aeration  of  the  blood  owing  to  diminished  lung  function  is 
tho  most  important  factor.  Another  view,  advocated  by  William  Hunter, 
was  that  the  discoloration  was  duo  to  the  admixti.  j  in  the  heart  of  venous 
and  arterial  blood  ;  but  lesions  may  exist  which  permit  of  very  free  mixt- 
ure without  producing  cyanosis. 

Diagnosis. — In  the  case  of  children,  cyanosis,  with  or  without  en- 
largement of  the  heart,  and  tho  existence  of  a  murmur  are  sufiieiont,  us  a 
rule,  to  determine  the  presence  of  a  congenital  heart-lesion.  The  cyano- 
sis gives  us  no  clew  to  the  precise  nature  of  the  trouble,  as  it  is  a  Kym|itoni 
common  to  many  lesions  and  it  may  bo  absent  in  certain  conditi(jns.  The 
murmur  is  usually  systolic  in  character.  It  is,  however,  not  always  pres- 
ent, and  there  are  instances  on  record  of  complicated  congenital  lesions  in 
which  tho  examination  showed  normal  heart-sounds.  In  two  or  throe 
instances  fa'tal  endocarditis  has  been  diagnosed  in  gravida  by  the  pres- 
ence of  a  rough  systolic  murmur,  and  tho  condition  has  been  corroborated 
subsequent  to  the  birth  of  the  child.  Hypertrophy  is  present  in  a  major- 
ity of  the  cases  of  congenital  defect.  It  is  impossible  in  the  scope  of  a 
work  of  this  sort  to  enter  upon  elaborate  details  in  diit'erential  diairnosis 
between  the  various  congenital  heart-lesions.  I  here  abstract  tho  conclu- 
sions on  this  question  given  by  Ilochsinger  in  ais  recent  monogra})li  :* 

"(1)  In  childhood,  loud,  rough,  musical  heart-murmurs,  with  normal 
or  only  slight  increase  in  the  hoart-dulness,  occur  only  in  congenital  luart- 
diseaso.  The  acquired  endocardial  defects  with  loud  heart-murmuis  in 
young  children  are  almost  always  associated  with  great  increase  in  the 
heart-dulness. 

"  (2)  In  young  children  heart-murmurs  with  great  increase  in  the 

y  ■  *  Die  Auscuitatiou  des  kindlichen  Uerzens,  Wien,  18D0. 


DEGENERATIONS. 


003 


ranliiic  dulness  and  feeblo  apex  boat  HiijjgoHt  oongotiital  oliangcs.  T\w 
iiicnMiHt'd  dultioss  ia  chiefly  of  tho  ri^ht  heart,  whcmiw  tho  left  ia  only 
Hlijj;iit!y  altered.  On  the  other  hand,  in  tlie  accjiiired  eiidt.caniiti.s  in  ehil- 
(hcti,  the  h'ft  heart  in  ehielly  atTeeted  and  the  apex  heat  is  visihle  ;  tlie 
dilatation  of  tho  rif^ht  heart  conion  late  and  docs  not  materially  change 
t\w  iiiereased  strength  of  tho  apox  l)cat. 

"  (;3)  Tho  entire  ahHoneo  of  inurmnrs  at  tho  apex,  with  their  evident 
j)ivsc?i('e  in  tho  region  of  the  anricloH  and  over  tho  |)ulnionary  orifice,  in 
uhvays  an  ini[)oriant  olonient  in  differential  diagnosis,  uiid  points  ratiier 
to  SI  ptinn  defect  or  pulmonary  stenosis  than  to  endocardilis. 

"  (4)  An  abnornudly  Avoak  second  pulmonic;  sound  associated  with  u 
distinct  systolic  murmur  is  a  symptom  which  in  early  childhood  is  only  to 
JH"  explained  by  the  assumption  of  a  congenital  i)ulmoiuiry  stenosis,  and 
jMisscsses  therefore  an  importance  from  a  point  of  dillorential  diagnosis 
which  is  not  to  bo  underestimated. 

"  (.'))  Absence  of  a  palpable  thrill,  despite  loud  murmurs  wliicdi  are 
lu'anl  ov(!r  the  whole  pra?cordial  region,  is  rare  except  with  congenital 
dclVcts  in  the  septum,  and  it  speaks  therefore  against  an  accjuired  cardiac 
alTi'ction. 

"  (r»)  Loud,  especially  vibratory,  systolic  murmurs,  witli  the  point  of 
maximum  intensity  over  tho  upper  third  of  the  sternum,  associated  with 
a  la(  k  of  marked  symptoms  of  hypertrophy  ot  the  loft  ventricle,  are  very 
iiiipurtant  for  the  diagnosis  of  a  persistence  of  the  ductus  liotalli,  and  can- 
not bo  explained  by  the  assumption  of  an  endocarditis  of  tho  aortic  valve." 

Treatment. — Tho  child  should  bo  warmly  clad  and  guarded  from  all 
circumstances  liable  to  excite  bronchitis.  In  tho  attacks  o£  urgent  dysp- 
noea with  lividity  blood  should  be  freely  lot.  Saline  cathartics  are  also 
usofiil.  Digitalis  must  bo  used  with  care,  and  it  is  sometimes  beneficial  in 
tlie  later  stages.  When  tho  compensation  fails,  the  indications  for  treat- 
uieut  are  those  of  valvular  disease  in  adults. 


III.  DISEASES  OF  THE  ARTERIES. 

I.  DEGENERATIONS. 

Fdffy  degeneration  of  the  intima  is  extremely  common,  and  is  scon  in 
the  form  of  yellowish-whito  spots  in  the  aorta  and  larger  vessels.  Calcijica- 
tion  uf  the  arterial  wall  follows  fatt}'^  degeneration,  atheromatous  changes, 
and  sclerosis.  It  occurs  in  either  the  intima  or  tho  media.  In  the  latter 
it  produces  what  is  sometimes  known  as  annular  calcjification,  which  oc- 
curs ])articularly  in  the  middle  coat  of  medium-sized  vessels  and  may  con- 
vert thorn  into  firm  tubes.  Calcification  of  the  intima  is  a  common 
terminal  process  of  arterio-sclerosia. 


1     u 


I') 


1*8  It 


G64 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Hijaline  degeneration  may  attack  either  the  larger  or  the  sniiillcr 
vessels.  In  the  former  the  intima  is  converted  into  a  smooth,  homogoru'oiis 
substance,  and  it  is  commonly  an  initial  stage  of  arterio-sclerosis.  in  the 
smaller  arteries  and  capillaries  the  hyaline  degeneration  is  often  soon, 
particularly  in  the  glomeruli  of  the  kidney.  Its  exact  production  is  still 
a  matter  of  some  doubt.  "  It  appears  to  arise  principally  by  homogeneous 
coagulation  of  an  albuminous  fluid,  either  within  tlu  vessels  or  iniiltnitinir 
the  cells  and  the  hyaline  transformation  of  proliferating  cells  and  of  leu- 
cocytes." 


II.  ARTERIO-SCLEROSIS  (Arterio-capillary  Fibrosis). 


1       ,  ■*  ) 


The  conception  of  arterio-sclerosis  as  an  independent  affection — a  gen- 
eral disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

DefLnition. — A  condition  of  thickening,  diffuse  or  circumscribed,  of 
the  intima,  consequent  upon  primary  changes  in  the  media  and  adveniitia. 
The  process  leads,  in  the  larger  arteries,  to  what  is  known  as  atheroma  or 
endarteritis  deformans. 

Etiology. — (1)  As  an  involution  process  arterio-sclerosis  is  an  ac- 
companiment of  old  age,  and  is  the  expression  of  the  natural  wear  and 
tear  to  which  the  tubes  are  subjected.  Longevity  is  a  vascular  question, 
and  has  been  well  expressed  in  the  axiom  that  "  a  man  is  only  as  old  as 
his  arteries."  To  a  majority  of  men  death  comes  primarily  or  secondarily 
through  this  portal.  The  onset  of  what  may  be  called  physiological 
arterio-sclerosis  depends,  in  the  first  place,  upon  the  quality  of  arterial  tis- 
sue (vital  rubber)  which  the  individual  has  inherited,  and  secondly  upon 
the  amount  of  wear  and  tear  to  which  he  has  subjected  it.  That  the 
former  plays  the  most  important  role  is  shown  in  the  cases  in  which 
arterio-sclerosis  sets  in  early  in  life  in  individuals  in  whom  none  of  the 
recognized  etiological  factors  can  be  found.  Thus,  for  instance,  a  man 
of  twenty-eight  or  twenty-nine  may  have  arteries  of  sixty,  and  a  man 
of  forty  may  present  vessels  as  much  degenerated  as  they  should  be  at 
eighty.  Entire  families  sometimes  show  this  tendency  to  early  arterio- 
sclerosis, a  tendency  which  cannot  be  explained  in  any  other  Avay  than 
that  in  the  make-up  of  the  machine  bad  material  was  used  for  the 
tubing. 

More  commonly  the  arterio-sclerosis  results  from  the  bad  use  of  good 
vessels,  and  among  the  circumstances  which  tend  to  produce  this  condi- 
tion are  the  following : 

(3)  Chronic  Intoxications. — Alcohol,  lead,  gout,  and  syphilis  play  an 
important  role  in  the  causation  of  arterio-sclerosis,  although  the  precise 
mode  of  their  action  is  not  yet  very  clear.  They  may  act,  as  Traube  sug- 
gests, by  increasing  the  peripheral  resistance  in  the  smaller  vessels  and  in 
this  way  raising  the  blood  tension,  or  possibly,  as  Bright  taught,  they  altei 


ARTERIO-SCLEROSIS. 


665 


the  quality  of  the  blood  and  reuder  more  difficult  its  passage  through  the 
capillaries. 

Tlie  poison  of  syphilis  and  of  gout  may  act  directly  on  the  arteries, 
producing  degenerative  changes  in  the  media  and  adventitia. 

(;})  Overeatmg. — ilany  authors  attribute  an  important  part  of  the 
ctiulogy  of  arterio-sclerosis  to  the  overfilling  of  the  blood-vessels  which 
occurs  when  unnecessarily  large  quantities  of  food  and  drink  are  taken. 
Particularly  is  this  the  case  in  stout  persons  who  take  very  little  exercise. 

(■1)  Ovcru'ork  of  the  muscles,  which  acts  by  increasing  the  peripheral 
resistance  and  by  raising  the  blood-pressure. 

(5)  Renal  Disease. — The  relation  between  the  arterial  and  kidney 
losious  has  been  much  discussed,  some  regarding  the  arterial  degenera- 
tion as  secondary,  others  as  primary.  There  are  certainly  two  groups  of 
cases,  one  in  which  the  arterio-sclerosis  is  the  first  change,  and  the  other 
in  wliich  it  appears  to  be  secondary  to  a  primary  aifection  of  the  kidneys. 
Tiie  former  occurs,  I  believe,  with  much  greater  frequency  than  has  been 
supposed. 

Morbid  Anatomy. — Thoma  divides  the  cases  into  prhnary  arterio- 
sclerosis, in  Avhich  there  are  local  changes  in  the  arteries  leading  to  dilata- 
tion and  a  compensatory  increase  of  the  connective  tissue  of  the  intima ; 
sccondarji  arterio-sclerosis,  due  to  changes  in  the  arteries  which  follow 
increased  resistance  to  the  blood-flow  in  the  peripheral  vessels.  This  in- 
creased tension  leads  to  dilatation  and  to  slowing  of  the  blood-stream  and 
a  secondary  compensatory  development  of  the  intima. 

In  a  recent  study  of  4i  autopsies  upon  arterio-sclcvotic  cases  from  my 
wards,  Councilman*  follows  the  useful  division  into  nodular,  senile,  and 
diffuse  forms. 

(rt)  Nodular  Form. — In  the  circumscribed  or  nodular  variety  the  ma- 
croscopic cbanges  are  very  characteristic.  The  aorta  presents,  in  the  early 
stages,  from  tlie  ring  to  bifurcation,  numerous  flat  projections,  yellowish 
or  yellowish  white  in  color,  hemispherical  in  outline,  and  situated  par- 
ticularly about  the  orifices  of  the  branches.  In  the  early  stage  these 
]iutclies  are  scattered  and  do  not  involve  the  eutire  intima.  In  more  ad- 
vanced grades  the  patch(?s  undergo  atheromatous  changes.  The  nuiterial 
constituting  tho  button  undergoes  softening  and  breaks  up  into  granu- 
lar material,  consisting  of  molecidar  debris — the  so-called  atheromatous 
abscess. 

In  the  circumscribed  or  nodular  arterio-sclerosis  the  primary  alteration 
consists  in  a  degeneration  or  a  local  infiltration  in  the  media  and  adven- 
titia, chiefly  about  the  vasa  vasorum.  The  affection  is  really  a  mesarteritis 
u'kI  a  periarteritis.  These  cl;anges  lead  to  the  weakening  of  the  wall  in 
th>  aiTected  area,  at  which  spot  the  proliferative  changes  commence  in  tho 
intima,  particularly  in  the  subendothelial  structures,  with  gradual  thick- 

*  Transactions  of  tho  Association  of  American  Physicians,  vol.  vi. 


l\ 


mil 


1;  ?3''cj,''  c,'k'< 


666 


DISEASES  OP  THE  CIllCULATORY  SYSTEM. 


■  n^ 


i '  \T 


ening  and  the  formation  of  an  atheromatous  button  or  a  patch  of  nodular 
arterio-sclcrosis.  The  researches  of  Thoma  have  shown  that  this  is  really 
a  compensatory  process,  and  that  before  its  degeneration  the  nodular  hut- 
ton,  which  post  mortem  projects  beyond  the  lumen,  during  life  tills  up 
and  obliterates  what  would  otherwise  be  a  depression  of  the  wall  in  conse- 
quence of  the  weakening  of  the  media.  A  similar  process  goes  on  in  the 
smaller  vessels,  and  in  any  one  of  the  smaller  branches  it  can  bo  readily 
seen  on  section  that  each  patch  of  endarteritis  corresponds  to  a  doi'eet  iu 
the  media  and  often  to  changes  in  the  adventitia.  The  condition  is  one 
which  may  lead  to  rapid  dilatation  or  to  the  production  of  an  aneurism, 
particularly  in  the  early  stage,  before  the  weakened  spot  is  thickened  and 
Btrcngthened  by  the  intimal  changes. 

(/;)  Senile  Arteriosclerosis. — The  larger  arteries  are  dilated  and  tort- 
uous, the  walls  thin  but  stiff,  and  often  converted  into  rigid  tul)es.  The 
subendothelial  tissue  undergoes  degeneration  and  in  spots  breaks  down, 
forming  the  so-called  atheromatous  abscesses,  the  contents  of  which  con- 
sist of  a  molecular  debris.  They  may  upen  into  the  lumen,  when  they 
are  known  as  atheromatous  ulcers.  The  greater  portion  of  the  intiiua 
may  be  occupied  by  rough  calcareous  ] dates,  with  here  and  there  fissures 
and  losses  of  substance,  upon  which  not  infrequently  white  thrombi  are 
deposited.  Microscopically  there  is  extreme  degeneration  of  the  coats, 
particularly  of  the  media.  Senile  atrophy  of  the  liver  and  kidneys  usually 
acconii)anies  these  changes.  Senile  changes  ai'e  common  in  other  organs. 
The  heart  may  be  small  and  is  not  necessarily  hypertrophied.  In  7  of  U 
cases  of  Councilman's  series  there  was  no  enlargement.  Brown  atrophy 
is  common 

{(■)  Diffuse  Arteriosclerosis. — The  process  is  wide-spread  throughout 
the  aorta  and  its  branches,  in  the  former  usually,  but  not  necessarily,  asso- 
ciated with  the  nodular  form.  The  subjects  of  this  variety  are  usually 
middle-aged  men,  but  it  may  occur  early.  Of  the  27  in  Coum  ilmau's 
series  belonging  to  this  group  the  majority  were  betw«en  the  ages  of  forty 
and  fifty-five.  The  youngest  was  a  negro  of  twenty-three  and  the  oldest  a 
man  of  sixty.  The  affection  is  very  prevalent  among  negroes ;  less  than 
fifty  per  cent  were  in  whites,  whereas  the  ratio  of  colored  to  white  |)atients 
in  the  wards  is  one  to  seven.  The  affection  is  met  with  in  strongly  built, 
muscular  men  and,  as  Councilman  remarks,  they  rarely  present  on  the 
autopsy  table  signs  of  general  anasarca  or,  if  oedema  exists,  it  has  come 
on  during  the  last  few  days  of  life. 

The  aorta  and  its  branches  are  more  or  less  dilated,  the  branches  some- 
times more  than  the  trunk.  The  intinia  may  be  smooth  and  show  very 
slight  changes  to  the  naked  eye;  more  commonly  there  are  scattered  ele- 
vated areas  of  an  opaque  white  color,  some  of  which  may  have  undergone 
atheromatous  changes  as  in  the  senile  form.  Microscojjically  the  mcilut 
shows  necrotic  and  hyaline  changes,  involving  in  the  larger  arti'ries  both 
muscular  and  elastic  elements,  and  the  iniinia  presents  a  groat  inereiioe 


■.-  ^"ip: 


ARTERIO-SCLEROSIS. 


6G7 


in  the  siibcndothelial  connective  tissue,  which  is  particularly  marked  oppo- 
pite  areas  of  advanced  degeneration  in  the  media.  The  small  arteries — 
tliose  of  the  kidneys,  for  example — shoiv  "  a  thickening  of  the  wall,  due  to 
tlio  formation  of  a  homogeneous  hyaline  tissue  within  the  muscular  coat. 
This  tissue  contains  but  few  cells,  is  faintly  striated,  and  stains  a  light 
brnwn  in  the  osmic  acid  used  in  the  hardening  solution.  In  many  of  tho 
pniaUost  vessels  nothing  can  be  seen  of  the  elastic  lamina,  in  others  only 
fragments  can  be  made  out,  in  others  it  is  preserved.  .  .  .  The  muscular 
fibres  of  the  media  show  marked  atrophic  changes.  Fatty  degeneration 
of  the  cells  can  bo  made  out  both  in  fresh  sections  and  after  hardening 
in  Fleming's  solution.  The  nuclei  arc  thin  and  atrophic  and  vacuoles  are 
sometimes  seen  in  them.  In  some  arteries  the  muscle-fibres  have  almost 
disa])peared  and  tho  media  is  changed  into  a  homogeneous  tissue,  similar 
to  tliat  in  the  thickened  intima"  (Councilman).  The  degeneration  of 
the  media  is  most  marked  in  the  smaller  arteries.  The  capillaries  arc 
thickened,  pai'ticularly  those  of  the  glomeruli  of  the  kidneys,  which  are 
often  obliterated  and  involved  in  extensive  hyaline  degeneration. 

It  is  in  this  group  of  cases  that  the  heart  shows  the  most  important 
changes.  The  average  weight  in  the  cases  referred  to  was  over  450 
grammes,  and  there  were  two  ciises  in  which  without  valvular  disease 
the  weight  was  over  800  grammes.  Fibrous  myocarditis  is  often  present, 
particuhu'ly  when  the  coronary  arteries  are  involved.  The  semilunar 
valves  are  sometimes  opaque  and  sclerotic,  and  may  be  incompetent.  Tho 
kidneys  may  show  extensive  sclerosis,  but  in  many  cases  the  changes  are 
so  sliglit  tliat  macroscopically  they  might  be  overlooked.  They  may  be 
increased  in  size.  The  capsule  is  usually  adherent,  the  surface  a  little 
rough,  and  very  often  presents  atrophic  areas  at  a  lower  level  of  a  deep- 
rod  color.    Increased  consistence  is  always  present. 

Sckro.'^is  of  the  jmlmonary  artery  is  met  with  in  all  conditions  which 
for  a  long  time  increase  the  tension  in  the  lesser  circulation,  particularly 
in  mitral-valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  reaches 
a  liigh  grade  and  is  accompanied  with  ancurismal  dilat-'tion  of  the  primary 
and  secondary  branches,  more  rarely  with  insufficiency  of  the  inilmonary 
valve.  In  a  remarkable  case  of  a  young  man  of  twenty-four,  reported  by 
Kombcrg  from  Curschmann's  clinic,  the  pulmonary  arteries  were  involved 
in  most  extensive  arterio-sclerosis ;  the  main  branches  were  dilated,  and  tho 
Rnialler  liranohes  were  the  seat  of  the  most  extreme  sclerotic  changes.  On 
the  other  hand,  the  aorta  and  its  branches  were  normal.  The  heart  was 
greatly  hypertroiihied,  and  the  clinionl  symptoms  were  those  of  a  congeni- 
tal lieart  affection.  In  many  cases  of  arterio-sclerosis  tho  condition  is  not 
confined  to  tlie  arteries,  but  extends  not  only  to  tho  capillaries  but  also  to 
the  veins,  and  may  properly  be  termed  avgio-Kclerosis. 

Sclerosis  of  the  veins — pldcbo-sclerosiH — is  not  at  all  an  uncommon 
accompaiiinient  of  arterio-sclerosis,  and  is  a  condition  to  which  of  late  a 
good  deal  of  attention  has  been  paid.     It  is  seen  in  conditions  of  height- 


tip 

Vi",  Ui 


.  f 


S 


668 


DISEASES  OP  THE  CIRCULATORY   SYSTEM, 


>        t     ' 


llf! 


•ifi 


am 


cncd  blocd-pressure,  as  in  tlio  portal  system  in  cirrhosis  of  the  liver  and  in 
the  pulmonary  veins  in  mitral  stenosis.  The  affected  vessels  are  nsually 
dilated,  and  the  intima  shows,  as  in  the  arteries,  a  compensatory  tliickcn- 
ing,  which  is  i)articularly  marked  in  those  regions  in  which  the  media  is 
thinned.  The  new-formed  tissue  in  the  endophlebitis  may  undergo  In-- 
line degeneration,  and  is  sometimes  extensively  calcified.  In  a  case  of 
fibroid  obliteration  of  the  portal  vein  of  long  standing,  I  found  the  intiiiuv 
of  the  greatly  dilated  gastric,  splenic,  and  mesenteric  extensively  calcidod. 
In  ordinary  diffuse  arterio-sclerosis  the  veins  may  also  be  involveil,  but 
rarely  to  a  marked  degree. 

Symptoms. — Many  patients  never  come  under  observation  during 
life,  but  are  seen  for  the  first  time  on  the  post-mortem  table,  having  d'wd 
suddenly  from  cerebral  haemorrhage,  blocking  of  a  coronary  artery,  or 
rupture  of  an  aneurism. 

Among  important  symptoms  are  the  following : 

Increased  Tension. — The  pressure  with  which  the  blood  flows  in  tlic 
arteries  depends  upon  the  degree  of  peripheral  resistance  and  the  force  of 
the  ventricular  contraction.  A  high-tension  pulse  may  exist  with  very 
little  arterio-sclerosis ;  but,  as  a  rule,  Avhen  the  condition  has  been  per- 
sistent,  the  sclerosis  and  high  tension  are  found  together.  The  pulse 
wave  is  slow  iti  its  ascent,  enduring,  subsides  slowly,  and  in  the  intiTvals 
of  the  beats  the  vessel  remains  full  and  firm.  It  may  bo  very  dillicult  to 
obliterate  the  pulse,  and  the  firmest  pressure  on  the  radial  or  tlio  tem- 
poral may  not  be  sufficient  to  annihilate  the  pulse  wave  beyond  the  point 
of  pressure.  The  sphygmographic  tracing  sliows  a  sloping,  sliort  up- 
stroke, no  percussion  wave,  and  a  slow,  gradual  descent,  in  which  tlio 
dicrotic  wave  is  very  slightly  marked.  It  may  be  difficult  to  estimate 
how  much  of  the  hardness  and  firmness  is  duo  to  the  tension  of  the  blood 
within  the  vessel,  and  how  much  to  the  thickening  of  the  wall.  If,  for 
example,  when  the  radial  is  compressed  with  the  index-finger  the  ai'teiy 
can  be  felt  beyond  the  point  of  c  )mpression,  its  walls'are  sclerosed. 

Hypertrophy  of  the  Heart. —  In  consequence  of  the  peripheral  resist- 
ance and  increased  work  the  I'.xt  ventricle  increases  in  size,  and  some  of 
the  purest  examples  of  simple  hypertrophy  occur  in  this  condition.  The 
chamber  may  be  little,  if  at  all,  dilated.  The  apex  beat  is  dislocated  iu 
advanced  cases  an  inch  or  more  beyond  the  nipple  line.  The  impulse  is 
heaving  and  forcible.  The  aortic  second  sound  is  clear,  ringing,  and 
accentuated. 

The  combination  of  increased  arterial  tension,  a  palpable  tlii('l«'tiiiig 
of  the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the 
aortic  second  sound  arc  signs  pathognomonic  of  arterio-sclerosis.  From 
this  period  of  establishment  the  course  of  the  disease  may  be  vei-y  varied. 
For  years  the  patient  may  maintain  good  health,  and  be  in  a  londitiou 
analogous  to  a  person  with  a  well-compensated  valvular  lesion.  Tlioro 
may  be  no  renal  symptoms,  or  thoro  may  bo  the  passage  of  a  larger 


ing  died 


ion.    Tlie 

located  in 

impulse  is 
igiug,  tiiid 

liii'lvening 

ion  of  ll'" 

ns.    l'i'<"" 

e,,-v  varied- 

,  Condition 

ARTERIO-SCLEROSIS. 


669 


In.     There 

If  a  liii-ger 


ainount  of  urino  than  normal,  with  transient  albuminuria,  and  now  and 
tlioa  liyaliue  tube-casts.  The  subsequent  history  is  extraordinarily  diverse, 
depending  upon  the  vascular  territory  in  which  the  sclerosis  is  most  ad- 
vuiicod,  or  upon  the  accidents  which  are  so  liable  to  happen,  and  the 
8yni])toms  may  be  cardiac,  cerebral,  renal,  etc. 

(1)  Cardiac. — The  involvement  of  the  coronary  arteries  may  lead  to 
tlie  various  symptoms  already  referred  to  under  that  section — thrombosis 
with  sudden  death,  fibroid  degeneration  of  the  heart,  aneurism  of  the 
heart,  rupture,  and  angina  pectoris.  Angina  pectoris  is  extremely  com- 
mon, and  in  the  true  variety  is  almost  always  associated  with  artcrio-scle- 
rosis.  A  second  important  group  of  cardiac  symptoms  results  from  the 
(lihitatiou  M'hich  ultimately  may  follow  the  hypertrophy.  The  patient 
then  presents  all  the  symptoms  of  cardiac  insufficiency — dyspnoea,  scanty 
urine,  and  very  often  serous  effusions.  If  the  case  has  come  under  obser- 
vation for  the  first  time  the  clinical  picture  is  that  of  chronic  valvidar  dis- 
ease, and  the  existence  of  a  loud  blowing  murmur  at  the  apex  may  throw 
tiie  practitioner  off  his  guard.     Many  cases  terminate  in  this  '  ^'ly. 

{'i)  The  cerebral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  onibrace  those  of  many  degenerative  processes,  acute  and  chronic  (which 
lollow  sclerosis  of  the  smaller  branches),  and  cerebral  haemorrhage,  which 
is  usually  associated  with  the  miliary  aneurisms. 

Transient  hemiplegia,  monoplegia,  or  aphasia  may  occur  in  advanced 
arterio-sclerosis.  Recovery  may  be  perfect.  It  is  difficult  to  say  upon 
wliat  those  attacks  depend.  Spasm  of  the  arteries  has  been  suggested,  but 
the  condition  of  the  smaller  arteries  is  not  very  favorable  to  this  view. 
Peabody  has  recently  called  attention  to  these  cases,  which  are  more  com- 
mon than  indicated  in  the  literature. 

(3)  Renal  symptoms  supervene  in  a  large  number  of  the  cases.  A 
sclerosis,  patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time 
of  autopsy,  and  the  condition  is  practically  that  of  contracted  kidneys.  It 
is  seen  in  a  typical  manner  in  the  senile  form,  and  not  infrequently  devel- 
ops early  in  life  as  a  direct  sequence  of  the  diffuse  variety.  It  is  often 
ditlicult  to  decide  clinically  (and  the  question  is  one  upon  Avhich  good  ob- 
eervers  might  not  agree  in  a  given  case)  whether  the  arterial  or  the  renal 
disease  has  been  primary. 

(4)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gan- 
grene (tf  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dis- 
lodgnient  of  thrombi.  Respiratory  symptoms  are  not  uncommon,  particu- 
larly bronchitis  and  the  symptoms  associated  with  emphysema. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as 
they  AYxm  in  connection  with  the  various  viscera.  In  the  early  stages,  be- 
fore any  local  symptoms  are  manifest,  the  patient  should  be  enjoined  to 
live  a  quiet,  well-regulated  life,  avoiding  excesses  in  food  and  drink.  It 
IS  usually  best  to  explain  frankly  the  condition  of  affairs,  and  so  gain  his 
intelligent  co-operation.     Special  attention  should  be  paid  to  the  state  of 


1 


I 


IW 


670 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


«  ''j 


Iff? 


tlio  boAvela  and  urine,  and  the  secretion  of  the  skin  should  be  kept  active 
by  daily  baths.  Alcohol  in  all  forms  should  bo  prohibited,  and  the  food 
should  be  restricted  to  plain,  wholesome  articles.  The  use  of  miiiorul 
waterj  or  a  residence  every  year  at  one  of  the  mineral  springs  is  usually 
servicealde.  If  there  has  been  a  syphilitic  history  an  occasional  course  of 
iodide  of  potassium  is  indicated,  and  whenever  the  pulse  tension  is  high 
nitroglycerine  may  be  used. 

In  cases  which  come  under  observation  for  the  first  time  with  dyspncjea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated. 
In  some  instances,  with  very  high  tension,  striking  relief  is  afforded  by  the 
abstraction  of  twenty  ounces  of  blood. 


III.  ANEURISM. 

The  following  forms  of  aneurism  are  usually  recognized : 

(a)  The  true,  in  which  the  sac  is  formed  of  one  or  more  of  the  arterial 
coats.  This  may  be  fusiform,  cylindrical,  or  cirsoid  (in  which  the  dilatation 
is  in  an  artery  and  its  branches),  or  it  may  be  circumscribed  or  sacculated. 
Aneurisms  are  usually  fusiform,  resulting  from  uniform  dilatation  of  the 
vessel,  or  saccular. 

(b)  The  false  or  dissecting  aneurism,  which  results  from  injury  or 
laceration  of  the  internal  coat.  The  blood  dissects  between  the  layers; 
hence  the  name,  dissecting  aneurism.  This  occurs  usually  in  the  aorta. 
It  may  dissect  the  entire  length  of  the  vessel,  and,  perforating  into  the 
lumen  of  the  vessel,  may,  as  in  a  case  reported  by  J.  E.  Graham,  persist 
for  years. 

{c)  Arterio-venous  aneurism  results  when  a  communication  is  estab- 
lished between  an  artery  and  a  vein.  A  sac  may  intervene,  in  which  case 
it  is  called  a  varicose  aneurism ;  but  in  many  cases  the  communication  is 
direct  and  the  chief  change  is  in  the  vein,  which  is  dilated,  tortuous,  and 
pulsating,  and  is  termed  an  aneurismal  varix. 

Etiology  and  Pathology. — Aneurisms  arise  :  (a)  By  the  gradual 
diffuse  distention  of  the  arterial  coats,  whicli  have  been  weakened  by 
arterio-sclerosis,  particularly  in  its  early  stages,  before  compensatory  en- 
darteritis develops.  The  arclx  of  the  aorta  is  often  dilated  in  this  way  so 
as  to  form  an  irregular  aneurism. 

(b)  In  consequence  of  circumscribed  loss  of  resisting  poAvor  in  the 
media  and  adventitia,  and  due  often  to  laceration  of  the  media.  Tliis  is 
the  most  common  cause  of  sacculated  aneurism.  The  laceration  is  fre- 
quently found  in  the  ascending  portion  of  the  arch  and  occurs  early  in 
the  process  of  arterio-sclerosis,  before  the  compensatory  thickeniiiir  has 
taken  place.  Occasionally  one  meets  with  remarkable  specimens  illustrat- 
ing the  important  part  played  by  this  process.  The  intima  may  also 
be  torn.     In  a  case  of  Daland's  there  was  just  above  the  aortic  valves 


-Wil 


jdia.    This  is 


ANEURISM. 


671 


an  olfl  transverse  tear  of  tlic  intima,  extending  almost  the  entire  circumfer- 
ence of  the  vessel.  Sclerosis  of  the  media  and  adventitia  had  taken  place 
and  the  process  was  evidently  of  some  standing.  An  inch  or  more  above 
it  was  a  fresh  transverse  rent  which  had  produced  a  dissecting  aneurism. 
Those  (irterio-sclerotic  aneurisms,  as  they  are  called,  are  found  also  in  the 
smaller  vessels. 

[c)  Embolic  Aneurism. — When  an  embolus  has  lodged  in  a  vessel  and 
permanently  plugged  it,  ancurismal  dilatation  may  follow  on  the  proximal 
side.  The  embolus  itself  may,  if  a  calcified  fragment  from  a  valve,  lacer- 
ate the  wall,  or  if  infected  may  produce  inflammation  and  softening.  In 
cither  case  aneurism  may  result. 

[(I)  Ml/cot ic  Aneurism. — The  importance  of  this  form  has  been  spe- 
cially considered  by  Eppinger  in  his  exhaustive  monograph.  Tlic  occur- 
rence of  multiple  aneurisms  in  malignant  endocarditis  has  been  observed 
by  several  writers.  Probably  the  first  case  in  which  the  mycotic  nature 
was  recognized  was  one  which  occurred  at  the  Montreal  General  Hospital 
and  is  reported  iu  full  in  my  lectures  on  malignant  endocarditis.  In  addi- 
tion to  the  ulceration  of  the  valves  there  were  four  aneurisms  of  the  arch, 
of  which  one  was  large  and  saccular,  and  three  were  not  bigger  than 
cherries.  An  extensive  growth  of  micrococci  was  present  iu  the  larger  as 
well  as  in  the  smaller  sacs. 

A  form  of  parasitic  aneurism  which  occurs  with  great  frequency  in 
the  mesenteric  arteries  of  the  horse  is  due  to  the  development  of  the 
strongylus  nrmatus. 

And,  lastly,  there  are  cases  in  which  without  any  definite  cause  there 
is  a  tendency  to  the  development  of  aneurisms  in  various  parts  of  the 
body.  A  remarkable  instance  of  it  in  our  profession  was  afforded  by  the 
brilliant  Thomas  King  Chambers,  who  first  had  an  aneurism  in  the  left 
popliteal  artery,  eleven  years  subsequently  an  aneurism  in  the  right  leg 
which  was  cured  by  pressure,  and  finally  aneurism  of  both  carotid  arteries. 

Aneurism  of  the  Thoracic  Aorta. 

The  causes  which  favor  the  development  of  arterio-sclerosis  prevail  in 
aortic  aneurism,  particularly  alcohol,  syphilis,  and  overwork.  The  great- 
est danger  probably  is  in  strong  muscular  men  with  commencing  degen- 
erative processes  in  the  arteries  (a  consequence  of  syphilis  or  alcohol  or  a 
result  of  hereditary  weakness  of  the  arterial  tissues),  who  during  a  sudden 
muscular  exertion  are  liable  to  lacerate  the  media,  the  intima  not  yet  being 
strengthened  by  compensatory  thickening  over  a  spot  of  mcsartcritis. 
Aneurisms  of  the  thoracic  aorta  vary  greatly  in  size  and  shape.  A  major- 
ity of  them  are  saccular.  They  may  be  small  and  situated  just  above  the 
aortic  ring.  Others  form  large  tumor?  vhich  project  externally  and  occupy 
a  largo  portion  of  the  upper  thorax.  Small  sacs  from  the  descending  por- 
tion of  the  arch  may  compress  the  trachea  or  the  bronchi.     In  the  tho- 


mi:  , 

tih:    I 


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i 

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■-Ml 


C72 


DISEASES  OF  THE  CIRCULATORY  SYSTEiM. 


racic  portion  the  sac  may  erode  the  vertebrae  or  gn  -.y  into  tlic  pleural  ravit  v 
and  compresa  the  lung.  In  some  instances  it  grows  through  the  ribs  and 
apjjears  in  the  back. 

Symptoms. — The  chief  influence  of  an  aneurism  is  manifested  in 
Avhat  are  known  as  pressure  effects.  In  the  absence  of  these  the  anourisins 
attain  a  large  size  without  ])roduciug  symptoms  or  seriously  intertVriii"' 
with  the  circulation.  Indeed,  a  useful  clinical  subdivision  as  given  l)v 
Ilramwell  is  into  three  groups — aneurisms  which  are  entirely  latent  and 
{jivo  no  i>hysical  signs;  aneurisms  which  present  signs  of  intrathoraeio 
pressure,  but  it  is  ditlicult  or  impossible  to  determine  the  nature  of  the 
lesion  producijig  tlie  pressure;  and,  lastly,  aneurisms  which  produce  dis- 
tinct tumors  with  well-marked  pressure  symptoms  and  external  signs.  It  is 
I)erhaps  best  to  consider  aneurisms  of  the  aorta  according  to  the  situation 
of  the  tumor. 

(«)  Ayieiirisms  of  the  Ascendhuj  Portion  of  the  Arch. — "When  just 
above  the  sinuses  of  Valsalva  they  are  often  small  and  latent.  The  iiist 
symptom  may  be  rupture,  which  usually  takes  place  into  the  pericardium 
and  causes  instant  death.  Above  the  sinuses,  along  the  convex  border  of 
the  ascending  part,  aneurism  frequently  develops,  and  may  grow  to  a 
largo  size,  either  passing  out  into  the  right  pleura  or  forward,  pointin-r  at 
the  second  or  tliird  interspace,  eroding  the  ribs  and  sternum,  aiid  ])rt)(liic- 
ing  large  external  tumors.  In  this  situation  the  sac  is  liable  indeed  to 
compress  the  superior  vena  cava,  causing  engorgement  of  the  vessels  of 
the  head  and  arm,  sometimes  compressing  only  the  subclavian  vein,  and 
causing  enlargement  and  oxlema  of  the  right  arm.  Perforation  may  take 
place  into  the  superior  vena  cava,  of  which  accident  Pepper  and  (irillilli 
have  collected  twenty-nine  cases.  Large  aneurisms  in  this  situation  may 
cause  much  dislocation  of  the  heart,  pushing  it  down  and  to  tlie  left, 
and  sometimes  compressing  the  inferior  vena  cava,  and  causing  swellinjf 
of  the  feet  and  ascites.  The  right  recurrent  laryngeal  nerve  is  often  in- 
volved in  these  tumors.  Death  commonly  follows  from  rupture  into  tlie 
pleura,  or  into  the  superior  cava ;  less  commonly  from  rupture  externally, 
sometimes  from  heart-failure. 

{b)  Aneurisms  of  the  Transverse  Arch. — These  may  grow  forward, 
erode  the  sternum,  and  produce  large  tumors.  More  commonly  tliey  are 
small  and  produce  no  external  tumor,  but  cause  marked  pressure  signs  in 
their  growtlr  backward  toward  the  spine,  involving  the  trachea  and  the 
oesophagus,  producing  cough,  which  is  often  of  a  paroxysmal  oliaraeter, 
and  dysphagia.  The  left  recurrent  laryngeal  is  often  involved  in  its 
courRe  round  the  arch.  A  small  aneurism. from  the  lower  or  posterior 
wall  of  the  arch  may  compress  a  bronchus,  inducing  bronchorrhcea, 
gradual  bronchiectasy,  and  suppuration  in  the  lung — a  process  whieh  by 
no  means  infrequently  causes  death  in  aneurism,  and  a  condition  which 
at  the  ^Montreal  General  Hospital  we  were  in  the  habit  of  terming  nnon- 
rismal  phthisis.     Occasionally  enormous  aneurisms  develop  in  this  situu- 


ANEURISM. 


073 


tioii,  and  grow  into  both  plcurcc,  oxtonding  between  tlio  manubrium  and 
the  v{  rtobrce,  and  may  persist  for  years.  The  sac  may  bo  evident  at  tho 
sternal  notch.  The  innominate,  less  commonly  tho  left  carotid  and  sub- 
clavian, may  bo  involved  in  tho  sac,  and  the  radial  or  carotid  pulso  may 
1)1.'  al)scnt  or  retarded.  Pi'esHuro  on  tlio  symi)athetic  may  at  iinst  causo 
dilatiiticm  and  subsequently  contractii^ii  of  tho  pupil.  Sometimes  tho 
tlionu'ic  duet  is  compressed. 

(r)  Aneurisms  of  the  Desccndhig  Porfion. — Pressure  si^ns  are  not  so 
marked.  The  pain  is  often  intense,  owing  to  erosion  of  the  vertebra). 
Dyspiiagia  may  occur.  Compression  of  the  lung  or  com})ressi()n  of  cer- 
tain l)ronchi  may  induce  bronchiectasy,  retention  of  secretions,  and  fever. 
A  tumor  may  appear  externally  in  the  region  of  the  scapula,  and  here 
uttiiin  an  enormous  size.  Occasionally  the  aneurisms  in  this  region  arc 
small  and  latent,  and  prove  fatal  by  rupture  into  the  (psnphagus.  I  have 
reported  a  case  of  sudden  death,  in  which  tho  heart  and  arch  of  tho  aorta 
were  normal  and  the  stomach  Avas  distended  with  blood,  which  lould  not 
be  accounted  for  until  the  cosophagus  was  slit  open,  when  it  was  found 
that  a  small  aneurism  in  the  thoracic  aorta,  smaller  than  a  walnut,  had 
ruptured  into  the  gullet.  The  sac  may  erode  tho  vertebri\3  and  open  tho 
spinal  canal,  producing  compression  of  the  cord.  Death  not  infrequently 
occurs  from  rupture  into  tlio  pleura. 

Diagnosis  and  Physical  Signs.— Tnspecf  ion. — In  many  instances 
this  is  negative.  On  either  side  of  the  sternum  there  may  be  abnormal 
pulsation,  due  to  dislocation  of  tho  heart  or  to  deformity  of  the  thorax. 
The  aneurismal  pulsation  is  usiudly  above  the  level  of  the  third  rib  and 
most  commonly  to  tho  right  of  the  sternum,  either  in  the  first  or  second 
hitorspace.  It  may  be  oidy  a  diffuse  heaving  impulse  without  any  exter- 
nal tumor.  Often  tho  impulse  is  noticed  only  when  the  chest  is  looked 
at  ohlifiuely  in  a  favorable  light.  "\Mien  the  innominate  is  involved  tho 
throbbing  may  pass  into  the  neck  or  be  apparent  at  the  sternal  notch. 
Posteriorly,  Avhen  pulsation  occurs,  it  is  most  commonly  found  in  tho  left 
scapular  region.  An  external  tumor  is  present  in  many  cases,  projecting 
cither  through  tho  iipper  part  of  the  sternum  or  to  the  right,  sometimes 
involving  the  sternum  and  costal  cartilages  on  both  sides,  forming  a  tumor 
the  size  of  a  cocoa-nut  or  even  larger.  The  skin  is  thin,  often  blood- 
stained, or  it  may  have  ruptured,  exposing  tho  lamiiuE  of  the  sac.  Tho 
apex  beat  may  be  much  dislocated,  ])articularly  when  the  sac  is  large.  It 
is  more  commonly  a  dislocation  from  pressure  than  from  enlargement  of 
the  heart  itself. 

Palpation. — The  area  and  degree  of  pulsation  are  best  determined  by 
palpation.  When  the  aneurism  is  deep-seated  and  not  apparent  exter- 
nally, the  bimanual  method  should  be  used,  one  hand  upon  tho  spine  and 
the  other  on  the  sternum.  When  the  sac  has  perforated  the  chest  wall 
the  impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  expansile.  The  re- 
sistance may  be  very  great  if  there  are  thick  laminsB;  beneath  the  skin ; 


t'li 


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DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


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11 


moro  rurcly  tho  sac  u  soft  and  fluctuating.  Tho  hand  upon  tlio  sac,  or 
on  the  region  in  wliicli  it  is  in  contact  with  tho  chest  wall,  feels  in  iiiiuiy 
casc3  a  diastolic  shock,  often  of  great  intensity,  which  forms  one  of  tlio 
valuable  physical  signs  of  aneurism.  A  systolic  thrill  is  sometimes  jji-ch- 
ont,  not  80  often  in  saccular  aneurisms  as  in  the  dilatation  of  tho  ureli. 
Tho  pulsation  may  sometimes  bo  felt  in  tho  suprasternal  notcli. 

Percussion.— Tho  small  and  deep-seated  aneurisms  are  in  this  rpsjjoct 
negative.  In  the  larger  tumors,  as  soon  as  tho  sac  reaches  the  chest  wall, 
tlicro  is  produced  an  area  of  abnormal  dulncss,  tho  position  of  which  de- 
pends upon  the  part  of  tho  aorta  ulTectcd.  Aneurisms  of  tho  aseciidiii;.; 
arch  grow  forward  and  to  tho  right,  producing  dulncss  on  one  side  of  tlic 
nmnubrium  ;  those  from  the  transverse  arch  produce  dulness  in  tho  iiud- 
dlo  line,  extending  toward  tho  left  of  tho  sternum,  while  aruinririms  of 
tho  descending  portion  most  commoidy  produce  dulncss  in  tho  left  inter- 
scapular and  scapular  regions.  Tho  percussion  note  is  flat  and  gives  n 
fooling  of  iiicreased  resistance. 

AiiscuUation. — Adventitious  sounds  arc  not  alwavs  to  be  heard.  Even 
in  a  largo  sac  there  may  be  no  murmur.  Much  depends  upon  the  thick- 
ness of  tho  hiniinfB  of  fibrin.  An  imjjortant  sign,  particularly  if  heard 
over  a  dull  region,  is  a  ringing,  accentuated  second  sound,  a  phenomenon 
rarely  missed  in  large  aneurisms  of  tho  aortic  arch.  A  systolic  inurinur 
may  be  present;  sometimes  a  double  murmur,  in  which  case  tlie  diastolic 
bruit  is  usually  due  to  associated  aortic  insufficiency.  The  systolic  niur- 
raur  alone  is  of  little  moment  in  tho  diagnosis  of  an  ancurismal  sac.  With 
tho  single  stethoscope  tho  shock  of  tho  impulse  Avith  the  first  sound  is 
sometimes  very  marked. 

Among  other  physical  signs  of  importance  are  slowing  of  tho  pulse  in 
tho  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  Then) 
may,  for  instance,  be  a  marked  difference  between  tho  right  and  left  nulial, 
both  in  volume  and  time.  A  physical  sign  of  large  thoracic  aneurism 
which  I  have  not  seen  referred  to  is  obliteration  of  the  pulse  in  the  al)- 
dominal  aorta  and  its  branches.  My  attention  Avas  called  to  tliis  in  a 
patient  who  was  stated  to  have  aortic  insufficiency.  There  was  a  well- 
marked  diastolic  murmur,  but  in  tho  femorals  and  in  the  aortii  I  was 
surprised  to  find  no  trace  of  pulsation,  and  not  tho  slightest  throbl)in!,'  ia 
the  abdominal  aorta  or  in  the  peripheral  arteries  of  tho  leg.  The  circula- 
tion was,  however,  unimpaired  in  them  and  there  was  no  dilatation  of  tho 
veins.  Attracted  by  this,  I  then  made  a  careful  examination  of  the  pa- 
tient's back,  when  the  circumstance  was  discovered,  which  neither  tiio 
patient  himself  nor  any  of  his  physicians  had  noticed,  that  he  had  a  very 
largo  area  of  pulsation  in  the  left  scapular  region.  Tho  sac  probably 
was  large  enough  to  act  as  a  reservoir  annihilating  tho  ventricular  systole, 
and  converting  the  intermittent  into  a  continuous  stream. 

The  tracheal  tur/ffing,  a  valuable  sign  in  deep-seated  aneurism.'^,  was 
described  by  Surgeon-Major  Porter,  and  has  been  specially  studied  by  my 


ANEURISM. 


675 


colleagues  Ross  and  MacDonnoll  *  ut  tlio  j\rontroal  General  Hospital.  To 
test  it  the  patient  hIiouU  sit  up  with  the  head  inclined  forward,  so  as  com- 
pU'li'ly  to  relax  the  neck.  The  cricoid  cartilage  is  grasped  between  the 
imlcx-finger  and  the  thumb  and  by  upward  pressure  the  trat-hoa  put  upon 
the  slrt'ti'h.  In  healthy  individuals  no  sensation  is  felt,  but  if  an  aiuMi- 
risiu  is  attached  to  it  or  is  adherent  in  the  immediate  vicinity,  the  stretch- 
ing i,s  accompaincd  by  a  well-marked  and  characteristic  tugging.  On 
several  occasions  I  have  known  this  to  bo  a  sign  of  great  value  in  the 
diagnosis  of  deep-seated  aneurisms,  I  have  never  felt  it  in  tumors,  or  in 
the  extreme  dynamic  dilatation  of  aortic  insufliciency. 

Occasionally  a  systolic  murmur  nuiy  be  heard  in  the  trachea,  as  pointed 
out  by  David  Drummond,  or  even  at  the  patient's  mouth,  when  opened. 
This  is  either  the  sound  conveyed  from  the  sac,  or  is  produced  by  the  air 
us  it  is  driven  out  of  the  wiiul-])ipo  during  the  systole. 

An  imi)ortant  but  variable  feature  in  thoracic  aneurism  is  pain,  which 
is  particularly  nuirked  in  deep-seated  tumors.  It  is  usually  paroxysmal, 
sharp,  and  lancinating,  often  very  severe  when  the  tumor  is  eroding  the 
vertebra^,  or  perforating  the  chest  wall.  In  the  latter  case,  after  perfora- 
tion the  pain  nuiy  cease.  Anginal  attacks  are  not  uncommon,  ])articularly 
in  aneurisms  at  the  root  of  the  aorta.  Frequently  the  pain  radiates  down 
the  left  arm  or  up  the  neck,  sometimes  along  the  upper  intercostal  nerves. 
Coufjh  results  either  from  the  direct  pressure  on  the  wind-pipe,  or  is  as- 
sociated with  bronchitis.  The  expectoration  in  these  instances  is  abundant, 
thin,  and  watery  ;  subsequently  it  becomes  thick  and  turbid.  Paroxysmal 
cough  of  a  peculiar  brazen,  ringing  character  is  a  characteristic  symptom 
in  some  cases,  particularly  when  there  is  pressure  on  the  recurrent  laryn- 
geal nerves. 

Difspncea,  which  is  common  in  cases  of  aneurism  of  the  transverse 
portion,  is  not  necessarily  associated  with  pressure  on  the  recurrent  laryn- 
geal nerves,  but  may  be  due  directly  to  compression  of  the  trachea  or  the 
left  bronchus.  It  may  occur  with  marked  stridor.  Loss  of  voice  and 
hoarseness  are  consequences  of  pressure  on  the  recurrent  laryngeal,  usually 
the  left,  inducing  either  a  spasm  in  the  muscles  of  the  left  vocal  cord  or 
paralysis. 

Paralysis  of  an  abductor  on  one  side  may  bo  present  without  any 
symptoms.  It  is  more  particularly,  as  Scmon  states,  when  the  paralytic 
contractures  supervene  that  the  attention  is  called  to  laryngeal  symptoms. 

Ihvmorrhacje  in  thoracic  aneurism  may  come  from  {a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  Avhich  case  the  sputa  are 
blood-tinged,  but  large  quantities  of  blood  are  not  lost;  {b)  from  rupture 
of  the  sac  into  the  trachea  or  bronchi ;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  prov- 
ing fatal,  and  is  a  common  cause  of  death.    It  may  persist  for  weeks  or 


^.''i    <^'     \  111 


*  London  Lancet,  1891. 


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C7C 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


niotiths,  in  wliich  niso  it  is  simply  lia'inorrlmgio  weeping  througli  the  sac, 
Avliicli  is  exposed  in  tlie  tniclieii.  In  some  instancoa,  even  after  a  very 
profuso  iiiiMuorrliage,  the  patient  recovers  and  may  live  for  years.  A  pa- 
♦  ieiit  with  Avell-marked  tlioracic  anenrism,  whom  T  showed  to  my  (■ia.>s  at 
the  I'liiversity  of  I'eniisylvania  four  years  ago  and  wlio  had  hiid  several 
brisk  luemorrhages,  died  recently,  luiving  in  the  mean  time  enjoyed  aver- 
age health. 

Dilliciilty  f)f  swallowing  u  a  oomparatively  rare  symptom,  and  mav  lie 
due  either  to  sj)asm  or  t)  direct  compression.  'I'he  sound  should  never 
he  passed  in  these  cases,  as  the  a'sophagus  may  bo  almost  eroded  and  u 
perforation  nuiy  bo  made. 

Among  othor  signs  and  symptoms  venous  compression,  whieli  lia.s 
already  been  mentioned,  may  involve  one  subclavian  or  the  superior  veiia 
ca.va.  A  curious  iihenomenon  in  intrathoracic!  aneurism  is  the  chii)l)iii<' 
of  the  fingers  aiul  incurving  of  the  nails  of  ono  hand,  of  which  two  ex- 
amples- have  been  under  my  care,  in  both  without  any  special  distention 
or  signs  of  venous  engorgement.  Tumors  of  the  arch  may  involve  tlio 
pulmonary  artery,  producing  compression,  or  in  some  instances  adlu'simi 
of  the  pubnonary  segments  aiuI  insufficiency  of  the  valve ;  or  the  sac  may 
rupture  into  the  artery,  an  accident  which  hapi)ened  in  two  of  my  cases, 
producing  instantaneous  death. 

Pressure  on  the  8ynii)athetic  is  particularly  liable  to  occur  in  growths 
from  the  ascending  portion  of  the  arch.  Either  the  U])per  dorsal  or  tliu 
lower  cervical  ganglion  is  involved.  1'ho  symptoms  are  varial)lo.  If  tlio 
nerve  is  simply  irritated  there  is  stimulation  of  the  vaso-dilator  tibres  ami 
dilatation  of  the  pupil.  AVith  this  may  l)e  associated  pallor  of  tlie  saiiio 
side  of  the  face.  On  the  other  hand,  destruction  of  the  cilio-s|iiiial 
branches  causes  paralysis  of  the  dilator  fibres,  in  conse(|uence  of  wliidi 
the  iris  contracts,  the  vessels  on  the  side  of  the  head  dilate,  causing  con- 
gestion, and  in  some  instances  unilateral  sweating.  It  is  much  more  com- 
mon to  see  the  pupillary  symptoms  alone  than  in  con^bination  cither  with 
pallor,  redness,  or  sweating. 

The  clinical  picture  of  aneurism  of  the  aorta  is  extremely  varied. 
Many  cases  present  characteristic  symptoms  and  no  physical  signs,  while 
others  have  well-marked  physical  signs  and  no  symjitoms.  As  Broadheiit 
remarks,  the  aneurism  of  physical  siijus  springs  from  the  ascending  jtor- 
tion  of  the  aorta ;  the  aneurism  of  sy.nptoms  grows  from  the  transverse 
arch. 

Aneurism  of  the  aorta  may  be  confounded  with:  {a)  The  violent 
throbbing  impulse  of  the  arch  in  aortic  insufficiency.  I  have  already  re- 
ferred to  a  case  of  this  kind  in  which  the  diagnosis  of  aneurism  was  made 
by  several  good  observers.  In  a  case  recently  under  observation  diilnei^s 
and  pulsation  existed  in  the  second  right  interspace  with  a  well-marked 
systolic  and  a  loud  diastolic  murmur,  which  was  heard  far  out  in  the  rijrht 
mammary  region.     The  question  arose  whether  aneurism  was  present  in 


ANEURISM. 


077 


inldition  to  tho  aortif  insiinicuMicy.  The  post-mortem  showed  the  mur- 
j;iii  of  tho  right  hing  retractcil  and  iidlu'reiit  to  tlie  ])ericiirdiiini,  h-avnij^ 
exposed  tho  aorta,  which  must  have  h('(Mi  greatly  distenth'd  (hiring  each 
fiptolc. 

(//)  Simple  Jhjnmnic  Puhation. — No  iiistanoo  of  this,  Mhich  is  eom- 
iiioii  ill  tlie  ab(h)nuiial  aorta,  has  ever  come  under  my  m)tice.  One  wliich 
(•iiiiic  unch'r  tlio  earo  of  William  Murray  and  Hraniwell  i)re8ented,  without 
any  pain  or  ])ressure  sym])toms,  i)ulsation  and  dulness  over  the  aorta.  Tho 
coiiiiition  gradually  disappeared  and  was  thought  to  ho  neurotie. 

((•)  Dislocation  of  the  heart  in  curvatiiro  of  the  8])ino  may  cause  great 
displacement  of  tho  aorta,  bo  that  it  luis  been  known  to  pulsate  forcibly 
to  tlic  right  of  the  sternum. 

[il)  Solid  Tumors. — AVhen  tho  tumor  projects  externally  and  pulsates 
the  (lifllculty  may  bo  corisiderable.  In  tumor  tho  heaving,  expannile  pul- 
sation is  absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so 
striking  in  tho  throbbing  of  a  perforated  aneurism.  There  is  not  to  ho 
{(It  as  in  aortic  aneurism  the  shock  of  the  heart-sounds,  ])articularly  tho 
(liiistolic  shock.  Auscultatory  sounds  are  less  delinite,  as  large  aneurisms 
limy, occur  without  murmur;  and,  on  the  other  hand,  murmurs  may  bo 
heard  over  tumors.  Tho  greatest  difiiculty  is  in  the  deep-seat(Hl  thoracio 
timiors,  and  hero  tho  diagnosis  may  bo  impossible.  I  have  already  rc- 
foncd  to  tho  case  which  was  regarded  by  Skoda  as  aneurism  and  by  Op- 
polzcr  as  tumor.  ^J'he  physical  signs  may  be  indefinite.  Tho  ringing 
aortic  second  sound  is  of  great  importance  and  is  rarely,  if  ever,  heard 
ov(M'  tumor.  Tracheal  tugging  is  hero  a  valuable  sign.  Pressure  ])he- 
noinona  are  less  common  in  tumor,  whereas  pain  is  more  frequent.  Tho 
general  appearance  of  the  patient  in  aneurism  is  much  better  than  in 
tumor.  There  may  be  signs  of  enlargement  of  the  glands  in  the  axilla  or 
in  tlie  neck.  Healthy  strong  males  who  have  worked  hard  and  have  hud 
syphilis  are  tho  most  common  subjects  of  aneurism.  Occasionally  cancer 
of  the  oesophagus  may  simulate  aneurism,  producing  pressure  on  the  left 
bronchus,  and  in  one  instance  at  the  Philadelphia  Hospital,  Avith  a  husky, 
brazen  cough,  tho  symptoms  were  very  suggestive. 

('')  Pulsating  Pleurisy. — In  cases  of  empyema  necessitatis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heart  and  pulsates,  the  condi- 
tion may  readily  be  mistaken  for  aneurism.  The  absence  of  the  heaving, 
firm  distention  and  of  the  diastolic  shock  would,  together  with  the  his- 
tory and  the  existence  of  pleural  effusion,  determine  the  nature  of  the  case. 
If  necessary,  puncture  may  be  made  with  a  fine  hypodermic"  needle.  In  a 
majority  of  the  cases  of  pulsating  pleurisy  the  throbbing  is  diffuse  and 
widespread,  moving  the  whole  side.  ' 

Prognosis. — The  outlook  in  thoracic  aneurism  is  always  grave.  Life 
may  Ijo  prolonged  for  some  years,  but  the  patients  are  in  constant  jeopardy. 
Spontaneous  cure  is  not  very  infrequent  in  the  small  sacculated  tumors  of 
the  ascending  and  thoracic  portions.    The  cavity  becomes  filled  with  lam- 


v.;  'W^-4 

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C78 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


inas  of  firm  fibrin,  which  become  more  and  more  dense  and  hard,  the 
sac  shrinks  considerably,  and  finally  lime  salts  are  deposit  d  in  the  old 
fibrin.  The  laminfE  of  fibrin  may  be  on  a  level  with  the  lumen  of  tlie  ves- 
sel, causing  complete  obliteration  of  the  sac.  The  cases  which  rupture  ex- 
ternally, as  a  rule  run  a  rapid  course,  although  to  this  there  arc  cxcei)tioiis ; 
the  sac  may  contract,  become  firm  and  hard,  and  the  patient  may  live  lor 
five,  or  even,  as  in  a  case  mentioned  by  Balfour,  for  ten  years.  Tlie  ca^'s 
which  have  lasted  longest  in  my  experience  have  been  those  in  which  a 
saccular  aneurism  has  projected  from  the  ascending  aich.  One  patient  in 
Montreal  had  been  known  to  have  aneurism  for  eleven  years.  Tlie  aneu- 
rism may  be  enormous,  occupying  a  large  area  of  the  chest,  and  yet  life  be 
prolonged  for  many  years,  as  in  the  case  mentioned  as  under  the  care  of 
Skoda  and  Oppolzer.  One  of  the  most  remarkable  instances  is  the  cane  of 
dissecting  aneurism  reported  by  (Jraham.  The  patient  was  invalided  after 
the  Crimean  War  with  aneurism  of  the  aorta,  and  for  years  was  under  the 
observation  of  J.  II.  Richardson,  of  Toronto,  under  whose  care  he  died 
in  1885.  Tlie  autopsy  showed  a  healed  aneurism  of  the  arch,  witli  a  dis- 
secting aneurism  passing  the  whole  length  of  the  aorta,  which  formed  u 
double  tube. 

Treatment. — In  a  large  proportion  of  the  eases  this  can  only  be  pal- 
liative. Still  in  every  case  measures  should  be  taken  which  are  known  to 
promote  clotting  and  consolidation  within  the  sac.  In  any  largo  series 
of  cured  aneurisms  a  considerable  majority  of  the  patients  have  not  been 
known  to  be  subjects  of  the  disease,  but  the  obliterated  sac  has  been  found 
accidentally  at  the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  carried  out 
thoroughly,  is  that  advised  by  the  late  ^Ir.  Tufnell,  of  Dublin,  the  essen- 
tials of  which  are  rest  and  a  restricted  diet.  Ilest  is  essential  and  tdiould, 
as  far  as  possible,  be  absolute.  The  reduction  of  the  daily  number  of 
heart-beats  when  a  patient  is  recumbent  and  makes  no  exertion  whatever 
amounts  to  many  thousands,  and  is  one  of  the  principal  advantages  of 
this  plan,  ^rental  quiet  should  also  be  enjoined.  The  diet  advised  by 
Tufnell  is  extremely  rigid — for  breakfast,  two  ounces  of  bread  and  butt<>r 
and  two  ounces  of  milk ;  for  dinner,  two  or  three  ounces  of  meat  and 
three  or  four  ounces  of  milk  or  claret;  for  supper,  two  ounces  of  liread 
and  two  ounces  of  milk.  This  low  diet  diminishes  the  blood-vohinie 
and  is  tliought  also  to  render  tho  Idood  more  fibrinous.  It  reduces 
greatly  tho  blood-pressure  within  the  sac,  in  this  manner  favoring  coagu- 
lation. This  treatment  should  be  pursued  for  several  months,  but,  except 
in  persons  of  a  good  deal  of  mental  stamina,  it  is  impossible  to  cuitv  it 
out  for  more  than  a  few  Aveeks  at  a  time.  It  is  a  form  of  treatnu'nt 
adapted  only  for  the  saccular  form  of  aneurism,  and  in  cases  of  large  sacs 
communicating  with  the  aorta  by  a  comparatively  small  orifice  the  cbances 
of  consolidation  are  fairly  good.  Unquestionably  rest  and  the  restriction 
of  tho  liquids  are  the  important  parts  of  the  treatment,  and  a  greater 


ANEURISM. 


679 


variety  and  quantity  of  food  may  be  alloAved  with  advantage.    If  this  plan 
cannot  be  thoroughly  carried  out,  the  patient  should  at  any  rate  be  ad- 
vI.simI  to  live  a  very  quiet  life,  moving  about  with  deliberation  and  avoiding 
all  sudden  mental  or  bodily  excitement.    The  bowels  should  be  kept  regu- 
lar, and  constipation  and  straining  should  be  carefully  avoided.    Of  medi- 
cines, iodide  of  potassium,  as  advised  by  Balfour,  is  of  great  value.     It 
may  be  given  in  doses  of  from  ten  to  fifteen  or  twenty  grains  three  times 
a  (lay.    Larger  doses  are  not  necessary.     The  mode  of  action  is  not  well 
understood.     It  may  act  by  increasing  the  secretions  and  so  inspissating 
the  blood,  by  lowering  the  blood-pressure,  or,  as  Balfour  thinks,  by  causing 
tliiokoning  and  contraction  of  the  sac.     The  most  striking  effect  of  the 
iodide  in  my  experience  has  been  the  relief  of  the  pain.     The  evidence  is 
not  conclusive  that  the  syphilitic  cases  are  more  benefited  than  the  non- 
syphilitic.    All  these  measures  have  little  value  unless  the  sac  is  of  a  suit- 
able form  and  size.     The  large  tumors  with  wide  mouths  communicating 
with  the  ascending  portion  of  the  aorta  may  be  treated  on  the  most  ap- 
proved plans  for  months  Avithout  the  slightest  influence  other  than  reduc- 
tion in  the  intensity  of  the  throbbing.     A  patient  with  a  tumor  j)roject- 
iiig  into  the  right  pleura  remained  on  the  most  rigid  Tufnell  treatment 
for  more  than  one  hundred  days,  during  which  time  he  also  took  iodide 
of  potassium  faithfully.    The  pulsations  were  greatly  reduced  and  the  area 
of  dulnoss  diminished,  and  wo  congratulated  ourselves  that  the  sac  was 
prol)ably  consolidating.     Sudden  death  followed  rupture  into  the  pleura, 
and  tlio  sac  contained  only  fluid  blood,  not  a  shred  of  fibrin.     In  cases  in 
wliieh  the  tumor  is  large,  or  in  which  there  seems  to  be  very  little  prospect 
of  consolidation,  it  is  perhaps  better  to  advise  a  man  to  go  on  quietly  with 
his  occupation,  avoiding  excitement  and  worry.     Our  profession  has  of- 
fered many  examples  of  good  work  thoroughly  and  conscientiously  carried 
out  ])y  men  with  aneurism  of  the  aorta,  who  wisely,  I  think,  as  the  late 
Hilton  Fagge,  preferred  to  die  in  harness.     Other  measures  to  induce 
coagulation  in  the  sac  are  electricity,  which  Inis  occasionally  proved  suc- 
cessful ;  the  insertion  of  horse-hair,  thin  wire,  or  needles ;  the  injection  of 
an  astringent  liquid,  such  as  perchloride  of  iron,  into  the  sac.     In  a  few 
oases  only  these  have  been  follov;ed  by  cure.     The  fine  silver  wire  ])uslied 
tiirougli  a  hypodermic  needle  is  probably  the  most  satisfactory  method, 
and  may  bo  combined  with  electrolysis,  the  method  known  as  Lorota's. 
Kerr  aiul  Rosenstein,  of  San  Francisco,  have  recently  reported  cases  in 
which  cure  was  effected  in  this  way. 

Other  S'i/mpfo?ns  rcquirinff  Treatment. — Pressure  on  veins  causing  en- 
gorgcmcmt,  particularly  of  the  head  and  arms,  is  sometimes  promptly  re- 
lieved by  free  venesection,  and  at  any  time  during  the  course  of  a  thonicic 
aneurism,  if  attacks  of  dyspnoea  with  lividity  supervene,  bleeding  may  bo 
resorted  to  with  great  benefit.  It  has  the  advantage  also  of  promptly 
checking  the  pain,  for  which  symjitom,  as  already  mentioned,  the  iodido 
of  potassium  often  gives  relief.     In  the  final  stages  morphia  is,  as  a 


.■'!' 


si 


■w 


Ir     t 


ir 


C80 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


rule,  necessary.  Dyspnoea,  if  associated  with  cyanosis,  ia  best  relieved 
by  bleeding.  Chloroform  inhalations  may  be  necessary.  Tlie  quest  iim 
sometinies  comes  nji  with  reference  to  tracheotomy  in  these  cases  of  urgcut 
dyspna>a.  If  it  can  be  shown  by  laryngoscopic  examination  that  it  is  due 
to  bilateral  abductor  jiaralysis  the  trachea  may  be  opened,  but  this  is  ex- 
tremely rare,  and  in  nearly  every  instance  the  urgent  dyspnani  is  caused 
by  pressure  about  tlie  bifurcation.  When  the  sac  appears  externally  and 
grows  large  an  ice-cap  may  be  applied  upon  it,  or  a  belladonna  ])Uistcr  h\ 
allay  the  pain.  In  some  instances  an  elastic  support  may  be  used  witli 
advantage,  and  I  saw  a  physician  with  an  enormous  external  aneurism  in 
the  right  mammary  region  who  for  many  months  had  obtained  groat 
relief  by  the  elastic  support,  passing  over  the  shoulder  and  under  tlie  arm 
of  the  opposite  side. 

Digitalis,  ergot,  aconite,  and  veratrum  viride  are  rarely,  if  ever,  of 
service  in  thoracic  aneurism. 

Aneurism  op  the  Abdomixal  Aouta. 


It 


The  sac  is  most  common  in  the  neighborhood  of  the  celiac  axis 
is  rare  in  comparison  with  thoracic  aneurism.  The  tumor  may  be  fusi- 
form or  sacculated,  aiul  it  is  sometimes  multiple.  Projecting  backward,  it 
erodes  the  vertebrae  and  may  cause  numbness  and  tingliiig  iu  the  logs 
and  fiually  })araplegia,  or  it  may  ])ass  into  the  thorax  and  burst  into  tiie 
pleura,  ;^^ore  commonly  the  sac  is  on  the  anterior  wall  and  projects  for- 
ward as  a  deiinite  tumor,  which  may  be  either  in  the  middle  line  or  a 
little  to  the  left.  The  tumor  may  be  large  and  evident,  or  wheu  liiirh  up 
beneath  the  pillar  of  the  diaphragm  i-t  nuiy  attain  considerable  size  with- 
out being  very  apparent  on  palpation. 

'J'he  symptoms  are  chiefly  pain,  very  often  of  a  cardialgii;  naliiro, 
passing  round  the  sides  or  localized  in  the  back,  and  gastric  symptoms, 
particularly  vomiting.  Iletai'dation  of  the  pulso  in  the  femoral  is  a  vory 
common  symptoni. 

Diagnosis  and  Physical  Signs.— Inspection  may  show  marked 
pulsation  in  the  epigastric  region,  sometimes  a  definite  tumor.  A  llnill  is 
not  uncommon.  The  pulsation  is  forcible,  expansile,  and  sometimes  doubk' 
Avhen  the  sac  is  large  and  in  contact  with  the  ])ericardium.  On  iN.lpaiioiia 
definite  tumor  am  be  felt.  If  large,  there  is  some  degree  of  dulncss  oti  per- 
cussion which  usually  merges  with  that  of  the  left  lobe  of  the  liver.  ( >n  aus- 
cultation, a  systolic  murmur  is,  as  a  rule,  audible,  and  is  sometimes  best 
heard  at  the  back.  A  diastcdic  murmur  is  occasionally  present,  usually 
very  soft  in  quality.  One  of  the  commonest  of  clinical  errors  is  to  mis- 
take a  throlibing  aorta  for  an  aneurism.  It  is  to  be  remembered  that  no 
pulsation,  however  forcible,  or  the  presence  of  a  thrill  or  a  systohc 
murmur  justifies  the  diagnosis  of  abdominal  aneurism  unless  there  is  ii 
drfinite  tumor  ivhich  can  be  grasped  and  tvhich  has  an  rxpansih'  jnika- 


ANEURISM. 


6S1 


iifi 


rm. 


Hon.  Attention  to  tliis  rule  Avill  save  many  errors.  The  throbbing  or 
pnl-iiting  aorta  is  mot  with  in  all  neurasthenic  conditions,  particularly  iu 
women,  and  it  is  remarkable  with  what  violence  the  epigastrium  may  bo 
driven  out  with  each  systole.  In  anaemia,  particularly  some  instances  of 
traiiiiKitic  antvmia,  the  throbbing  may  be  very  great.  In  the  euso  of  a 
lurjic  stout  man  with  severe  hannorrhagcs  from  a  duoileual  ulcer  tlio 
thnibbing  of  the  abdominal  aorta  not  only  shook  viidently  the  whole  ab- 
domen, but  communicated  a  pulsation  to  the  bed,  the  shock  of  which 
Avas  distinctly  iierccjitible  to  any  one  sitting  upon  it.  \'cry  frequently 
ii  tumor  of  the  i)ylorus,  of  the  pancreas,  or  of  the  left  lobe  of  tlie  liver  is 
lifted  with  each  impulse  of  the  aorta  and  may  bo  confouiuled  with  aneu- 
rism. The  absence  of  the  forcible  expansile  impulse  and  the  examina- 
tion iu  the  knee-elbow  position,  in  which  the  tumor,  as  a  rule,  falls  for- 
ward, and  the  pulsation  is  not  then  communicated,  sufllce  for  differentia- 
tion. 

The  outlook  in  abdominal  aneurism  is  bad.  A  few  cases  heal  spon- 
taneously. Death  may  result  from  (a)  complete  obliteration  of  the  lumen 
by  clots ;  (b)  compression  j)araj)legia ;  (c)  rupture  either  into  the  jjlcura, 
n'troperitoneal  tissues,  peritonanim  or  the  intestines,  very  commonly  the 
duodenum  ;  (d)  by  embolism  of  the  superior  mesenteric  artery,  producing 
infarction  of  the  intestines. 

The  treatment  is  such  as  already  advised  in  thoracic  aneurism,  ^^'heu 
tlie  aneurism  is  low  down  jjressure  has  been  successfully  ap[)lie(l  in  a  case 
by  .Murray,  of  Newcastle.  It  must  be  kept  up  for  many  hours  under  chlo- 
roform. The  plan  is  not  without  risk,  as  patients  have  died  from  bruising 
and  injury  of  the  sue. 

AXKURISM   OF  THE    BRANCHES   OF  THE   AnDOMIXAL   AORTA. 

The  cceliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  I'ortion  of  the  abdominal  aorta.  Of  its  branches,  the  splenic  artery  is 
covuiionally  the  scat  of  aneurism.  This  rai'cly  causes  tumor  large  enough 
*■     .;  'ell;  sometimes,  however, the  tumor  is  of  largo  size.    I  htive  reported 

■  ■ '  c>  i  .  u  man,  aged  thirty,  who  had  an  illness  of  several  months'  dura- 
tio,  ;  v.Mv  epigastric  pain  and  vomiting,  which  led  his  physicians  in  New 
York  lo  diagnose  gastric  ulcer.  There  was  a  deep-seated  tumor  in  the  left 
liypochondriac  region,  the  dulnessof  which  merged  with  that  of  the8])leen. 
Tluu'e  was  n  pulsation,  but  it  was  thought  on  one  occasion  that  a  bruit 
wiis  beard.  The  chief  symptoms  while  under  observation  Avere  vomiting, 
severe  epigastric  pain,  occasional  ha?matemesis,  and  finally  severe  hsmor- 
rliago  from  the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a 
eoeoa-nutAvas  situated  between  the  stomach  above  and  the  transverse  colon 
'ielow,  :uul  extended  to  the  left  as  far  as  the  level  of  the  navel.     The  sac 

<^'H  liiud  densely  laminated  fibrin.  It  had  perforated  the  colon.  I  have 
twice  seen  snudl  aneurisms  on  the  splenic  artery.    Of  thirty-nine  instances 


u  4  fiW 


I'  '  '  ih  5' 


G82 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


ifn    f  .,. 


of  aneurism  on  the  branches  of  the  abdominal  aorta  collected  by  Lcbort, 
ten  were  of  the  splenic  artery. 

Aneurism  of  the  hepatic  artery  is  very  rare,  and  there  are  only  ten  or 
twelve  cases  on  record.  Tlie  symi)tonis  are  extremely  indefinite ;  thi;  cdii- 
dition  could  rarely  be  diagnosed.  In  the  case  reported  by  Hoss  and 
myself,  a  man  aged  twenty-one  had  tlie  symptoms  of  pyamiia.  The  Hvor 
was  greatly  enlarged,  weighed  nearly  5,000  grammes,  and  presented  innu- 
merable small  abscesses.  An  ova!  aneurism,  half  the  size  of  a  small  lemon, 
involved  the  right  and  part  of  tlio  left  branches. 

A  few  cases  of  aneurism  of  the  superior  mesenteric  rt;7er?/ are  on  record. 
The  diagnosis  is  scarcely  possible.  Plugging  of  the  branches  or  of  thr  ..lin 
stem  may  cause  the  symptoms  of  infarction  of  the  bowels  which  have  al- 
ready been  considered. 

Small  aneurisms  of  the  renal  artery  are  not  very  uncommon.  Large 
tumors  arc  rare.  The  sac  may  rupture  and  give  rise  to  extensive  retro- 
peritoneal hffimoi     ;i'^". 

AitTEUIO-VENOUS   ANEURISM. 

In  this  form  there  is  abnormal  communication  between  an  artery  and 
a  vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aueu- 
rism ;  when  there  is  a  direct  communication  without  tumor  the  vein  is 
(diiefly  distended  and  the  condition  is  known  as  aneurismal  varix. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  open  directly 
into  the  vemi  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed 
by  Pepper  and  Griffith.  Cyanosis,  codema,  and  great  distention  of  the 
veins  of  the  upper  part  of  the  body  are  the  most  frequent  symptoms,  and 
develop,  as  a  rule,  with  suddenness.  Of  the  physical  signs  a  thrill  is  pres- 
ent in  some  cases.  A  continuous  murmur  with  systolic  intensification  is 
of  great  diagnostic  value.  In  a  recent  case,  after  the  existence  for  somo 
time  of  pressure  symptoms,  intense  cyanosis  developed  with  engorgement 
of  the  veins  of  the  head  and  arms.  Over  the  aortic  region  there  was  a 
loud  continuous  murmur  with  systolic  intensification. 

A  majority  of  the  cases  of  arterio-venous  aneurism  and  of  aneurismal 
varix  result  from  the  accidental  opening  of  an  artery  and  vein  as  in  vene- 
section, and  are  met  with  at  the  bend  of  the  elbow  or  sometimes  in  the 
temporal  region.  The  condition  may  persist  for  years  without  causing 
any  trouble.  Pulsation,  a  loud  thrill,  and  a  continuous  humming  mur- 
mur are  usually  present.  ^ 

Congenital  Aneurism. 

In  consequence  of  failure  of  proper  development  of  the  elastic  coat  m 
many  places  in  the  arterial  system,  multiple  aneurisms  may  develoi).  In 
the  well-known  case  described  by  Kiissmaul  and  Maier,  upon  many  of  tho 


ANEURISM. 


683 


ine<linm-sized  arteries  there  were  nodular  prominences,  which  consisted  of 
tliickening  of  the  intima  and  infiltration  of  the  adventitia  and  of  the 
media,  with  a  nuclear  growth  which  in  places  looked  quite  sarcomatous. 
Tlioy  called  it  a  case  of  periarteritis  nodosa,  and  Eppinger  holds  that  it 
belongs  to  the  category  which  he  makes  of  congenital  aneurism.  As 
many  as  sixty-three  ancurismal  tumors  have  been  found  in  one  case.  In 
the  smaller  branches,  such  as  the  coronary  and  the  mesenteric  arteries  or 
in  the  pulmonary  arteries,  there  may  be  numerous  elongated  or  saccular 
iineurisms  varying  in  size  from  a  cherry  to  a  hazel-nut.  These  are  true 
ancurismal  dilatations,  and,  according  to  Eppinger's  careful  study,  consist 
of  tlio  intima  and  the  adventitia,  the  elastic  lamina  having  disappeared. 
The  condition  has  been  met  with  in  children  Some  of  the  cases,  how- 
ever, have  been  in  adults ;  but  the  term  as  applied  by  Eppinger  ex- 
presses, and  probably  correctly,  the  deep-seated  fundamental  error  in 
development  which  must  be  at  the  basis  of  this  condition.  The  coronary 
arteries  is  a  favorite  situation ;  a  case  has  been  reported  by  Gee  in  a  boy 
of  seven. 


jll 


-  i 


44 


I^R   > 

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1 

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B 

V'l 


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SECTION  VI. 

DISEASES  OF  THE  BLOOD  AND  DUCTLESS 

GLANDS. 


I.  AN>EIVIIA. 

Anemia  may  be  defined  as  a  reduction  in  the  amount  of  the  blood  as 
a  whole  or  of  its  corpuscles,  or  of  certain  of  its  more  important  constitu- 
ents, such  as  albumen  and  h£emoglobin.  The  condition  may  be  general 
or  local.  The  former  alone  we  are  here  considering.  It  is  interesting 
to  note,  however,  that  the  pallor,  particularly  of  the  face,  which  is  one 
of  the  most  striking  symptoms  of  anaemia,  is  just  as  characteristic  of  local 
ana;mia  due  to  fright  or  to  nausea.  There  are  persons  persistently  ])alo 
without  actual  ana3mia  in  whom  the  condition  may  be  due  to  inherited 
peculiarities. 

Our  knowledge  is  not  yet  sufficiently  advanced  to  classify  satisfactorily 
the  various  forms  of  anaemia.  The-  following  provisional  grouj)ing  may 
be  made  :  (1)  Secondary  or  symptomatic  anasmia;  (2)  primary,  essential, 
or  cytogenic  anaemia. 

Secondary  An.tjmia. 

t 

Under  this  division  comes  a  large  proportion  of  all  cases.  The  follow- 
ing are  the  most  important  groups,  based  on  the  etiology : 

(I)  Anmmia  from  hmmorrhnge,  either  traumatic  or  spontaneous.  The 
loss  of  blood  nuiy  be  rapid,  as  in  lesions  of  large  vessels,  in  injury  or  in 
rupture  of  aneurisms,  or  in  cases  of  ulcer  of  the  stomach  or  duodenum, 
or  post-partum  haemorrhage.  If  the  loss  is  excessive,  death  results  from 
lowering  of  the  arterial  pressure.  In  sudden  profuse  haemorrhage  the 
loss  of  three  or  four  pounds  of  blood  may  prove  fatal.  In  the  rupture  of 
an  aneurism  into  the  pleura  the  loss  of  blood  may  amount  to  seven  ]«iuiuls 
and  a  half,  the  largest  quantity  I  have  known  to  be  shed  into  one  cavity. 
In  a  case  of  htematemesis  the  patient  lost  over  ten  pounds  by  measure- 
ment in  one  week  and  yet  recovered  from  the  immediate  effects.  Even 
after  very  severe  hsemoirhage  the  number  of  red  blood-corpuscles  is  not 
reduced  so  greatly  as  in  forms  of  idiopathic  anaemia.    Thus  in  a  case  just 


ANylilMIA. 


085 


jnoiitioned,  at  the  teriniimtion  of  the  week  of  hleediiig  thero  were  nearly 
1,;)'J(),U()0  red  blood-cor})iKschjs  to  tlie  oiibic!  millimetre.  The  process  of 
rcjfeiieratiou  goes  on  with  great  raj)i(lity,  and  in  some  "  bleeders  "  a  week 
or  ton  days  suffice  to  re-establish  the  normal  amount.  The  M'atery  and 
saUiie  constituents  of  the  blood  are  readily  restored  by  al)sori)ti(jn  from 
the  i^astro-intestinal  tract.  The  albuminous  elements  also  are  quickly  re- 
iicwcil,  but  it  may  take  weeks  or  months  for  the  corfjuscles  to  reach  the 


m-M 


'l':l^^i^^>W/ 


'  o 

APRIL. 

MAY.                          1                        JUNE.                              1    JULY,      1 

SliSSS. 

.-.2s:r;§ssss 

g(,.„..  =  ;;t;;ssts|--"n 

110:< 

, 

lOOf 

r).(X)0,(X>o 

00% 

! 

1 

.-' 

80^ 

4,000,000 

_p--T"' 

^ 

^ 

70% 

-- 

^.,'' 

^^ 

60% 

3,000,000 

\ 

/ 

\ 

J 

bO% 

\  1 

iO% 

2.000.000 

30% 

A—* — A-  i 

_-.V.-- 

->!- 

-' 

•1 

- 

.fr- 

- 

i: 

--•.;- 

_  ..:._  _ 

1 

u.ooo 

1 

12.000 

fv        < 

-L 

10,000 

1  - 

s 

S.OOO      1 

\ 

0,000 

\-^ 

- 

-- 

_  J 

4,000 

K. 

,„^ 

2,(XX) 

L_         __     _ 

BUCK,  RED  CORPUSCLES. 


RED,  HAEMAClOBIN, 


MEAN  NORM. 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLUE,  COLOALESS  CORPUSCUS. 


Chart  .KVT. — Illustrates  the  rapidity  with  which  anaemia  is  produced  in  purpura  has- 
morrhagica  and  the  gradual  recovery.* 

normal  standard.     The  accompanying  chart  illustrates  the  rapid  fall  and 
gradui'.l  restitution  in  a  case  of  severe  purpura  hnpmorrhagica. 

The  microscopical  characters  of  the  blood  after  severe  haemorrhage  are 
not  much  changed ;  the  white  corpuscles  are  relatively  increased,  pro- 
iluciiig  a  condition  of  leucocytosis.  Nucleated  red  corpuscles  are  present, 
tlioiigli  usually  not  numerous.     In  the  regeneration  of  the  blood  the  de- 


*  Oil  Soptcnibor  27th  the  patient  returned  from  the  country,  wiicro  she  had  spent 
the  siuiuiicr.  The  blood  count  was  then:  lied  corpuscles,  5,350,000;  white  corpus- 
cles, 5,500 ;  hannoglobin,  ninety-four  per  cent. 


ti        I  f   i?*S 


Lift. « 


?n 


'  i     I 


1 

if  i 


I 


P' 


68(5 


DISEASES  OF  THE   HLOOD  AND   DUCTLESS  (iLANDS. 


velopment  of   the   limmoglobin   does   not   keep  puce   with    that  of   the 
corpuscles. 

(2)  Aiuemia  is  fre(|uently  produced  by  long-continued  drain  on  iIk; 
albuminous  materials  of  the  blood,  as  in  chronic  suppuration  and  Urijfjit's 
disease.  Prolonged  lactiition  acts  in  the  same  way.  Jiapidly  gronjiHr 
tumors  may  cause  a  profound  anajmia,  as  in  gastric  (iancser.  'I'he  ch:ir- 
acter  of  the  blood  in  these  cases  is  similar  to  that  in  ana-mia  after  haiiiior- 
rhage. 

(3)  Aninmia  from  Inanition. — This  maybe  brought  about  by  dclVctivc 
food  supply,  or  by  conditions  which  interfere  with  tlie  proper  reception 
and  preparation  of  the  food,  as  in  cancer  of  the  a'sophagus  and  clironio 
dys])epsia.  The  reduction  of  the  blood  mass  may  be  extreme,  Init  tlu^ 
plasma  sulfers  proportionately  more  than  the  corpuscles,  whi(;li,  even  in 
the  wasting  of  cancer  of  the  oesophagus,  nuiy  not  be  reduced  more  than 
one  half  or  three  fourths. 

(4)  Toxic  anwmia,  induced  by  the  action  of  certain  poisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  iiu)rganic  substances, 
and  the  virus  of  syphilis  and  nudaria  among  organic  poisons.  They  act 
either  by  directly  destroying  the  red  blood -corpuscles,  as  in  malaria,  or  by 
increasing  the  rate  of  ordinary  consumption.  The  anaemia  of  pyiexia 
may  in  part  be  due  to  a  toxic  action,  but  is  also  caused  in  part  by  tiie 
disturbance  of  digestion  and  interference  with  the  function  of  the  blood- 
making  organs. 

Primary  or  Essential  Anaemia. 

1.  Chlorosis. — An  essential  anosmia  met  with  chiefly  in  young  girls, 
characterized  by  a  marked  relative  diminution  of  the  hemoglobin. 

Etiology. — Cases  are  rarely  seen  in  men.  Blondes  are  more  fre- 
quently affected  than  brunettes.  The  age  of  onset  is  usually  between  tlie 
fourteenth  and  the  seventeenth  years.  Recurrences  throughout  the  tliini 
decade  are,  however,  not  uncommon.  Chlorosis  is  extremely  rait'  in 
young  children. 

Hereditary  influences  probably  play  a  part.  Virchow  pointed  out  that 
in  many  cases  there  was  a  defective  development  of  the  circulatory  sys- 
tem, either  congenitiil  or  resulting  in  a  failure  of  the  normal  rate  of 
growth.  In  some  instances  a  compensatory  hypertrophy  of  the  heart 
has  been  found. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of 
large  towns,  who  are  confined  all  day  in  close,  badly-lighted  rooms,  or 
have  to  do  much  stair-climbing.  Cases  are  frequent,  however,  under  the 
most  favorable  conditions  of  life.  Lack  of  proper  exercise  and  i\vA\  air, 
and  improper  food  are  important  factors.  Emotional  and  nervous  dis- 
turbances may  be  prominent,  so  prominent  that  certain  writers  liiive 
regarded  the  disease  as  a  neurosis.     Menstrual  disturbances  are  not  un- 


n-irls, 


out  tluit 

itory  s 

vs- 

1  nitc 

of 

ho  111 

!irt 

I  }lii''~ 

of 

rooms 

,  or 

iiult.1' 

the 

frosli 

air, 

rvoiis 

(lis- 

tois  1 

uive 

i  not 

im- 

AN/KMIA. 


687 


common,  but  arc  probably  a  sequonce,  not  a  cause  of  chlorosis.  Sir 
And  row  Clurk  bolievos  that  constipation  plays  an  important  role,  and  that 
tho  coiidition  is  in  reality  a  coprcBinla  duo  to  the  absorption  of  poisons — 
Ifiiooinainoa  and  ptomaines — from  tho  lar^^e  bowel. 

Morbid  Anatomy.— Fortunately  the  disease  is  rarely  fatal.  The 
flit  is  well  retained.  lly])oplasia  of  tho  aorta  and  larger  arteries  has  been 
found  in  some  cases,  and  the  vessels  have  had  a  remarkable  degree  of  clas- 
tioity.  The  heart  is  usually  dilated  and  tho  left  ventricle  hypertrophied. 
]Iy[ioi)lasia  of  the  uterus  and  defective  development  of  the  genitalia  have 
also  lioon  found. 

Symptoms. — The  blood  examination  :  Johann  Duncan  in  18(;7  first 
oallctl  attention  to  the   fact  tliat  the  essential  feature  was  not  a  (pian- 
titativo  but  a  qualitative  change   in  the  luemoglobin.      This   has  been 
abundantly  confirmed.     The  red  blood-eorpuscles  may  show  only  a  modef- 
ato  <:ra(le  of  reduction,  but  the  corpuscles  themsolvos  arc  very  poor  in 
lui-'iiioglobiu.     Thus  in  forty  consecutive  cases  examined  at  my  clinic  by 
Tliayor,  tho  average  number  per  (mbic  millimetre  of  the  red  blood-corpus- 
cles was  4,225,181,  or  over  eighty  per  cent,  whei-eas  the  percentage  of  luiemo- 
jrlobin  for  tho  total  number  was  44-1  per  cent.     The  accompanying  chart 
ilhisliates  well   these  striking  differences.     The  least  blood-count  in  the 
sorios  of  cases  referred  to  above  was  l,932,00u.    There  nuiy  be  all  the  physi- 
cal characteristics  and  symptoms  of  a  profound  anaemia  with  blood-corpus- 
clos  nearly  at  the  normal  standard.    Thus  in  one  instance  the  globular  rich- 
ness was  over  eighty-five  per  cent  with  the  luemoglobin  about  thirty-five. 
Tlicsc  characteristics  are  distinctive,  I  believe,  and  not  found  in  the  same 
grade  in  any  other  form  of  anaemia.     The  importance  of  the  reduction  in 
the  luvmoglobin  depends  upon  the  fact  that  it  is  the  iron-containing 
element  of  tho  blood  with  which  in  respiration  the  oxygen  enters  into 
combination.     This  marked  diminution  in  tho  iron  has  also  beoji  doter- 
tiiiiu'd  by  chemical  analysis  of  the  blood.     The  microscopical  character- 
istics of  the  blood  are  as  follows :   In  severe  cases  the  corpuscles  may  be 
extremely  irregular  in  si^e — poikilocytosis — which  may  occasionally  bo  as 
marked  as  in  pernicious  anaemia.     The  large  forms  of  red  blood-cells  are 
common,  but  the  average  size  is  stated  to  be  below  normal.     The  color  of 
the  corpuscles  .s  noticeably  pale  and  the  deficiency  may  be  seen  either  in 
individual  corpuscles  or  in  the  blood  mixture  prepared  for  counting.    The 
leucocytes  nuiy  show  a  slight  increase ;  thus,  the  average  of  the  forty  cases 
above  referred  to  was  8,250  per  cubic  millimetre. 

The  general  symptoms  of  chlorosis  are  those  of  an  ana?mia  of  moderate 
grade.  The  subcutaneous  fat  is  well  retained  or  even  increased  in  amount. 
The  complexion  is  peculiar ;  neither  the  blanched  aspect  of  haemorrhage 
nor  the  muddy  pallor  of  grave  anaemia,  bui  a  curious  yellow-green  tinge 
wliicli  has  given  the  name  to  the  disease,  and  to  its  popular  designation, 
the  f,qeen  sickness.  In  cases  of  moderate  grade  the  color  may  be  decep- 
tive, as  the  cheeks  have  a  reddish  tint,  particularly  on  exertion  (chlorosis 


■:%■ 


:-,'ti 


•  it* 


'    .ft 


:iv0' 


1^; 


"u 


;H 


688 


DLSKASKS  OF  TIIK   HliOOI)    AND    DUCTLKSS   (JI.AN'DS. 


rubni).     The  subjects  coiiipljiin  of  breathlesHiiess  mul    iJiilpitution,  imd 
tliore  may  bo  a  tondoney  to  faintinjif.     Tlio  palpitation  and  bnuithlcssiicmH 


JANUARY,                                        FEDHUAHY.                                          MARCH. 

120« 

0,000,000                                                                      A 

110% 
100* 

5,000,000                                                        /                        i      /                             ; 

90X 

/                                        '        „ 

80^ 
10% 

4,000,000                                            ^^                                                                 1 

C0% 

3,000,000 

bO% 

40^ 

2,000,000 

aox 

,/■ 

20^ 

1,000,000 

i: — * — 1?J—  ')  -  —ft'-  -'i  -  ''   h  '.'     -  *  -  -*  \-  4:    -  -i      -*-  -' :  -  ■«-     •.'     - '.';     -•':      ■.'• 

14,000 

12,000                                            ^ 

10,000                                        /^     \ 

./'             \          •                                             __l > 

8,000                     ^'''                      "^^                                    /•■ 

6,000               '                                           '     '"--[..^           / 
4,000                                                                                    ~  ■" 

2,000 

BLACK,  RED  CORPUSCLES. 


RED,  HAEMAGLOBIN. 

Chart  XVII. — Chlorosis, 


MEAN  NOnM. 

NUMBER  OF 

WHITE 

conpu9ci.es 


BLUE,  COLORLESS  CORPUSCLES. 


often  lead  to  the  suspicion  of  heart  or  lung  disease.  The  eyes  have  a 
peculiar  brilliancy  and  the  sclerotics  are  of  a  sky-blue  color  Occiisionully 
the  skin  shows  areas  of  pigmentation,  particularly  about  the  joints. 

Digestive  symptoms  are  common.  The  appetite  is  capricious  and  the 
patients  often  have  a  longing  for  unusual  articles,  particularly  acids.  In 
some  instances  they  eat  all  sorts  of  indigestible  things,  such  as  cludk  or 
even  earth.  Constipation  is  a  common  symptom,  and,  as  already  men- 
tioned, has  been  regarded  as  an  important  element  in  causing  the  disease. 
Contourier  has  noted  the  frequent  association  of  dilatation  of  the  ,-^toiii!iih 
with  chlorosis,  and  states  that  in  some  cases  this  may  be  an  etiological 
factor,  while  in  others  it  may  be  a  result. 

The  circulatory  symptoms  are  important.     Palpitation  of  the  lunut  oc- 


r-'-   'H^ 


*.      11/ ♦ 


ANEMIA. 


C81» 


>■  ''My-ji 


MEAN  HOny. 

NUMBER  Of 

WHiTC 
CORPUSCLt* 


|eS8  CORPUSCLES. 

hyes  have  a 

Icoasionally 

lilts. 

lus  iiiul  the 
acids.  In 
18  cliiilk  or 

J-eady  m^n- 

jtlie  (liseaiio. 

Ihc  stomach 
etiologii'iil 

lie  heart  oc- 


otirH  on  exertion,  and  may  bo  the  most  distressing  symptom  of  which  tlm 
patit'ut  conijihiins.  Percussion  may  show  slight  increase  in  tlie  trMnsverse 
(hihiess.  A  systolic  murmur  is  lieard  at  the  apex  or  at  the  buso ;  more 
commonly  at  the  latter,  but  in  extreme  cases  at  both.  A  diastolic  murmur 
is  nircly  heard.  I'he  systolic  murmur  is  usually  loudest  in  tiie  second  left 
intercostal  space,  where  there  is  sometimes  a  distinct  pulsation.  The 
exact  mode  of  ])roduction  is  still  in  dispute.  Balfour  hoUls  that  it  is  ])ro- 
(liiccd  at  the  mitral  orifice  by  relative  insufTieiency  of  the  valves  in  the 
dilated  condition  of  the  ventricle.  On  the  right  side  of  the  neck  over  the 
jufTiilar  vein  a  continuous  murmur  is  heard,  the  bruit  cle  (liable,  or  hum- 
iniiig-to])  murmur. 

'J'lie  pulse  is  usually  full  and  soft.  Pulsation  in  the  peripheral  veins  is 
sometimes  seen.  There  is  a  tendency  to  thrombosis  in  the  veins ;  most 
eoiiunonly  in  the  femoral,  but  in  other  instances  in  the  longitudinal  sinus, 
or  the  thrombosis  may  be  multiple.  Except  in  tho  sinuses,  the  condition 
is  rarely  serious.  Tuckwell  has  reported  an  instance  in  which  there  was 
embolism  of  the  right  axillary  artery  with  the  loso  nt  a  thumb  and  part 
of  tho  fingers.  Brayton  Ball  has  recently  called  attention  to  the  im^jor- 
tunce  of  this  feature  of  chlorosis. 

As  in  all  forms  of  essential  ana?mia,  fever  is  not  uncommon.  Especial 
attention  has  of  late  been  directed  to  this  by  i'Vench  writers.*  Clilorotic 
patients  suffer  frequently  from  headaclie  and  neuralgia,  which  may  be 
{laroxysnial.  Hysterical  manifestations  are  not  infrequent,  ^lenstrual 
(lislurbauces  are  very  common — amenorrho-a  or  dysmenorrhcea.  ^Vith 
the  improvement  in  the  blood  condition  this  function  is  usually  restored. 
Diagnosis. — 'J'he  green  sickness,  as  it  is  sometimes  called,  is  in  many 
instances  recognized  at  a  glance.  The  well-nourished  condition  of  the 
girl,  the  peculiar  complexion,  which  is  most  marked  in  brunettes,  and  the 
white  sclerotics  are  very  characteristic.  A  special  danger  exists  in  mis- 
taking the  anemia  of  the  early  stage  of  pulmonary  tuberculosis  for  chlo- 
rosis. Tho  palpitation  of  tho  heart  and  shortness  of  breath  frequently 
suffgest  haart-disease,  and  the  cedema  of  the  feet  and  general  pallor  cause 
the  cases  to  be  mistaken  for  Bright's  disease.  In  the  great  majority  of 
cases  the  characters  of  the  blood  readily  separate  chlorosis  from  other 
forms  of  anaemia. 

'I  Idiopathic  or  Progressive  Pernicious  Anaemia.— The  disease  was 
first  clearly  described  by  Addison,  who  called  it  idiopathic  u-vmia. 
Chaiuiing  and  Gusserow  described  the  cases  occurring  post  parturn,  but 
to  Biornior  we  owe  a  revival  of  interest  in  the  subject. 

Etiology. — The  existence  of  a  separate  disease  worthy  of  the  term 
progressive  pernicious  anaemia  has  been  doubted,  but  there  are  unques- 
tionably cases  in  which,  as  Addison  says,  there  exist  none  of  the  usual 
causes  or  concomitants  of  anaemia.     Clinically  there  are  several  different 


rnfl 


i  I 


•  Trazit,  Paris  Thesis,  1888. 


!  i 


Vi 


m. 


v'-l   '\      ''' 


m:\ 


!! 


690 


DISEAST^S  OP  TIIR  BLOOD  AND   DUCTLESS  GLANDS. 


groups  wlii(!h  prosent  tlio  clitimctei'H  of  ix  progressive  and  perni(!ious  anai. 
mlu  and  are  ctiologically  diflorcMit.  Thus,  a  fatal  anminia  may  he  duo  to 
t'lo  presence  of  parasit(!s,  or  may  follow  ha'morrha<,'e,  or  be  associilcd 
witli  chronic  atropliy  of  tlie  stomach;  !)ut  when  we  hnvc  exchidcd  all 
these  causes  there  remains  a  f^roup  whicdi,  in  the  v.ords  of  Addison,  1^ 
(diaracterizod  by  a"gen(n'al  uiuemia  occurring  without  any  discovcnililo 
cause  whatever,  cases  in  whicli  tlicro  had  been  no  jjrevious  h^ss  of  blood, 
no  exhausting  diarrhma,  no  chlorosis,  no  purpura,  no  retiul,  splenic,  mias- 
matic, gUmdular,  strumous,  or  malignant  disease." 

Idiopathic  amwuiia  is  widely  distributed.  It  is  of  frequent  occurronco 
in  the  Swiss  Catitons,  and  is  not  un(K)mmou  in  this  country.  It  alTecti 
middle-aged  persons,  but  instances  in  children  liavo  been  described,  (irif- 
fith  mentions  about  ten  cases  occurring  under  twelve  years  of  age.  'i'lio 
youngest  ]mtient  I  have  seen  was  a  girl  of  twenty.  Males  are  more  fiis 
quently  aiTected  than  females.  Of  my  27  cases,  10  were  females  and  17 
were  nudes.  Of  110  cases  collected  by  Coupland,  50  were  in  men  and  54 
in  women. 

With  the  following  conditions  may  be  associated  a  j)rofound  anan.ia 
not  to  be  distinguished  clinically  from  Addison's  idiopathic  form  : 

(a)  Pregnancy  and  Parturition. — The  symptoms  may  develop  durinjj 
pregnancy,  as  in  19  of  29  cases  of  this  group  in  Eichhorst's  table.  More 
commonly,  in  my  experience,  the  condition  has  been  post  partum ;  thus, 
of  my  27  cases,  5  followed  delivery. 

{b)  Atrophy  of  the  Stoviach. — This  condition,  early  recognized  by  Flint 
and  Fenwick,  may  certaiidy  cause  a  progressive  pernicious  ana;mi:i.  I'y 
modern  methods  it  may  now  be  possible  to  exclude  this  extreme  gastrio 
atrophy. 

{(•)  Parasites. — The  most  severe  form  may  be  due  to  the  presence  of 
parasites,  and  the  accounts  of  cases  depending  upon  the  anchylostoma  utuI 
the  bothriocephalus  describe  a  progressive  and  often  pernicious  anaMiiia. 

After  the  exclusion  of  these  forms  there  remains  a  large  proportion, 
numbering  eighteen  cases  in  my  series,  which  correspond  to  Addison's 
description.  The  etiology  of  these  cases  is  still  dark.  The  researches  of 
Quincke  and  his  student  Peters  showed  that  there  was  an  enormous  in- 
crease in  the  iron  in  the  liver,  and  ho  suggested  that  the  aflection  was 
probably  due  to  increased  haemolysis.  This  has  been  strongly  sujiportoil 
by  the  extensive  observations  of  Hunter,  who  has  also  shown  that  the 
urine  excreted  is  darker  in  color  and  contains  pathological  urobilin.  Tho 
lemon  tint  of  tho  skin  or  the  actual  jaundice  is  attributed,  on  this  view, 
to  tho  changes  in  the  liver  cells  produced  by  the  excessive  amount  of  pi;?- 
ment,  but  in  the  light  grades  it  is  unquestionably  haamatogenous.  To 
explain  the  haemolysis,  it  has  been  thought  that  in  the  condition  of  faulty 
gastro-intestinal  digestion,  which  is  so  commonly  associated  with  these 
cases,  poisonous  materials  are  developed,  which  when  absorbed  cause  de- 
struction of  tho  corpuscles.     Certainly  the  evidence  for  hiemolysis  is  very 


AN.EMIA. 


C91 


utrotif,',  hut  wo  are  Btill  fur  awuy  from  a  full  knowledge  of  the  ootulitioTi« 
under  which  it  is  produeed. 

On  the  other  hand,  F.  1*.  Henry,  8tej)hen  Mackenzie,  and  other  au- 
thorities inelino  to  the  helief  that  the  essenee  of  the  diHejwe  U  in  defective 
hienio^eiu'-tis,  in  consequence  of  whicli  the  red  l)lood-corj)uscle3  are  uhnor- 
iiiiilly  vuliuTahle.  A  point  noted  hy  Copenian,  that  the  luertujglobiii  cryH- 
tilli/A's  from  tlie  hlood-corpuseles  witli  great  rc^adineas,  can  Kcanely  be 
regarded  as  favoring  the  view  of  imperfect  ha^rnogenesia,  since  this  is  a 
feature  KpcH'ially  eharaciteriatic  of  tlie  blood  of  the  young. 

Morbid  Anatomy. — The  body  is  rarely  enuiciattul.  A  lemon  tint 
(if  tlie  skin  is  i)resent  in  a  majority  of  the  cases.  'I'he  musch's  often 
lire  intensely  red  in  color,  like  horse-flesh,  while  the  fat  is  light  yellow. 
I[a'nu)rrhagc3  are  common  on  the  skin  and  serous  surfaces.  The  heart  ib 
usually  larg(!,  flabby,  and  empty.  In  one  instjinco  I  obtained  only  two 
(Iniclims  of  blood  from  the  right  heart,  and  between  three  ami  four  from 
tlic  left.  The  muscle  substance  of  the  heart  is  intensely  fatty,  and  of  a 
])ale,  light-yellow  color.  In  no  affection  do  we  see  more  extreme  fatty 
degeneration.  The  lungs  show  no  sj)ecial  changes.  The  stonuich  in  numy 
itisUinccs  is  normal,  but  in  some  cases  of  fatal  anaimia  the  mucosa  has 
been  ext(^!nsively  atrophied.  In  the  case  described  by  Henry  and  myself 
the  mucous  membrane  had  a  smooth,  cuticular  a])p(!arance,  and  there  was 
c()ni[»letc  atrophy  of  the  secreting  tubiUes.  The  liver  may  be  enlarged 
i.iid  fatty.  In  most  of  my  autopsies  it  was  nornuil  in  size,  but  usu- 
ally fatty.  The  iron  is  in  excess,  aiul  in  striking  contrast  to  cases  of 
Kecondary  annpmia.  It  is  deposited  in  the  outc;r  imd  middle  zones  of  the 
lobules,  and  in  two  specimens  which  I  examined  seemed  to  have  sudi  a 
(lii^tributiun  that  the  bile  capillaries  were  distinctly  outlined.  This  is 
certaiidy,  as  Hunter  states,  a  special  and  characteristic  lesion,  possibly 
peculiar  to  pernicious  anaemia.  A.  J.  Scott  examined  for  me  the  livers 
in  forty-five  consecutive  autopsies  without  finding  (except  in  pernicious 
auteiaia)  this  special  distribution  of  pigment. 

The  spleen  shows  no  important  changes.  In  one  of  Palmer  Howard's 
cases  the  organ  weighed  only  an  ounce  and  five  drachms.  The  iron  pig- 
ment is  usually  in  excess.  The  lymph  glands  may  be  of  a  deep  red  color. 
The  amount  of  iron  pigment  is  increased  in  the  kidneys,  chiefly  in  the 
convoluted  tubules.  The  bone  marrow,  as  j)ointed  out  by  H.  C.  Wood, 
may  resemble  that  of  a  child.  This  observation  has  been  repeatedly  (!on- 
linned,  but  the  condition  does  not  appear  to  be  constant.  Changes  in  the 
ganglion  cells  of  the  sympathetic  have  been  reported  on  several  occasions. 
Liehtheim  has  found  sclerosis  in  the  posterior  columns  of  the  cord,  which 
lie  tliinks  secondary  to  the  anaemia,  and  a  similar  change  has  been  mot 
with  in  two  recent  cases  by  Morris  Lewis  and  Burr. 

Symptoms. — The  patient  may  have  been  in  previous  good  health, 
Imt  in  many  cases  there  is  a  history  of  gastro-intestinal  disturbance,  mental 
shock,  or  worry.     The  description  given  by  Addison  presents  the  chief 


-r'f  p• 


^!, 


I     l> 


:^  '''Ml 


m 


lOT*- 


it)  ,* 


692 


DISEASES  OP  THE  BLOOD  AND   DUCTLESS  GLANDS. 


m 


i.  I 


features  ot  Mie  disease  in  a  masterly  manner.  "  It  make-  its  ai)proiu'li  in 
80  slow  and  insidious  a  manner  that  the  patient  can  hardly  ilx  a  date  to 
the  earliest  feeling  of  that  languor  wliieh  is  shortly  to  become  so  cxtronu!. 
The  countenance  gets  pale,  tiie  whites  of  the  eyes  become  pearly,  the 
general  frame  flabby  rather  than  wasted,  the  palse  perhaps  large,  but 
remarkably  soft  and  compressible,  and  occasionally  with  a  slight  jerk, 
especially  under  the  slightest  excitement.  There  is  an  increasing  iiiiiis- 
positiou  to  exertion,  with  an  uncomfortable  feeling  of  faintness  or  brealh- 
lessness  in  attempting  it;  tlie  heart  is  readily  made  to  palpitate;  the  whole 
surface  of  the  body  presents  a  blanched,  smooth,  and  waxy  appearance ; 
the  lips,  gums,  and  tongue  seem  bloodless,  the  flabbiness  of  the  solids  in- 
creases, the  appetite  fails,  extreme  languor  and  faintness  sui)erveiie, 
breathlessness  ami  palpitations  are  produced  by  the  most  trifling  exertion 
or  emotion;  some  slight  (wdema  is  probably  perceived  about  the  ankles; 
the  debility  becomes  extreme — the  patient  can  no  longer  rise  from  bed; 
the  mind  occasionally  wanders  ;  he  falls  into  a  prostrate  and  hnlf-torpid 
state,  and  at  length  expires ;  nevertheless,  to  the  very  last,  and  after  ii 
sickness  of  several  months'  duration,  the  bulkiness  of  the  general  fraino 
and  the  amount  of  obesity  often  present  a  most  striking  contrast  to  tin; 
failure  and  exhaustion  observable  in  every  other  respect." 

The  Blood. — The  corpuscles  may  sink  to  <me  fifth  or  loss  of  the  nonnul 
number.  They  may  sink  to  500,000  per  cul)ic  millimetre,  and  in  a  euso 
of  Quincke's  the  number  was  reduced  to  1-43,000  per  cubic  millimetre. 
The  lucmoglobin  is  relatively  increased,  so  that  the  individual  globular 
richness  is  plus,  a  condition  exactly  the  opposite  to  that  whicdi  occurs  in 
(dilorosis,  in  which  the  corpuscular  richness  in  coloring  matter  is  miiuis. 
The  relative  increase  in  the  haemoglobin  is  probably  associated  with  the 
average  increase  in  the  size  of  the  red  blood-corpuscles.  The  accompany- 
ing chart  illustrates  these  points.  Microscopically  the  red  blood-corjius- 
cles  present  a  great  variation  in  size,  and  there  can  be  seen  large  giant 
forms,  megalocytes,  wl-ndi  are  often  ovoid  in  form,  measuring  eight,  clcvon, 
or  even  fifteen  micromillimetres  in  diameter,  a  circumstance  which  Henry 
regards  as  indicating  a  reversion  to  a  lower  type,  liaacho  thinks  tiicso 
pathognomonic,  and  they  certainly  form  a  constant  feature.  Ther(>  are 
also  small  round  cells,  microcytes,  from  two  to  six  micromillitiietros  in 
diameter,  and  of  a  deep  red  color.  The  corpuscles  show  a  rciiiarkalile 
irregularity  in  form,  elongated  and  rqdlike  or  pyriform ;  one  end  of  ii 
corpuscle  may  retain  iU  shape  while  the  other  is  narrow  and  extended. 
To  this  condition  of  irregularity  'vuincke  gave  the  name  poikilncytosis. 
The  leucocytes  are  generally  diminished  in  number,  and  the  relative  jier- 
centage  of  the  mononuclear  elements  is  somewhat  higher  than  in  normal 
blood. 

Nucleated  red  blood-corpur-cles  are  constantly  present,  as  pointed  out 
by  Ehrlich.  Besides  the  ordinary  form,  which  is  of  the  same  size  as  tlio 
common  corpusclo  and  which  has  a  small,  deeply  stained  nucleus  (nornio- 


ANJEiMIA. 


698 


blasts),  there  are  very  large  forins  witli  large,  palely  stiiiniug  nuclei  (gigan- 
t(>l)liists),  which  resemble  somewhat  the  larger  megalocytes.     Ehrlieh  re- 


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MEAN  NORM. 
NUMBER  or 

WHITE 
CORPUSCLES 


BLACK,  RE.D  CORPUGCLES. 


RED,  HAEMOGLOBIN. 

Chart  XV'IH. — Pernicious  miiiMuift. 


BLUE,  COLORLESS  CORPUSCLES. 


pmls  fiio  presence  of  these  as  almost  distinelive  of  i)rogressive  pernieioiis 
iina'tiiiii ;  they  are  only  found  here  and  in  the  hiior  stages  of  leuka'inia. 
riic  blood-plates  are  cither  absent  or  very  scant} . 

The  cardio-vascular  symptoms  are  important  and  are  noted  in  the  de- 
soription  given  above.  ILvmic  murmurs  are  constantly  present.  The 
liii'L'ir  arteries  pulsate  visibly  and  the  throbbing  in  tluun  may  be  distress- 
ing to  the  patient.  The  pulse  is  full  and  frequently  suggests  the  water- 
luuiimor  beat  of  aortic  insufficiency.  The  capillary  pulse  is  frequently  to 
he  seen.  The  Buperficial  veins  are  often  prominent,  and  in  two  cases  I 
liav'  <('(Mi  well-marked  pulsation  in  them.    Uoemorrhagea  may  occur,  either 


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i'Si 


694 


DISEASES  OP  THE   BLOOD  AND   DUCTLESS  GLANDS. 


m  ; 


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;u:i;t|: 


in  the  skin  or  from  tlie  mucous  surfaces.     Retinal  hajmorrliagcs  are  com- 
mon.    There  are  rarely  symjitoms  in  the  respiratory  organs. 

Gastro-intostinal  symptoms,  such  as  dyspepsia,  nausea,  and  vomitiiiir, 
may  be  present  throughout  the  disease.  Diarrha;a  is  not  infrequent,  'i'lio 
urine  is  usually  of  a  low  specific  gravity  and  sometimes  pale,  but  in  other 
instances  it  is  of  a  deep  sherry  color,  shown  by  Hunter  and  ]\Iott  to  ho 
duo  to  great  excess  of  urobilin.  Fever  is  a  variable  symptom.  For  wenks 
at  a  time  the  temperature  may  be  normal,  and  then  irregular  pyrexia  iiiiiy 
develop.  Nervous  symptoms  may  occur,  numbness  and  tingling,  and  oc- 
casionally symptoms  resembling  those  of  tabes.  Lepiue  reports  a  cuso  of 
extensive  paralysis. 

Diagnosis. — From  chlorosis  the  disease  is  readily  distinguished,  i 
have  not  seen  a  case  in  which  the  two  diseases  could  have  been  con- 
founded. Two  points  in  the  blood  examiiuition  are  of  importance— 
namely,  the  relative  increase  in  the  liiEinoglobin  and  the  presence  of  the 
large  forms  of  nucleated  red  blood-corpuscles,  the  gigantoblasts  of  Ehr- 
lich.  Poikilocytosis  may  occur  in  any  severe  arucmia.  The  sopanitioii 
of  the  different  clinical  forms  above  referred  to  can  usually  be  mack;.  The 
profound  secondary  aniBmia  of  cancer  of  the  stomach  may  somotinics  he 
puzzling,  but  the  skin  is  rarely,  if  ever,  lemon-tinted,  and  the  blood  Ims 
the  characteristics  of  a  secondary,  not  a  primary  ana3mia. 

Prognosis. — In  the  true  Addisonian  cuses  the  outlook  is  bad,  thoiii:h 
of  late  years  on  the  arsenic  treatment  the  ^iroportion  of  re(K)very  is  incrcaseil. 
My  personal  experience  is  as  follows :  Of  the  27  cases  4  are  now  under  oh- 
servation,  3  of  these  having  recovered  with  arsenic.  Of  the  remaininu;  v':] 
the  following  statement  may  be  made :  Four  of  the  5  post-partuni  cases 
recovered,  and  when  I  left  Montreal ;}-  of  these  castas  had  remained  in  i,fofti] 
health  for  several  years.  Of  the  remaining  18  cases  2  were  lost  sight  of; 
1  had  improved  very  much.  The  remaining  10  are  dead.  Six  of  these 
fatal  cases  recovered  from  the  first  attack  ;  one  had  an  interval  of  nearly 
three  3'ears,  and  another  nearly  two  years,  before  the  return.  I  know  of 
no  instance  in  a  male  in  which  the  recovery  has  lasted  for  five  years.  In 
Pye-Smith's  article  in  Guy's  iros])ital  Reports,  he  mentions  twenty  I'ases 
of  rriovery.  Hale  White,  in  a  recent  article,  states  that  one  of  these 
cases,  treated  by  arsenic  in  1880,  remained  alive  and  well  .January,  ISDl. 
One  of  my  patients  made  an  apparently  complete  recovery  and  rosiiineil 
active  business  and  political  duties.  So  characteristic  are  rccurroiH'is  in 
this  affection  that  Stephen  Mackenzie,  in  his  recent  lectures,  consi'k'red 
them  under  a  separate  heading  of  relapsing  pernicious  anajmia. 

Treatment  of  Aneemia. — Secnndary  A?ia'>nia. — The  tramnatie 
cases  do  best,  and  with  plenty  of  good  food  ajid  fresh  air  the  hloml 
is  readily  restored.  The  extraordinary  rapidity  with  which  the  nornial 
percentage  of  nnl  blood-corpuscles  is  reached  without  any  niodiiation 
whatever  is  an  important  lesson.  The  cause  of  the  hamiorrhage  shoiiM  hn 
sought  and  the  necessary  indications  met.     The  large  group  depeinlin;,' 


ANiEMIA. 


695 


inim;iti(' 

|.     llloilll 

iiiiniiiil 

rKatiiiii 

(liliii  l>o 

icinliii},' 

on  the  drain  on  the  albuminous  materials  of  the  blood,  as  in  Bright's 
disease,  suppuration,  and  fever,  is  diflicult  to  treat  successfully,  and  so  long 
as  ihe  cause  keeps  up  it  is  impossible  to  restore  the  noruuil  blood  con- 
dition. The  ana3mia  of  inanition  requires  plenty  of  nourishing  food. 
Wlien  depeiulent  on  organic  changes  in  the  gastro-intestinal  mucosa  not 
niueli  can  be  expected  from  either  food  or  medicine.  In  the  toxic  cases 
(hie  to  mercury  and  lead,  the  poison  uuist  be  eliminated  and  a  nutritious 
diet  given  with  full  doses  of  iron.  In  a  great  majority  of  tliesc  cases 
there  is  deficient  blood  formation,  and  the  indications  are  briefly  three — 
plenty  of  food,  an  open-air  life,  and  iron.  As  a  rule  it  makes  but  little 
ditTcreiice  what  form  of  the  drug  is  administered. 

The  treatment  of  chlorosis  affords  one  of  the  most  brilliant  instances — 
of  wliich  we  have  but  three  or  four — of  the  specific  action  of  a  remedy. 
Apart  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury  and 
iodide  of  })otassium  in  syphilis,  there  is  no  other  remedy  the  beneficial 
t'tt'ects  of  whicli  we  can  trace  with  the  accuracy  of  a  scientific  experiment. 
It  is  a  minor  matter  hoio  the  iron  cures  chlorosis.  In  a  week  we  give  to  u  case 
iis  much  iron  as  is  contained  in  the  entire  blood,  as  even  in  the  worst  case 
of  clilorosis  there  is  rarely  more  than  a  deficit  of  two  grammes  of  this  metal. 
Iron  is  present  in  the  faeces  of  chlorotic  j)aticnts  before  they  are  placed 
upon  any  treatment,  so  that  the  disease  does  not  result  from  any  deficiency 
of  available  iron  in  the  food.  Bunge  believes  that  it  is  the  suli)hur  which 
interferes  with  the  digestion  and  assinulation  of  this  natural  iron.  The 
sulphides  are  produced  in  the  process  of  fermentation  and  decomposition 
ill  the  fivocs,  and  interfere  with  the  assimilation  of  the  normal  iron  con- 
tained in  the  food.  By  the  administration  of  an  inoi -anic  jtrcparation  of 
iron  with  which  these  sulphides  coml)ine  the  natural  organic  combinations 
in  the  food  are  spared.     In  studying  a  numbt  i-harts  of  clilorosis  it  is 

seen  that  there  is  an  increase  in  the  red  blooU-i  ■  piisi  Ics  under  the  influ- 
ence of  the  iron,  and  in  some  instances  the  globular  liclir  ess  ri.scs  aboro 
normal.  The  increase  in  the  haimoglobin  is  slower  and  the  maximuiTf 
percentage  may  not  be  reached  for  a  long  time.  I  have  for  \  ears  in  the 
treatment  of  chlorosis  used  with  the  greatest  success  lilaud's  pills,  made 
and  iriven  according  to  the  formula  in  Niemeyer's  text-book,  in  wliicdi 
each  pill  contains  3  grs.  of  the  sulphate  of  iron.  During  the  firsi  weef^  '>nc 
pill  is  given  three  times  a  day.  In  the  second  week,  two  pilis;  in  the  third 
week,  three  pills,  three  times  a  day.  This  dose  should  be  continued  for 
fnnr  or  five  weeks,  at  least,  before  reduction.  An  important  feature  in  the 
treatment  of  chlorosis  is  to  persist  in  the  use  o'  the  iron  for  at  least  tli 
months,  and  if  necessary  subsequently  to  resume  it  in  smaller  doses,  as  re- 
currences are  so  common.  The  diet  should  consist  of  good,  easily  digested 
food.  Special  care  should  be  directed  to  the  bowells,  and  if  constipation  is 
present  a  saline  purge  should  be  given  eacli  morning.  Such  stress  does 
^ir  Andrew  Clark  lay  on  the  importance  of  constipation  in  chlorosis  that 
he  states  that  if  limited  to  the  choice  of  oiUOjdrug  ■»«  ,the  treatment  of  the 


'Mi 


696 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


ml 
It 

1  i^i 


5  I   >i  y- 


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i   >i  5  ., 


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1  I .,» 


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disease  he  would  choose  a  purgative.    Dilute  hydrochloric  acid,  manganese, 
phosphorus,  and  oxygen  liave  been  recommended. 

Treatmcvt  of  Pernicious  Ancomia. — Since  the  introduction  by  Byroni 
Bramwell  of  arsenic  in  this  affection  a  largo  number  of  cases  have  been 
temporarily,  a  few  permanently,  cured  by  it.  It  should  be  given  as  Fowler's 
solution  in  increasing  doses.  It  is  usually  well  borne,  and  patients,  as  ti 
rule,  take  "p  to  twenty  minims  three  times  a  day  without  any  disturbance. 
I  usually  begin  with  three  minims  and  increase  to  five  at  the  end  of  the 
first  week,  to  ten  at  tlie  end  of  the  second  week,  to  fifteen  at  the  end  of 
the  third  week,  and,  if  necessary,  increase  to  twenty  or  twenty-five.  In  a 
case  in  which  the  recovery  persisted  for  nearly  three  years,  the  dose  was 
gradually  increased  to  thirty  minims.  These  patients  seem  to  bear  the 
arsenic  extremely  well.  It  is  sometimes  better  borne  as  arsenious  acid  in 
pill  form.  Vomit:  ng  and  diarrhani  are  rare ;  occasionally  puffiness  of  the 
face  is  produced,  and  in  some  cases  pigmentation  of  the  skin. 

Rest  in  bed  and  a  light  but  nutritious  diet  (giving  the  food  in  small 
amounts  and  at  fixed  intervals)  are  the  first  indications.  I  always  prefer 
to  begin  the  treatment  of  a  case  of  pernicious  anaemia,  whatever  the  grade 
may  be,  with  rest  in  bed  as  one  of  the  essential  elements.  Massage  will 
also  be  found  very  beneficial.  I  have  abandoned  the  use  of  rectal  injec- 
tions of  dried  blood.  Iron  seems  to  have  no  action  in  this  form,  but  in 
a  case  in  which  the  arsenic  disagrees  it  may  be  tried. 


II.   LEUKiCMIA. 

Deflnition. — An  afl^ection  characterized  by  persistent  increase  in  the 
white  blood-corpuscles,  associated  with  enlargement,  either  alone  or  to- 
gether, of  the  spleen,  lymphatic  glands,  or  bone  marrow. 

The  disease  was  described  almost  simultaneously  by  Virchow  and  by 
Bennett,  who  gave  to  it  the  name  leucocythaimia. 

Btiology. — Wo  know  notliing  of  the  conditions  under  wliioli  th.) 
disease  develops.  It  is  not  uncommon  on  this  continent.  Of  17  eases  of 
which  I  have  notes,  11  occurred  in  Montreal,  2  in  Phihulelphia,  and  4 
within  the  past  two  years  at  the  Johns  Hopkins  Hospital.  It  does  not 
seem  more  frequent  in  the  southern  part  ^  of  the  country. 

The  disease  is  most  common  in  the  middle  perioti  of  life.  The  younjr- 
est  of  my  ca83S  was  a  cliild  of  eight  months,  and  cases  are  on  record  of 
the  disease  as  early  as  the  eighth  or  tenth  week.  It  may  occur  as  late  as 
the  seventieth  year.  Males  are  more  prone  to  the  affection  than  females. 
Of  my  cases  11  were  in  males  and  6  in  females.  Birch-IIirschfeld  st;itos 
that  of  200  cases  collected  from  the  literature,  135  were  males  and  05 
females. 

A  tendency  to  hemorrhage  has  been  noted  in  many  cases,  and  soim) 
of  the  patients  have  suffered  repeatedly  from  nose-bleeding.     In  women 


LEUKEMIA. 


697 


the  disease  is  most  common  at  the  climacteric.  There  are  instances  in 
which  it  has  developed  during  pregnancy.  The  case  described  by  J. 
Chalmers  Cameron,  of  Montreal,  is  in  this  respect  remarkable,  as  the  pa- 
tient passed  through  three  pregnancies,  bearing  on  each  occasion  non- 
leuk.'emic  children.  The  case  is  interesting,  too,  as  showing  the  hcredi- 
tjiry  character  of  the  affection,  as  the  grandmother  and  mother,  as  well 
&.<.  a  brother,  suffered  from  symptoms  strongly  suggestive  of  leukaemia. 
One  of  the  patient's  children  had  leukaemia  before  the  mother  showed  any 
signs,  and  a  second  died  of  the  disease.  At  the  last  report  this  patient 
had  gradually  recovered  from  the  third  confinement  and  the  red  blood- 
corpuscles  had  risen  to  4,000,000  per  cubic  millimetre,  and  the  ratio  of 
wliite  to  red  1  to  200.  Sanger  has  reported  a  case  in  which  a  healthy 
mother  bore  a  leukaemic  child. 

Malaria  is  believed  by  some  to  be  an  etiological  factor.  Of  150  cases 
analyzed  by  Cowers,  there  was  a  history  of  malaria  in  30 ;  in  my  series 
tlierc  was  a  history  in  at  least  7.  Syphilis  appears  in  some  cases  to  have 
been  closely  associated  with  the  disease.  The  disease  has  followed  injury 
or  a  blow. 

The  lower  animals  are  subject  to  the  affection,  and  cases  have  been 
described  in  horses,  dogs,  oxen,  cats,  swine,  and  mice. 

Morbid  Anatomy. — The  wasting  may  bo  extreme,  and  dropsy  is 
sometimes  present.  There  is  in  many  cases  a  remarkable  condition  of 
polya;mia ;  the  heart  and  veins  are  distended  with  large  blood-clots.  In 
Case  XI  of  my  series  the  weight  of  blood  in  the  heart  chambers  alone 
was  020  grammes.  There  may  be  remarkable  distention  of  the  portal, 
cerebral,  pulmonary,  and  subcutaneous  veins.  The  blood  is  usually  clotted, 
and  the  enormous  increase  in  the  leucocytes  gives  a  pus-like  appearance 
to  the  coagula,  so  that  it  has  happened  more  than  once,  as  in  ^'irchow-'s 
memorable  case,  that  on  opening  the  right  auricle  the  observer  at  first 
tliought  he  had  cut  into  an  abscess.  The  coagula  have  a  peculiar  greenish 
color,  somewhat  like  the  fat  of  a  turtle.  The  alkalinity  of  the  blood 
is  diminished.  The  fibrin  is  increased.  The  character  of  the  corpus- 
cles will  be  described  under  the  symptoms.  Charcot's  octohedral  crystals 
separate  from  the  blood  after  death.  The  P])Ocific  gravity  of  the  blood  is 
somewhat  lowered.     There  may  be  pericardial  ccchymoscs. 

The  spleen  in  the  great  majority  of  cases  is  enlarged.  Strong  adhe- 
sions may  unite  it  to  the  abdominal  wall,  the  diaphragm,  or  the  stomach. 
The  oajjsnle  may  be  thickened.  The  vessels  at  the  hilus  are  enlarged ; 
the  weight  may  range  from  two  to  eighteen  pounds.  The  organ  is  in  a 
condition  of  chronic  hyperplasia.  It  cuts  with  resistance,  has  a  uniformly 
mldisli-brown  color,  and  the  ^Malpighian  bodies  are  invisible.  Grayish- 
white,  circumscribed,  lymphoid  tumors  may  occur  throughout  the  organ, 
contrasiting  strongly  with  the  reddish-brown  matrix.  In  the  early  stage 
the  swollen  spleen  pulp  is  softer,  and  it  is  stated  that  rupture  has  occurred 
from  tlio  intense  hypcraamia.     Enlargement  of  the  lymphatic  glands  may 


^  f}      J  if  M 


•[ 


698 


DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 


.      **  hi 

ml''      '^  ,i 

ml  t   '. 

I  'J  ma      »'*       i(    '' 


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11      ik?S 


occur,  cither  in  conjunction  with  splenic  enlargement  or  alone.  In  only 
one  of  my  cases  was  the  enlargement  notable.  In  the  cases  of  lynnihatic 
leukaemia  the  cervical,  axillary,  mesenteric,  and  inguinal  groups  may  be 
much  enlarged,  but  the  glands  are  usually  soft,  isolated,  and  movable. 
They  may  vary  considerably  in  size  during  the  course  of  the  disease.  Tho 
tonsils  and  the  lymph  follicles  of  the  tongue,  pharynx,  and  mouth  may 
be  enlarged. 

In  the  majority  of  cases  the  bone  marrow  is  involved  with  the  Pi)looii, 
the  lieno-medullary  form  of  the  (Jermans.  The  marrow  may  be  involved 
alone,  forming  a  pure  myelogenous  leukicmia.  Instead  of  a  fatty  marrow, 
the  medulla  of  the  long  bones  may  resemble  the  consistent  matter  wlikli 
forms  the  core  of  an  abscess,  or  it  may  be  dark  brown  in  color.  In  Pon- 
fick's  case  there  were  ha'morrhagic  infarctions.  There  may  be  nuuli  ex- 
pansion of  the  shell  of  bone  and  localized  swellings  which  are  tender  ami 
may  even  yield  to  firm  pressure.  Histologically,  there  are  found  in  the 
medulla  large  numbers  of  nucleated  red  corpuscles  in  all  stages  of  develop- 
ment, numerous  cells  Avith  eosinophilic  granules,  and  also  many  colls  cor- 
responding to  the  myclucijfes  found  in  the  blood.  Large  mononuclear  cells 
in  the  process  of  division  by  karyokinesis  may  be  abundant.  Polynuelear 
leucocytes  are  also  present,  as  well  as  a  certain  number  of  small  mononu- 
clear elements. 

The  thymus  is  rarely  involved,  though  it  has  been  enlarged  in  some 
of  the  cases  of  acute  lymphatic  leukaemia. 

In  a  few  instances  there  have  been  leuka?mic  enlargements  in  the 
solitary  and  agminated  glands  of  Peyer.  In  a  case  of  Willcocks  there 
were  growths  on  the  surface  of  the  stomach  and  gastro-splcnic  (Mnentiun. 

The  liver  may  be  enlarged,  and  in  a  case  described  by  Welch  it 
weighed  over  thirteen  pounds.  The  enlargement  is  usually  due  to  h 
diffuse  leukemic  infiltration.  The  columns  of  liver  cells  are  widely 
separated  by  leucocytes,  which  are  partly  within  and  partly  outside  the 
lobular  capillaries.     There  may  be  definite  leukaemic  growths. 

There  are  rarely  changes  of  importance  in  the  lungs.  The  kidneys 
are  often  enlarged  and  i)ale,  the  capillaries  may  be  distended  with  leu- 
cocytes, and  leukajmic  tumors  may  occur.  The  skin  may  be  involved,  as 
in  a  case  described  by  Kaposi. 

Leuka^mic  tumors  in  the  organs  are  not  common.  They  were  ])resent 
in  only  one  of  the  twelve  autopsies  in  my  series.  In  159  cases  collected 
by  Gowers  there  were  only  thirteen  instances  of  leukajmic  nodules  iu  the 
liver  and  ten  in  the  kidneys.  These  new  growths  probably  devebt])  from 
leucocytes  which  leave  the  capillaries.  Bizzozero  has  shown  that  the  cells 
which  compose  them  are  in  active  fission. 

Symptoms. — The  onset  is  insidious,  and,  as  a  ride,  the  |i;itieiit 
seeks  advice  for  progressive  enlargement  of  the  abdomen  and  shortness 
of  breath,  or  for  the  enlarged  glands  or  the  pallor,  palpitation,  and  other 
symptoms  of  anajmia.     Bleeding  at  the  nose  is  common.     Gastro-intcstiual 


in  the 

s  tlioro 
ncntum. 
■Icli  it 

110    to   11 

wiil'.'ly 
.M^  the 


c  present 

colloi'tod 

los  in  tlic 

(>1»  from 

;  the  cells 

patient 

slioi'tness 

[mil  other 

[intestinal 


LEUKEMIA, 


699 


symptoms  may  precede  the  onset.  Occasionally  the  first  symptoms  are  of 
a  very  serious  nature.  In  one  of  the  cases  of  my  series  the  boy  played 
lacrosse  two  days  before  the  onset  of  the  final  hii-nuitemesis,  mid  in  another 
ease,  a  girl  who  had,  it  was  supposed,  only  a  slight  chlorosis,  died  of  fatal 
ha'iuorrliage  from  the  stomach  before  any  suspicion  had  been  aroused  as 
to  the  true  condition. 

JlJood. — In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
examination  of  the  blood,  as  it  alone  offers  distinctive  features.     In  the 
iiormul  blood  Ehrlich  recognizes  the  following  varieties  of  colorless  ele- 
ments :   (rt)   Lymphocytes — small   cells   about   the  size  of    ^  red   blood- 
oorpuscle,  and  probably  derived  from  the  lymphatic  glands,  which  have 
a  single  large,  round,  deeply  staining  nucleus,  surrounded  by  a  narrow 
rim  of  non-granular  protoplasm.      (b)  Large  mononuclear  leucocytes — 
cells  several  times  as  large  as  the  red  blood-corpuscle,  with  an  oval  or 
elli])licid  nucleus  and  a  relatively  larger  amount  of  ungranulated  proto- 
plasm,    (c)  'JVansitional  forms — cells  which  resemble  the  last  variety, 
hut  have  indentations  and  irregularities  in  the  nucleus,     (d)  Polynuclear 
leucocytes — these  arc  about  the  same  size  or  a  little  smaller  than  the  last 
variety.     The  nucleus  is  a  long,  deeply  staining  body  which  is  bent  and 
twisted  on  itself  into  irregular  shapes.     The  protoplasm  of  these  cells  is 
filled  with  granules,  which  ;ire  stained,  not  by  acid  or  basic  coloring  mat- 
ters alone,  but  only  by  a  combined  fluid.    The  granules  are  therefore 
termed  neutrophilic,  and  the  name  "  neutrophiles  "  is  given  to  these  cells. 
(c)  Cells  about  the  same  size  as  the  last,  but  containing  large,  highly 
refractile,  fat-like  granules,  which  have  an  affinity  for  acid  coloring  mat- 
ters.   On  account  of  their  affinity  for  eosin,  Ehrlich  terms  them  eositio- 
philcx.     In  normal  blood  these  cells  occur  in  a  definite  proportion  to  each 
other;  the  lymphocytes  fifteen  to  thirty  per  cent,  the  polynuclear  sixty- 
five  to  eighty  per  cent,  the  mononuclear  and  transitional  forms  about  six 
per  eent,  and  the  eosinophiles  two  to  four  per  cent. 

The  most  striking  change  in  the  more  common  form,  the  lieno- 
myclogcnic,  is  the  increase  in  the  colorless  corpuscles.  The  average  num- 
ber of  white  per  cubic  millimetre  is  estimated  at  about  0,000;  thus  the  pro- 
portion of  white  to  red  is  1  to  500 — 1,000.  In  leuka}mia  the  proportion 
may  he  1  to  10,  or  1  to  5,  or  the  ratio  may  reach  1  to  1.  There  are  in- 
stances on  record  in  which  the  number  of  leucocytes  has  exceeded  that  of 
the  red  corpuscles. 

The  character  of  the  cells  in  splenic  myelogenous  leukaemia  is  as 
follows:  The  lymphocytes  are  little,  if  at  all,  increased ;  relatively  they 
are  greatly  diminished.  The  eosinophiles  are  present  in  normal  or  in- 
creased relative  proportion,  so  that  there  is  a  great  total  increase,  and 
t'-ieir  jirosence  is  a  striking  feature  in  the  stained  blood-slide.  IMie  poly- 
mielear  neutrophiles  may  be  in  normal  proportion ;  more  frequently  they 
arc  relatively  diminished,  and  in  the  latter  stages  they  may  form  but  a 
Bniall  proportion  of  the  colorless  elements.    The  most  characteristic  feature 


>     !| 


11 


i 


rm 


DISExVSES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 


of  the  blood  in  this  form  of  Icnkaemia  is  the  presence  of  cells  which  do 
not  occur  in  normal  blood.  They  appear  to  be  derived  from  the  marrow, 
and  are  called  by  Ehrlich  myelocytes.  They  are  as  large  or  even  lar<ier 
than  the  large  mononuclear  leucocytes,  and  are  similar  to  them  in  ii)i- 
pearance,  but  differ  from  them  in  the  fact  that  the  protoplasm  is  (illcd 
with  the  fine  neutrophilic  gnmules.  Miiller  has  recently  found  niaiiv 
large  mononuclear  elements  with  karyokinetic  figures  in  leuka^mic  blood 
and  in  the  marrow. 

Nucleated  red  blood-corpuscles  are  present,  usually  in  coiisidoraljlc 
numbers.  There  is,  as  a  rule,  only  a  moderate  reduction  in  the  number 
of  red  blood-corpuscles,  rarely  under  two  million  per  cubic  millimotrc. 
The  haemoglobin  is  usually  reduced  in  a  somewhat  greater  proportion. 
The  accompanying  blood  chart  is  from  a  case  of  leukaemia  with  un  enor- 
mously enlarged  spleen. 

The  histological  characters  of  the  blood  in  acute  lymphatic  Icuka'mia 
differ  materially.  The  increase  in  the  colorless  elements  is  never  so  great 
as  in  the  preceding  form ;  a  proportion  of  one  to  ten  would  be  extreme. 
This  increase  takes  place  solely  in  the  lymphocytes,  all  other  forms  of  leu- 
cocytes being  present  in  greatly  diminished  relative  proportion.  In  Uthe- 
mann's  case  ninety-three  per  cent  of  all  the  leucocytes  were  lympliocytes. 
Eosinophiles  and  nucleated  red  corpuscles  are  rare.  Myelocytes  are  not 
present.  As  occasionally  combined  forms  of  leuk.nsmia  may  occur,  so  un- 
doubtedly variations  from  these  two  types  of  blood  may  be  met  with,  and 
in  a  case  of  acute  leukaemia  observed  at  the  Johns  Hopkins  Hospital,  in 
which  glands,  marrow,  and  spleen  were  affected,  there  was  present,  besides 
a  large  proportion  of  lymphocytes  and  myelocyte  >,  a  considerable  luunher 
of  large  mononuclear  leucocytes.  Among  other  points  about  leukannic 
blood  may  be  mentioned  the  feebleness  of  the  amojboid  movement,  as  noted 
by  Cafafy,  which  may  be  accounted  for  by  the  large  number  of  mono- 
nuclear elements  present,  the  polynuclear  alone  possessing  this  power. 
The  blood-plates  exist  in  variable  numbers;  they  may  be  remarkably 
abundant.  The  fibrin  network  between  the  corpuscles  is  usually  tliiek  and 
dense.  In  blood-alides  which  are  kept  for  a  short  time,  Charcot's  oetohe- 
dral  crystal?  separate,  and  in  the  blood  of  Icuktemia  the  haemoglobin  show.s 
a  remarkable  teiidency  to  crystallize. 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an 
interspace  by  the  enlarged  spleen.  Toward  the  close,  as  a  consequence  of 
the  feeble  circulation,  oedema  may  occur  in  the  feet  or  there  may  be  gen- 
eral anasarca.  Haemorrhage  is  a  common  symptom  and  may  be  either 
late  or  early.  Epistaxis  is  the  most  frequent  form.  Haemoptysis  and 
haematuria  are  rare.  Bleeding  from  the  gums  may  be  present,  lliemate- 
mesis  proved  fatal  in  two  of  my  cases,  and  in  a  third  a  large  cerebral 
hnamorrhage  rapidly  killed.  The  leukaemic  retinitis  is  a  part  of  the  luem 
orrhagic  manifestations. 


LEUKAEMIA. 


701 


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due,  as  ii  rule,  to  the  uimMiiiii.     Toward  tlie  end  there  may  be  nnlema  of 


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BLACK,  RED  CORPUSCLES. 


REO,   HAEMOQLOBIN. 

Chart  XIX. — LeukaMiiia. 


MEAN  NOnM. 
NUMBCn  OF 


BLUE,  COLORLESS  CORPUSCLES. 


tho  liiii^'s  or  pneumonia  may  carry  otf  the  patient.  Tlie  gastro-intcstinal 
syniptonis  are  rarely  absent.  Nausea  and  vomiting  are  early  features  in 
some  ciise.s.  Diarrhoea  may  be  very  troublesome,  even  fatal.  Intestinal 
liaMiioirliage  is  not  common.  There  may  be  a  dysenteric  jjrocess  in  the 
colon.  Jaundice  rarely  occurs,  though  in  one  case  of  my  series  there  were 
recurrent  attacks.     Ascites  may  be  a  prominent  symptom,  probably  due 


i 


702 


DISKASKS  OF  THE   HLOOD  AND  DUCITLESS  GLANDS. 


i 

hB^H^hISiS 

'•i 

■? 

'1 

to  tlic  jirescnce  of  the  splciiR',  tumor.     A  hmkii'iuic  jx-ritoiiitis  also  inay])e 
prcsont,  duo  to  nuw  growths  in  tho  nuMubniiirs. 

Tho  nervous  HyHterii  is  iu)t  often  involved.  I leiidiiche,  dizziness,  and 
fainting  spells  are  duo  to  unainiiu.  The  patiejits  are  usually  traiKiiiil  and 
resigned.     Sudden  eomu  may  follow  cerebral  luemorrhage. 

The  special  senses  are  often  alTected.  There  is  a  })eculiar  retinitis,  (hie 
chiefly  to  the  extravasation  of  blood,  but  there  may  be  aggregatii)ns  of 
leucocytes,  formijig  small  leukacmic  growths.  0])tic  neuritis  is  rare.  Deaf- 
ness has  frequently  been  observed ;  it  may  appear  early  and  possibly  is  due 
to  hiumorrhage. 

The  urine  presents  no  constant  clumges.  The  uric  aciid  excnU'd  is 
always  in  excess,  and  possibly,  as  Salkowski  suggests,  stands  in  direct  re- 
lation to  the  splenic  tumor. 

Priapism  is  a  curious  symptom  which  h;is  been  present  in  a  large  imni- 
bor  of  cases.  It  may,  as  in  one  of  Edes'  cases,  be  the  first  symptom,  i'eubddy 
reports  a  case  in  which  it  persisted  for  six  weeks.     The  cause  is  not  known. 

Slight  fever  is  present  in  a  majority  of  cases.  Periods  of  pyrexia  may 
alternate  with  prolonged  intervals  of  freedom.  The  temj)erature  may 
range  from  103°  to  103°. 

IVie  Spleen. — Oradual  increase  in  volume  of  this  organ  is  tlui  most 
prominent  symptom  in  a  majority  of  tho  cases.  Pain  and  tenderness  are 
common,  though  the  progressive  enlargement  may  be  painless.  A  creak- 
ing fremitus  may  bo  felt  on  pal})ation.  The  eidarged  organ  extends 
downward  to  tho  right,  and  may  be'felt  just  at  the  costal  edge,  or  when 
largo  it  may  extend  as  far  over  as  the  navel.  In  many  cases  it  oeeupie.s 
fully  one  half  of  the  abdomen,  reaching  to  the  pubes  below  and  extending 
beyond  the  middle  line.  As  a  rule,  tho  edge,  in  some  tho  notch  or  notches, 
can  be  felt  distinctly.  Its  size  varies' greatly  from  time  to  time.  It  may 
be  perceptibly  larger  after  meals.  A  luemorrhage  or  free  diarrlio'u  may 
reduce  the  size.  Tho  pressure  of  tho  enlarged  organ  may  cause  distress 
after  eating;  in  one  case  it  caused  fatal  obstruction  of  the  bowels.  A 
murmur  may  sometimes  be  heard  over  the  spleen,  and  Gerhardt  lias  di'- 
scribed  a  pulsation  in  it. 

I'fte  Lymph  Glatids. — Lymphatic  leukasmia  is  rare.  As  mentioned,  in 
but  1  of  my  series  of  17  cases  were  the  glands  enlarged;  indeed,  no  in- 
stance of  pure  lymphatic  leukaemia  has  come  under  my  observation.  Tlic 
su})erficial  groups  are  usually  most  involved,  and  even  when  alTected  it  is 
rare  to  see  such  large  bunches  as  in  IJodgkiu's  disease.  External  lympli 
tumors  arc  rare. 

The  pure  myelogenous  cases  without  associated  enlargement  of  the 
spleen  are  rare.  Tho  most  extreme  hyperplasia  of  the  bono  marrow  may 
exist  without  any  tenderness.  Occasionally  the  sternum,  ribs,  and  Hat 
bones  vshow  great  irregularity  and  deformity,  owing  to  definite  tiimor-like 
expansions. 

Diagnosis. — The  recognition  of  leukaemia  can  bo  determined  only 


■   v"\ 


liEUK.TlMIA. 


703 


liy  iniorosoopicul  examination  of  the  blooJ.  Tlio  dinioal  feature.?  may  bo 
idoiitioal  witli  tlioao  of  ordinary  splonio  anajmia,  or  witli  ilodijkiu's  diiaasi) 
An  interesting  qnestion  arises  whether  real  iiuirease  in  the  leueooytes  i.s 
tlu!  only  criterion  of  the  existence  of  the  disease.  Thus,  for  instance,  in 
the  <'!Uso  whoso  chart  is  given,  on  page  701,  the  patient  came  under  obser- 
vation in  September,  1S'.»0,  with  2,000,000  red  blood-corpnsch'.s  per  cubic 
inilliuietre,  thirty  per  cent  of  hjemoglobin,  and  500,000  white  bh)od-cor- 
piLsclt's  per  cubic  millimetre — a  proportion  of  one  to  four.  As  shown  by 
tlie  chart,  througliout  September,  October,  November,  and  December,  this 
ratio  was  maintained.  Early  in  January,  under  treatment  with  arsenic, 
the  white  corpuscles  began  to  decrease  aiul  gradually,  as  shown  in  the 
chart,  the  normal  ratio  was  reached.  At  this  time  could  it  be  said  that 
the  case  was  one  of  leukaMuia  without  increase  in  the  number  of  leu- 
cocytes? The  blood  examination  by  Ebrlich's  method,  as  made  by 
Thuyer,  showed  that  the  characteristic  myelocytes,  elements  which  are  not 
present  in  normal  blood,  were  still  present  in  numbers  sunicient,  at  any 
rate,  to  suggest,  if  the  patient  had  come  under  observation  for  the  first 
time,  that  leukcX>mia  might  occur.  By  Ehrlich's  method  of  blood  exam- 
ination a  condition  of  leucocytosis  can  readily  bo  distinguished  from  that 
of  leukivmia,  for  in  all  o^-dinary  leucocytoses  the  increase  takes  place  solely 
in  the  polynuclear  neutrophilic  leucocytes,  forming  quite  a  dilTereut  pu;t- 
iire  from  the  characteristic  conditions  described  above. 

Prognosis. — Recovery  occasionally  occurs.  A  great  majority  of  the 
oases  })rovo  fatal  within  two  or  three  years.  Unfavorable  signs  are  a 
temlency  to  hannorrhage,  persistent  diarrhoea,  early  drojjsy,  and  high  fever. 
Homarkablo  variations  are  displayed  in  the  course,  and  a  transient  im- 
provement may  take  place  for  weeks  or  even  months.  The  pure  lym- 
pliatic  form  seems  to  be  of  particular  malignancy,  some  cases  proving 
fatal  in  from  six  to  ciglit  weeks. 

Treatment. — Fresh  air,  gocfd  diet,  and  abstention  from  mental  worry 
and  cure,  are  the  important  general  indications.  The  indicatio  morbi  can- 
not be  met.  There  are  certain  remedies  which  have  an  influence  upon 
tho  disease.  Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  havo 
repeatedly  seen  improvement  under  its  use.  On  the  other  hand,  there  are 
curious  1  emissions  in  the  disease  which  render  therapeutical  deductions 
very  fallacious.  I  havo  seen  such  marked  improvement  without  special 
treatment  that  the  patient,  from  a  bed-ridden,  wretched  condition,  recov- 
ered strength  enough  to  enable  him  to  attend  to  light  duties. 

Quinine  may  bo  given  in  cases  with  a  malarial  history.  Iron  may  bo 
of  vuluo  in  some  cases,  as  may  also  inhalations  of  oxygen. 

Excision  of  the  leukiE  nic  spleen  has  been  performed  twenty-four  timet^, 
with  one  recovery — the  case  of  Franzolini.  Fussell  gives  the  statistics 
of  105  cases  of  splenectomy  'vith  48  deaths.  Of  the  cases  of  simple 
liypertrophy,  28  in  number,  9  recovered.  Of  IG  cases  of  floating  spleen, 
Ij  recovered. 


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fOl  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

III.   HODCKIN'S  DISEASE. 

Definition. — An  afTection  cluinicterized  by  progrossivo  hyperplasia 
of  tlie  lyinpli  glurulrf,  with  anivniia,  and  occasionally  tho  (lovolojjiiu'iit  of 
secondary  lymphoid  growths  in  iivcr,  spleen,  and  other  organs.  'I'lu'  dis- 
case  ha&  also  the  names  pscudo-lcuhwinia^  general  It/mphudrnoma,  md 
advnic. 

Ilodgkin,  the  well-known  morbid  anatomist  of  Guy's  IIospitaK  (irst 
described  cases  in  detail,  and  by  the  labors  of  Wilks,  Virchow,  BiUnjtli, 
and  Cohnheim  the  disease  attained  definite  recognition. 

Etiology. — A  majority  of  the  eases  are  in  young  persons.  In  (Jowors' 
table  of  100  cases,  30  were  under  twenty  years,  34  between  twenty  and 
forty,  and  3G  above  forty.  Three  fourths  of  the  cases  are  in  males.  In  a 
few  instances  heredity  has  been  adduced  as  a  j)ossible  cause,  and  unU'ce- 
dcnt  disease,  such  as  syphilis,  but  this  is  doubtful.  More  important  is  local 
irritation,  upon  which  Trousseau  lays  special  stress,  and  gives  instances  in 
which  chronic  irritation  of  the  skin,  chronic  nasal  catarrh,  or  tin-  irrita- 
tion of  a  decayed  tooth  gave  rise  to  local  gland  swellings,  which  preceded 
a  general  development  of  the  disease.  In  a  large  majority  of  the  cases  tlie 
disease  comes  on  insidiously,  without  any  recognizable  cause. 

Morbid  Anatomy. — 2'he  Lymph  Glands. — In  a  few  cases  the  en- 
large I  glands  are  hard  and  firm,  but  in  a  majority  the  growth  \a  soft  and 
elastic.  In  the  early  stage  tho  individual  glands  are  isolated,  not  larjjcr 
than  almonds  or  walnuts,  and  readily  separated  and  movable.  When  ad- 
vanced the  glands  fuse  together,  and  a  group,  as  in  the  neck,  may  form  a 
large  tumor,  the  size  of  an  orange  or  even  of  a  cocoa-nut.  About  such 
masses  the  capsular  tissues  are  luird  and  dense,  forming  a  firm  investment. 
A  growth  may  perforate  the  capsule  and  invade  contiguous  parts,  such  as 
the  muscles,  skin,  or  the  solid  organs.  On  section,  the  tumor  has  a  ^'ray- 
ish-white  appearance ;  it  is  smooth,  and  of  variable  consistence,  either  firm 
and  dry  or  soft  and  juicy.  Suppuration  is  most  frequently  seen  when  the 
growth  reaches  the  skin.  In  the  deep  glands  the  formation  of  jtiis  is  rare. 
Caseation  is  not  common ;  occasionally  there  are  areas  of  necrosis  very 
like  it  Tho  superficial  glands  are  most  often  attacked,  particularly  tlie 
cervical  groups,  and  the  glands  may  bo  traced  as  continuous  clmiiis  akmg 
the  trachea  and  the  carotids,  uniting  tho  axillary  and  mediastinal  ^Mands. 

The  axillary  group  is  involved  next  in  order  of  frequency,  and  the 
masses  may  pass  beneath  the  pectorals  and  beneath  the  scapula\  'i'lic 
inguinal  glands  occasionally  form  very  large  masses.  Of  the  internal 
groups,  those  of  the  thorax  are  most  often  affected,  either  the  chain  in  tlio 
posterior  mediastinum  or  the  bronchial  group,  or  those  of  the  anterior 
mediastinum.  The  trachea  and  the  aorta  with  its  branches  may  be  com- 
pletely surrounded  by  tho  growths,  and  bo  but  little  compressed.  From 
tho  anterior  mediastinum  the  masses  may  perforate  the  sternum  and  ap- 
pear as  an  external  tumor. 


IIODQKIN'S   DISEASE. 


705 


Of  tho  abdominal  groups,  tho  rctroporitonoiil  ia  most  froquciitly  in- 
volved and  may  form  a  continuouH  duiin  from  tho  diapltragin  to  tho 
iii^Miinal  canals,  and  oxtond  into  the  pelvis.  Tho  glands  may  compress  tho 
ureters,  involve  the  sacral  or  lumbar  nerves,  or  compress  tlie  iliac  veins. 
Occasionally  they  adhere  to  tho  uterus  and  broad  ligament  so  as  to  simu- 
lute  fibroids.  I  saw,  some  years  ago,  one  of  tho  most  distinguished  gyna> 
cologists  of  (termany  perform  lapaio  omy  in  a  ca.so  of  this  kind,  in  which 
the  diagnosis  of  myomatous  tumors  of  the  uterus  had  been  made.  Occa- 
sioiiidly  tho  mesenteric  or  hepatic  lymph  glaiuls  may  form  large  abdominal 
tuuKirs. 

Ilishhtijirnlly  tho  chief  change  is  an  incroasc  in  the  cells,  with  or 
without  thickening  of  the  reticulum.  In  tho  early  stage  there  is  simple 
liypcrplasia  and  tho  relations  of  tho  lymph  paths  are  maintained,  but  when 
the  gliinds  are  greatly  enlarged  tho  nornuil  arrangement  is  disturbed.  'I'ho 
reticulum  varies  extremely  ;  in  the  softer  growths  it  is  oxpandeil  and  can 
soiirooly  be  found  ;  in  the  harder  structures  the  network  of  fibres  is  very 
distinct,  and  there  is  probably  an  increased  dcveloj)ment  of  the  adenoid 
tissue. 

><pji'i'n. —  [n  seventy-five  i)er  cent  of  the  cases  collected  by  CJowers  this 
organ  was  hypertrophied,  and  in  fifty-six  of  these  cases  it  presontetl  lym- 
phoid growths.  The  enlargement  is  rarely  great,  and  does  not  approxinuite 
to  the  large  leukajmic  spleen.  Tho  lymphoid  tumors  form  grayish-whito 
bodies  ranging  in  size  from  a  pea  to  a  walnut,  and  may  resemble  lymph 
jllands  in  appearance  and  consistence.  Histologically,  they  consist  of 
lymph  corpuscles  in  a  fibrous  reticulum. 

The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymphoid 
tissue ;  in  a  few  instances  the  pyoid  form,  such  as  is  more  common  in  leu- 
kteniiii,  luis  been  found.  The  tonsils  may  be  involved  and  the  follicles  at 
the  root  of  the  tongue.  Occasionally  secondary  growths  are  seen  in  the 
intestines.        •  • 

The  liver  is  often  enlarged  and  may  present  scattered  lymphoid  tumors. 
The  kidneys  are  occasionally  involved  and  arc  the  seat  of  growths  similar 
to  tliose  of  the  spleen  and  liver.  The  lungs  are  occasionally  directly  at- 
tacked from  the  bronchial  glands  at  the  root,  and  secondary  nodules  may  be 
found  throughout  their  substance.  Pleural  effusions  are  not  uncommon. 
Involvement  of  the  nervous  system  is  rare,  but  paraplegia  may  be  induced 
by  iiuiision  of  the  spinal  oaiuil.  The  skin  may  be  the  seat  of  adenoid 
growths,  as  in  a  case  reported  by  Oreenfield. 

Symptoms. — Enlargement  of  the  glands  of  the  nock,  axilla,  or 
eroins  is  usually  the  first  symptom  noticed.  In  a  few  cases  the  aniemia 
and  constitutional  symptoms  attract  attention  before  the  glandular  in- 
volvement is  evident.  When  the  trouble  begins  in  the  deeper  groups, 
pressure  effects  may  bo  first  noticed  ;  thus,  paroxysmal  dyspncoa  with  pain 
in  the  chest  may  result  from  enlargement  of  the  bronchial  glands  before 
any  pliysical  signs  can  be  detected.     (Edema  of  the  feet  and  shooting 


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706 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


13 !    ■*• 


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pains  in  the  nerves  were  the  first  symptoms  in  one  case  which  I  dis- 
sected for  Eoss,  and  in  another  ease  at  the  Montreal  General  Hospital 
there  was  paraplegia  from  i)ressure  on  the  cord.  Such  instances,  however, 
are  exceptional,  and  in  the  majority  of  cases  the  swelling  of  the  suj)(>rfici!il 
glands  is  the  earliest  symptom.  Epistaxis  has  occasionally  been  noted,  but 
not  so  fre(iuently  as  in  leuka-mia.  With  progressive  enlargement  of  the 
glands  tlie  patient  becomes  anaMuic. 

Usually,  tiio  cervical  group  i-^J  first  affected,  and  it  may  be  impnssiblo 
to  decide  whether  the  enlargement  is  syphilitic,  tuberculous,  or  lyniphad- 
enomatous.  One  side  is  first  alTected  as  a  rule,  and  it  may  be  montlis,  or 
even,  as  in  one  of  my  cases,  three  years  before  the  affection  extends  to 
other  groups  Ultimately  huge  tumors  may  develop,  which  obliterate  the 
neck  and  extend  upon  the  shoulders  and  over  the  clavicles  and  stonmm. 
The  trachea  is  surrounds  I,  great  dyspnoea  is  produced,  and  not  iiifre- 
(juently  tracheotomy  is  necessary.  In  the  later  stages,  the  skin  becomes 
involved  and  ulcerates.  The  axillary  group  may  form  large  tumors,  which 
compress  the  brachial  or  axillary  veins  and  cause  swelling  of  the  arms. 
The  inguinal  glands  arc  not  so  often  involved,  but  may  form  large  or 
even  pendulous  tumors 

In  the  thoracic  glands,  as  mentioned,  the  various  groups  may  be  in- 
volvcd  and  produce  pressure  upon  the  veins  or  upon  the  trachea.  lu  a 
case  at  present  under  observation  the  superior  cava  is  completely  obliter- 
ated and  a  very  extensive  collateral  circulation  has  been  establislied  by 
means  of  the  mammary  and  epigastric  veins.  The  skin  over  the  sternum 
is  a  mass  of  fluctuating  veins,  some  of  which  contain  phleboliths.  In  the 
abdomen  the  mesenteric  glands  may  be  enlarged,  or  nore  commonly  the 
retroperitoneal  group.  When  the  jratient  is  thin  there  may  be  no  difti- 
oulty  in  detecting  these,  but  in  stout  persons  the  diagnosis  hiay  be  im'ws- 
sible.  In  connection  with  tb.3  atfections  of  the  abdominal  glands  there 
may  be  bronzing  of  the  skin,  which  was  well  marked  in  'Jase  IV  of  my 
series.  A  remarkable  feature  is  the  variations  in  the  rate  of  growth  and 
in  the  size  of  the  glands.  They  may  reduce  rapidly  and  almost  disujipear 
from  a  region,  and  before  death  the  tumors  may  diminish  very  nuich. 
The  spleen  may  be  enlarged  and  readily  })alpable.  The  thyroid  also  may 
be  involved,  and  in  a  few  instances  the  thymus  has  been  affected.  Though 
present  in  a  majority  of  the  cases,  there  mi  y  be  enormous  cnlargeniont  of 
the  lymph  glands  withoat  mar'ed  anaemia.  In  one  vf  my  cases  tlie  blood- 
corpuscles  did  not  sink  below  4,000,000  par  cubic  millimetre,  and  in  only 
one  instance  have  I  counted  the  blood  below  2,000,000.  The  red  blood- 
corpuscles  rarely  show  extreme  ])oikilo((ytosis.  Tho  white  corpus<l('.<  nuiy 
be  moderately  increased  am^  the  lymphocyti^s  most  abundant.  Occasion- 
ally the  leucocytes  are  greatly  increased  and  the  characters  of  the  blood 
'  jcome  those  of  a  lymphatic  leuka;mia.  Nucleated  red  blood-corpuscles 
may  be  present,  but  not  in  such  numbers  as  in  leukiemia. 

Of  cardiac  Mymptoms,  palpitation  ia  common,     lla^mic  murnuirs  are 


IIODGKIN'S  DISEASE. 


707 


often  heard  over  the  heart.  Sliortness  of  breath  may  he  due  to  tlie  annsmia, 
to  pressure  upon  the  trachea,  or,  in  some  instances,  to  pleuritic  effusi(m 
associated  with  mediastinal  growths.  Fever  is  observed,  in  nearly  all  cases; 
even  in  the  early  stages  there  is  slight  elevation.  It  nuiy  be  of  an  irregu- 
lar hectic  type,  or  continuous,  with  evening  exacerbation.  \'cry  remarka- 
ble are  the  cases  with  ague-like  paroxysn\s,  which  nuiy  persist  for  wcc^ks 
01'  months.  They  were  present  in  Case  I  of  my  series.  Pel,  of  Amster- 
dam, has  given  a  thorough  descrij)tion  of  these  attacks,  and  Ebstein  has 
(los(  riliod  a  case  under  the  renuirkal)le  title  of  "  Chronic  Recurrent  Fever,  a 
New  Infectious  Disease."  In  his  case  during  nine  months  tlie  attacks  were 
present  for  periods  of  from  twelve  to  fourteen  days  and  alternated  with 
apyroxia  for  ten  or  eleven  days. 

The  digestive  sym})toms  are  usually  not  marked.  It  is  not  uncommon 
to  find  albumen  in  tlie  urine.  Headache,  giddiness,  and  noises  in  the  ear 
may  be  associated  with  the  ana?mia.  Delirium  and  coma  may  be  present. 
Doainess  may  be  produced  by  growth  of  the  adenoid  tissue  in  the  phar- 
ynx (lose  to  the  Eustachian  tubes.  Inequality  of  the  pu))ils  nuiy  be  pres- 
ent, owing  to  pressure  of  the  glands  on  the  cervical  sympathetic.  The  skin 
may  show  delinite  secondary  lymphatic  tunu)rs,  bronzing  may  occur,  ami 
occasionally  a  most  intense  ami  troublesome  j)rurigo. 

Diagnosis. — A  tubercuitn.,-.  :idenitis  may  at  first  be  very  dithcidt 
to  (lillerentiate.  The  chief  points  of  distinction  are  as  follows:  Tuber- 
culous adenitis  is  more  comnum  in  the  young  and  involves  the  submaxil- 
lary gronj)  of  glands  more  frequently  than  those  of  the  anterior  and  })08- 
terior  cervical  triangles,  which  are  iv  .udly  affected  first  in  Ilodgkin's 
disease.  Tiie  enlargement  nuiy  last  for  years  in  a  group  witiiout  exteiul- 
iiiir.  The  bunches  are  often,  when  small,  welded  together  and,  most  im- 
portant of  all,  tend  to  suppurate — a  feature  rarely  seen  in  true  lymphade- 
Ji(iin;i.  except  when  it  has  attained  very  large  size.  Stri(!t  limitation  to 
one  side  of  the  neck  or  to  the  axilla  is  suggestive  of  tuberculous  disease 
lather  than  lymphadenoma. 

There  is  an  acute  tuberculous  adenitis,  which  may  involve  the  lymph 
glands  of  the  neck,  ]»r;Hlucing  enormous  ejilargement.  A  num,  aged  twenty- 
four,  was  admitted  to  the  (Jeneral  Hospital,  Montreal,  with  great  swelling  of 
the  eervieal  glands  on  both  sides,  tonsillitis,  and  sloughing  pharyngitis, 
with  irreirnlar  fever  and  diarrho-a.  The  case  was  at  first  regarded  as  one 
i>f  ll<.(l_fkin's  disease.  Tin  occurrence  of  rigors  ami  intermittent  pyrexia 
i^  ill  favor  of  lymphadenoma.  There  are  cases  in  which  it  may  for  a 
tiiiii  he  iMi])()S8ible  to  make  a  diagnosis.  When  the  glands  arc  only  mod- 
erately enlarged  on  one  side  of  the  neck  or  axilla,  they  should  be  removed, 
iinl  till'  diagnosis  can  then  bt    thoroughly  establislicd. 

Prognosis. — Recovery  is  very  rare.  'I'he  course  of  the  disease  is  ex- 
tivuKi,  variable.  Early  and  rapid  growth  in  the  nu'diastinal  groups  may 
prodiKo  pressure  etTetits  and  cause  death  before  the  develojunent  is  ex- 
treme. In  some  cases  the  enlargements  spread  rapidlv  and  group  after 
45 


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DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


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group  becomes  involved  in  a  few  months.  Those  acute  cases  may  nm  a 
course  in  three  or  four  montlis.  Chronic;  cases  may  last  for  throe  or  i'./ur 
years.  I'c^riods  of  (juiosceuce  uro  not  uncommon.  The  tumors  niav  not 
only  coase  to  }iru\y,  hut  j^rachuiUy  diniiuish  and  oven  disappear,  without 
special  treatinout.  Usually  a  cachexia  develops,  the  anaMuia  projrrosscs, 
and  there  are  dropsii;al  symi)toms.  The  mode  of  death  is  usnullv  by 
asthenia ;  less  commonly  by  pressure  from  a  tumor ;  and  occasionally  by 
coma. 

Treatment. — When  small  and  localized  the  f,dands  should  ho  rotnovod. 
Local  applications  are  of  doubtful  benefit.  1  have  never  seen  special  im- 
provement follow  the  persistent  use  of  iodine  or  the  various  ointuients. 

Arsenic  has  a  positive  value  in  the  disease.  It  should  be  iriveii  in  in- 
creasing doses,  and  stopped  when  un})loasant  olTocts  are  manifestid.  Tlie 
results  have  in  many  instsinces  hvan  striking.  J)ue  allowance  nnist  be 
made  for  the  fluctuations  in  the  size  of  the  growths  which  occur  s|ioiita- 
neously.  I  have  seen  no  ill  effects  from  the  administration  of  Fowler'o 
solution  for  Tuojiths  at  a  time,  and  numy  ])atients  have  taken  from  lii'tcen 
to  twenty  minims  three  times  a  day  for  weeks,  an<l  in  some  instaincs  for 
months.  Recoveries  have  been  reported  under  this  treatment.  JVison- 
ally,  no  instance  of  recovery  has  come  under  my  notice  in  the  eases  of 
which  I  have  notes.  Phosphorus  is  recommended  by  Gowers  and  Hroail- 
bent,  and  should  be  used  if  the  arsenic  is  not  well  borne.  Quinine,  iron. 
and  cod-liver  oil  are  useful  as  tonics.  Every  possible  means  must  be 
taken  to  support  the  patient's  strength. 


IV.  ADDISON'S  DISEASE. 

Definition, — A  (constitutional  affection  characterized  by  astlienia, 
depressed  circulation,  irritability  of  the  stomach,  and  ])ignuMitation  of  the 
skin.  In  a  majority  of  the  cases  it  is  associat^^Ml  with  tul)orculous  ilise,isc 
of  the  adren-ids,  in  otiior  instiinces  with  wasting  of  these  organs  or  with 
changes  in  the  abdominal  sympathetic  system. 

The  recognitirm  of  the  disease  is  due  to  Addison,  of  (luy's  Ifosjiilal, 
whose  monograph  on  The  Constitutiojud  and  Local  KfTects  of  Disease  of 
the  Su])raronal  ('ai)sulos  was  pirblishod  in  1S,"»,"). 

Etiology. — Males  are  more  frequently  attacked  than  femah-;.  In 
(Jreenhow's  analysis  of  183  cases  11&  were  males  and  04  fennili'-^.  A  ma- 
jority of  the  cases  occur  between  the  twentieth  and  the  fortielli  year.  A 
congenital  ease  has  boon  described  in  whi<'h  the  skin  had  a  yellou-irniy 
tint.  The  child  lived  for  eight  weeks,  and  post  morti-m  the  atlriMials  were 
found  to  be  large  and  cystic.  Injury,  such  as  a  blow  upon  the  alMloincn 
or  back,  and  caries  of  the  spine  have  in  many  cases  preceded  the  attaek. 
The  disease  is  rare  in  Ameri(!a.  Eight  cases  have  come  under  mv  I'or- 
sonal  observation,  either  clinically  or  anatomically. 


ADDISON'S  DISEASK 


709 


Morbid  Anatomy  and  Pathology.— There  is  rarely  emaciation 
or  iiiiiBmiu.  In  a  great  majority  of  the  cases  tlio  adrenals  are  affected. 
There  may  be  (a)  atrophy  of  one  or  both  ghiiula,  due  to  an  interstitial 
eirrliosis,  of  whicli  cases  have  been  described  l)y  Hadden  and  (ioodhart. 
(/;)  Tuberculosis,  which  is  the  common  condition.  The  capsuh's  are  thick- 
ened and  present  tirm  caseous  masses,  surrounded  by  conne<'tive  tissue. 
There  is  usually  much  fibrous  thickening  and  matting  ol"  the  atljacent 
structures,  and  the  affection  has  delinitily  been  shown  to  be  tuberculous. 
Tuberculous  lesions  are  common  in  othc-r  parts,  jtarticularly  in  the  lungs, 
tlioiigh  in  a  number  of  the  cases  tuberculosis  has  been  limited  to  the 
adrenals,  (r)  There  may  be  malignant  disease  of  the  adrenals,  which  has 
been  present  in  a  few  instances  of  genuine  AddisoTi's  disease.  Among 
other  anatomical  features  the  comlition  of  the  abdomiiuil  sympathetic  has 
boeu  sjiecially  studied.  The  nerve-cells  of  the  semilumir  ganglia  have 
been  described  as  degenerated  and  deeply  pigmented,  and  the  nerves  scle- 
rotic. The  ganglia  are  not  uncommonly  en  Singled  in  the  cicatricial  tissue 
nboiit  tlie  adrenals.  The  spleeti  has  occasionally  been  found  enlarged  ;  tiie 
thymus  may  jiersist  and  be  larger  than  nornuil. 

It  is  ditlicult  to  explain  satisfactorily  all  the  .symptoms  of  this  remark- 
able ilisease.  The  theories  which  have  been  advanced  are  briefly  as  follows  : 
{(i)  Tiuit  the  disease  depended  upon  the  lo.ss  of  functioti  of  the  adrenals. 
This  was  the  view  of  Addison.  It  is  held  that  the  blood  is  gradually 
{ioisoned  by  the  retention  of  some  nuiterial,  the  destruction  or  alteration 
of  which  is  a  function  of  the  suprarenal!*;  (/;)  that  it  is  an  affection  of 
the  abdominal  sym})athetic  system,  induced  most  commonly  by  disease  of 
the  aiirenals,  but  also  by  other  chronic  affections  whicdi  involve  the  solar 
plexus  and  its  ganglia.  According  to  this  vunv,  it  is  an  affection  of  the 
nervous  system,  and  the  pigmentation  has  its  origin  in  changt's  induced 
through  the  trophic  nerves.  The  pronounced  debility  is  the  outcome  of 
disturbed  tissue  metabolism,  and  the  circulatory,  resitiratory,  and  digestive 
sym|)toius  are  due  to  implication  of  the  pneumogastric.  The  changes 
fouud  ill  the  abdominal  sympatiu'tic  are  held  to  support  this  view,  and  its 
iiilvociites  urge  the  occurrence  of  pigmentation  of  the  skin  iu  tulx'rculosis 
of  the  peritonanim,  cancer  of  the  pancreas,  or  aneurism  of  the  ab(hnniiud 
iiortji,  ()p]M)sed  to  it  are  the  facts  that  the  lesions  described  in  the  sym- 
pathftic  system  are  indefinite,  aiul  identical  changes  occur  without  the 
syni|it(iius  of  Addison's  disease. 

Symptoms. — In  the  words  of  Addison  the  charncteristic  sym])tom8 
iiro  ".UKvmia,  general  languor  or  debility,  remarkable  feebleness  of  the 
heart's  action,  irritability  of  the  stomach,  and  a  peculiar  change  of  colnr 
in  the  skin." 

Till'  pigmentation  is  the  8ymj)tom  whitdi,  as  a  rule,  first  attracts  at- 
ttntioii.  The  grades  of  coloration  range  from  a  light  yellow  to  a  deep 
hrown,  or  even  black.  In  ty})ical  cases  it  is  diffuse,  but  always  det^per  on 
the  exposed  parts  and  in  the  regions  where  the  normal  pigmentation  is 


■Mm  I 


if:' 


!•  .       .      M 


i 


Ill  Ml.    '-  li      I 

■  i  •'  *■, 


lis 


.if' 


710 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


most  intense.  At  first  it  may  be  confined  to  the  face  and  hands.  Ooca- 
sionally  it  is  absent.  Patches  of  atrophy  of  ])igment,  lou(;o(lernia,  mav  oc- 
cur. The  pif^inentation  is  found  on  the  mucous  membranes  of  the  nioiiTli, 
conjunetivie,  and  vagina.  A  patcliy  pigmentation  (^f  tlie  sctous  iikih- 
branes  has  often  been  found.  The  anaemia,  upon  whicli  Addison  hiid 
stress,  is  of  a  moderate  grade.  It  was  not  present  in  a  marliod  degree  in 
any  of  my  cases. 

(iastric  disturbances  are  common ;  nausea  and  vomiting  maybe  ciuly 
and  ])rominent  symptoms;  diarrliani,  too,  is  frequent,  and  may  conic  an 
witliout  cause.  Tlie  pulse  is  small  and  rapid,  and  tlie  heart's  action 
feeble.  Sometimes  there  is  a  special  liability  to  syncope.  One  (if  the 
most  pronounced  features  of  the  disease  is  the  profound  asthenia,  whicli 
is  out  of  all  proportion  to  the  general  condition.  The  patient  com  plains 
of  a  lack  of  energy,  both  mental  and  bodily;  the  least  exertion  is  an 
efl'ort,  and  nuiy  be  followed  by  giddiness  or  noises  in  the  ears.  Headache 
is  a  frequent  sym[)tom.  With  the  advancement  of  the  disease  the  pinstra- 
tion  becomes  more  marked,  the  i)atient  remains  in  bed,  the  voice  gets 
weak,  the  intelligence  dulled,  and  death  occurs  either  by  syncope  or 
gradual  astheiua.  Occasionally  there  are  convulsions.  The  mine  is 
usually  normal.  Polyuria  has  been  described.  The  urinar\  pigments 
have  l)een  found  increased. 

Diagnosis. — Pigmentation  of  the  skin  is  not  confined  to  Addisun's 
disease.  The  following  are  the  conditions  which  may  give  rise  to  an  in- 
crease in  the  pigment : 

(1)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tiiher- 
culosis  of  the  peritonanim  pigmentation  is  not  uncommon. 

(2)  Pregnancy,  in  whicli  the  discoloraticm  is  usually  limited  to  the 
face,  the  so-called  masque  des  femmes  enceinte.  Uterine  disease  is  ii 
coiujuon  cause  of  a  patchy  nudasma. 

(;5)  Hepatic  disease,  which  may  induce  definite  pigmentation,  as  in 
the  diabetic  cirrhosis.  More  commonly  in  overworked  ])ersons  of  con- 
stipated habit  and  with  sluggish  livers  there  is  a  patchy  staiiung  iil)oiit 
the  face  and  forehead. 

(4)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  ami 
dirt,  which  may  reach  a  very  high  grade,  and  has  sometimes  hecn  mis- 
taken for  Addison's  disease. 

(5)  In  rare  uistaiu;es  there  is  deep  discoloration  of  the  skin  in  mela- 
notic cancer,  so  deep  and  general  that  it  has  been  confounded  with  nnhtsma 
suprarenale. 

((>)  In  certain  cases  of  exophthalmii;  goitre  abnormal  pigmental  ion 
occurs,  as  noted  by  Drummoiul  and  others. 

In  any  case  of  unusiml  pigmentation  th.cso  various  condition,-  nuist 
be  sought  for,  and  tin*  diagitosis  of  Addison's  disease  is  scarci  Iv  jus- 
tifiable without  the  asthenia.  In  many  instances  it  is  dilliciilt  early 
in   the  disease   to  arrive  at  a  definite  condusiou.    The  occurrence  of 


DISEASES  OP  THE  THYROID  GLAND. 


7U 


fiiinting  fits,  of  nuusfa,  and  gastric  irritability  is  an  important  indica- 
tion. 

Prognosis. — 'Vhv  disease  is  nsually  fatal.  The  cases  in  which  the 
bronzing  is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are 
ociasionally  acute  cases  which,  with  great  weakness,  vomiting,  and  diar- 
rlidii,  i)rove  fatal  in  a  few  weeks.  In  a  few  cases  the  disease  is  much 
prolonged,  even  to  six  or  ten  years.  In  rare  instances  recovery  has  taken 
place,  and  periods  of  improvement,  lasting  many  months,  may  occur. 

Treatment. — The  causal  indications  cannot  be  met.  When  there 
is  profound  asthenia  the  ])atient  should  bo  confined  to  l)ed,  as  fatal 
svncnpe  may  at  any  time  occur.  In  three  of  my  cases  death  was  sudden. 
When  anaemia  is  present  iron  may  be  given  in  full  doses.  Arsenic  and 
strychnia  are  useful  tonics.  Fen*  the  diarrhoea  large  doses  of  bismuth 
should  be  given  ;  for  the  irritability  of  the  stomach,  creosote,  hydrocyanic 
aciil,  ice,  aiul  cham])agne.  The  diet  should  be  light  and  nutritious. 
Many  patients  thrive  best  on  a  strictly  milk  diet. 


V.  DISEASES  OF  THE  THYROID  GLAND. 


•,'•1 


(JOITKK. 

Definition. — Hypertrophy  of  the  thyroid  gland,  occurring  sporadi- 
cally or  (mdemically. 

In  tiiis  country  sporadic  cases  are  common.  Endemically  it  is  found 
particidarly  in  the  mountainous  regions  of  Switzerlaiul  and  in  paits  of 
hilly.  No  satisfactory  explanation  has  been  given  of  the  existence  of  the 
(lisi'iisc  iti  this  form. 

Anatomicallv  the  following  varieties  nuiy  be  distinguished  :  {(i)  Paren- 
I'liyniaiou.s,  in  which  the  enlargement  is  general  and  the  follicles,  usually 
mnvly  formed,  contain  a  gelatincms  colloid  material,  (b)  Va.scular,  in 
wliicli  the  eidargement  is  chielly  due  to  dilatation  of  the  blood-vessels 
witlioiit  the  new  fornuition  of  glamlular  tissue,  (r)  Cystic  goitre,  in  which 
tlio  tiilarged  gland  is  occupied  by  large  cysts,  the  walls  of  which  often 
ini(U>rifi)  calcification. 

Symptoms. — 'I'he  enlargement  may  be  uniform  throughout  the 
intirc  n!;i„,|^  or  .jlf^i,.(  oidy  one  lobe,  or  the  isthmus  alone.  When  snudl, 
il  jriiitrc  causes  no  inconvenience.  In  its  growth  it  may  compress  the 
trachi'ii,  causing  dyspnu'a,  or  may  pass  beneath  the  sternum  and  compress 
'lu'  viitis.  These,  however,  are  exceptional  circumstances,  and  in  a  large 
I'niportion  of  all  cases  no  serious  symptoms  are  noted.  The  alfection 
"■'ually  comes  under  the  care  of  the  surgeon.  Suddeii  death  occasionally 
wi'iir.-i  in  large  bronchocelcs.  In  some  instances  it  nuiy  be  difficult  to  de- 
termine the  cause  and  it  has  been  thought  to  be  associated  with  j)ressure 
*jntlK'  vagi.    I  have  reported  an  instance  in  which  it  resultod  from  ha.'mor' 


1 

IS 

••I 

If 


il2 


DISEASES   OF  THE  BLOOD   AND  DUCTLESS  GLANDS. 


:%#^ 


'p']'m- 


rlijigc  into  the  gland  und  into  the  adjacent  tissncs.  Tlic  blood  passed  into 
the  cellular  tissues  of  the  neck  and  into  the  sterniun,  covering  the  aorta 
and  pericardium. 

Tumors  of  the  Tiiyuoid. 

These  are  very  varied,  (it)  Adenomata,  either  simple  or  mali;,'nant. 
The  latter  may  1'(»rm  extensive  metastases.  A  case  is  reported  l)y  I  lav- 
ward  in  which  growths  reseml)]ing  thyroid  tissue  occurred  in  the  lunijsaiul 
various  lK)nes  of  the  body,  (h)  Cancer,  of  which  several  forms  iiavc  Ikcii 
described,  (r)  Sarcoma.  All  of  these  have  a  surgical  rather  tliaii  u 
medical  interest. 

It  may  be  mentioned  that  the  aberrant  or  accessory  thyroid  gland  jiiay 
form  large  tumors  in  tlie  mediastinum  or  in  the  ])leura.  J  have  ro|i(irt((i 
two  cases  of  tiiis  kind,*  and  an  instance  is  on  recutrd  in  which  an  enor- 
mous cystic  accessory  thyroid  occupied  the  entire  right  j)leura. 

ExorifTir.VLMrc  Goitue  {Graves^s  Disease  j  Base(loio\s  Disease). 

Definition. — A  disease  of  unknown  origin,  characterized  by  oxopli- 
thalmos,  eidargement  of  the  thyroid,  and  functional  disturbance  of  tlie 
vascular  system. 

Xitiology. — The  disease  is  rare  in  men.  The  age  of  onset  is  nsiially 
from  the  twentieth  to  the  thirtieth  year.  It  is  sometimes  seen  in  scvcial 
members  of  the  .same  family.  Worrv',  fright,  and  depressing  cuiotidus 
precede  the  development  of  the  disease  in  a  number  of  cases. 

Morbid  Anatomy  and  Pathology. — No  constant  changes  have 
been  found  in  exophthalmic  goitre. .  Special  attention  has  been  ]iaiii  to 
the  condition  of  the  sympathetic  system,  as  the  rapid  action  of  the  heart 
and  dilatation  of  the  vessels  has  been  attril)uted  to  paralysis  of  the  sympa- 
thetic iibres,  particularly  the  vaso-dilators.  This  view  has  found  many 
sujiporters,  but  neither  in  the  ganglia  nor  in  the  nerves  are  tlii'ic  any 
changes  which  can  be  regarded  as  constant  and  peculiar  (Hale  White). 
On  the  otluM'  hand,  many  features  of  the  disease  are  ex])licable  on  tlie 
view  that  it  is  an  alTection  of  the  medulla  oblongata,  and  Hale  White 
ha.s  rejiorted  a  case  dying  of  an  acute  intercurrent  disease  in  which  ihctr 
were  Inemorrhages  in  the  lloor  of  the  fourth  ventricle.  The  vascular  and 
nervous  features  might  be  due  to  a  lesion  of  this  part;  but  it  is  dillirult 
on  any  theory  to  explain  all  the  symptoms  of  the  disease  and  to  hrinp 
into  line  the  mental  and  vascular  i)henomena,  the  exophthalmos  aiil  tlie 
goitre. 

Symptoms. — Acute  and  i-hronic  forms  may  be  recognized.  In  tlie 
acute  form  the  disease  may  develop  with  great  rapidity.  In  a  jiatiiiit  of 
J.  II.  Lloyd's,  of  Philadeli)hia,  a  wonuin,  aged  thirty-nine,  who  had  ln'ou 
considered   j)erfectly  healthy,  but  whose  friends   had    noticed    thiit  for 

*  Mcdicdl  News,  1890. 


i.'ll 

tlu've 

■lllil 

•  and 

s  ilillicult 

to 

hriiig 

■i  !in 

1  the 

.     1 

11  tlu' 

Klli' 

'lit  of 

iiita 

ln'OU 

til 

it  for 

DISEASES  OF  THE  THYROID  GLAND. 


713 


some  time  her  eyes  looked  rather  prominent,  was  suddenly  seized  with 
iiitoiiso  vomiting  and  diarrhoea,  rai)id  action  of  tlio  lieart,  and  great  throh- 
biiij,'  of  tlio  arteries.  The  eyes  were  prominent  anil  staring  and  the 
tliyroid  ghmd  was  found  much  enhirged  and  soft.  Tlie  gastro-intestinal 
syiiiptonis  continued,  the  pulse  became  more  rapid,  the  vomiting  was  in- 
cessant, and  tlu)  patient  died  on  the  third  day  of  the  illness;  only  the 
alMlniiiinal  and  thoracic  organs  could  l)e  examined  and  no  changes  were 
foiuiil.  Two  ra2)i(lly  fatal  cases  occurred  at  the  Phila(k'l[)hia  Hospital, 
OIK!  i>(  which,  under  F.  1*.  Henry's  care,  had  marked  cerc])ral  sym])tom8. 
MoiH'  friMjui'iitly  the  onset  is  gradual  and  the  disease  is  chronic.  The 
thrt'c  characteristic  symptoms  vary  a  good  deal  in  their  onset.  Cardiac 
and  vascular  symptoms  are  ixsually  first  to  develop  and  the  patient  com- 
plains of  i)al|)itation  with  breathlessness,  and  on  examination  the  im- 
pulse is  found  to  be  inc-reased  in  force,  the  apex  beat  is  in  normal  j)osi- 
tion,  tlie  carotids  throb,  and  the  abdominal  aorta  pulsates  visibly.  This 
is  one  of  the  conditions  in  which  the  capillary  pulse  and  the  pulsation  in 
the  veins  of  the  hands  are  occasi(mally  seen.  The  pulse-rate  at  first  may 
not  he  inore  than  95  or  100,  but  when  the  disease  is  established  may  reach 
140  or  100.  Any  emotional  excitement  sets  the  heart  beating  with  great 
intensity,  and  on  exposure  of  the  skin  of  the  upper  part  of  the  chest  a 
transient  liyperannia  is  seen.  Soft  murmurs  are  not  uncommon  at  the 
base  of  the  heart.  In  the  long-standing  cases  the  heart  may  be  hypertro- 
pliied  and  the  sounds  very  intense.  In  rare  instances  they  may  be  heard 
some  distance  from  the  patient;  according  to  Gravis,  as  far  as  four  feet.. 

Exophthalmos  usually  follows  the  vascular  disturbance.  It  is  readily 
recognized  by  the  protrusion  of  the  balls,  and  partly  by  the  fact  that  the 
lids  do  not  completely  cover  the  sclerotics,  so  that  a  rim  of  white  is  seen 
above  and  below  the  cornea.  The  ])rotrusion  nuiy  become  very  great  and 
the  eve  may  even  be  dislocated  from  the  socket.  The  vision  is  normal. 
Graefo  noted  that  when  the  eyeball  is  moved  downward  the  upjier  lid  does 
not  f(dlow  it  as  iu  health.  This  is  known  as  (Jraefe's  sign.  The  palpe- 
l»ral  a]ierture  is  wider  than  in  health,  owing  to  spasm  or  retraction  of  the 
upper  lid  (Stellwag's  sign).  Changes  in  the  j>uj)ils  and  in  the  optic  nerves 
are  rare.     Pulsation  of  the  retinal  arteries  is  common. 

The  eidargement  of  the  thyroid  commonly  develops  with  the  exoph- 
thaliiKis.  It  may  be  genera)  or  in  oidy  one  lobe,  and  is  rarely  as  large  as 
iu  ordinary  goitre.  The  vessels  are  usually  much  dilated,  and  the  whole 
gland  may  be  seen  to  pulsate.  A  thrill  may  be  felt  on  pali)ation  and  on 
iUiseultation  a  loud  systolic  murmur,  or  nu)re  commonly  a  bniit  de  cliahh. 
Anioiiir  other  symptoms  which  may  develop)  are  aiuemia,  emaciation,  and 
slijrlit  l\ver.  Attacks  of  vomiting  and  diarrluea  may  occur.  Tremor  is 
present  in  many  cases,  involving  the  hands,  and  is  usually  very  fine.  The 
greatest  complaint  is  of  the  unpleasant  throbbing  in  the  arteries,  often 
aceom])anied  with  uni)leasant  flusiies  of  heat  and  profuse  persj)irations. 
^kin  symptoms  are  not  infrequent — pigmentation,  patches  of  leucoderma, 


W^^ 


-  —   »^« 


714 


DISEASES  OF  THE  BLOOD  AND   DUCTLESS  GLANDS. 


it   : 


or  atrophy  of  ])i{?m(Mit,  and  urticariii.  In  tho  very  aciito  case  above  iv- 
ferred  to,  urticaria  was  a  prominent  symptom.  Irritability  of  tcni|i(r, 
change  in  disposition,  and  great  mental  depresssion  have  been  descril'cd. 
An  important  coniplieation  is  acute  mania,  in  wliich  the  patient  luav  die 
in  a  few  days.  Symptoms  of  general  jiaresis  luive  been  noted  in  a  lew 
eases.  A  feature  of  interest  noted  by  Clnireot  is  the  great  diiniiiiitiiMi  in 
the  electrical  resistance,  which  may  be  due  to  the  saturation  (if  the 
skin  with  moisture!  owing  to  the  vaso-inotor  dilatation  (Ilirt).  Hrv- 
son  has  noted  the  fact  that  the  chest  expansion  may  be  greatly  dimiii- 
ished. 

The  course  of  the  disease  is  usually  chronic,  lasting  s-veral  years. 
After  j)ersi.sting  for  si.x  months  or  a  year  the  symptcuuri  may  (lisa|i|ieiir. 
There  are  remarkable  instances  in  which  the  symptoms  have  come  on  with 
great  intensity,  following  fright,  and  have  disappeared  again  in  a  few  days. 
A  certain  ])r<)])ortion  of  the  casus  recover,  but  when  the  disease  is  well  de- 
veloped recovery  is  rare. 

Treatment. — Medicinal  measures  are  notoriously  uncertain.  The 
combination  of  digitalis  and  iron  may  he  tried,  and,  when  there  is  atuviiiia, 
often  does  good  1  have  never  seen  any  advantage  from  the  use  of  aco- 
nite or  veratrum  viride.  The  tincture  of  strophanthus  will  sometimes 
reduce  the  rapidity  of  the  heart's  acti(m.  Ergot  is  warndy  reconimendetl 
by  some  writers.  Helladona  gives  relief  occasiomdly,  and  should  be  ad- 
ministered until  the  dryness  of  the  throat  is  obtained.  No  measures  arc 
8(4  successful  as  rest  in  bed  with  an  i(!e-bag  or  Leiter's  tube  applii'd  oc- 
casionally over  the  heart,  or,  what  is  sometimes  more  agreeable,  over  the 
lower  ])art  of  the  neck  awl  manubrium  sterni.  I  have  known  the  jndse 
to  be  reduced  in  this  way  from  140  to  90.  Electricity  has  been  iniidi 
lauded  and  instances  of  cure  have  l)een  reported.  In  many  cases  tnii- 
porary  improvement  certaiidy  follows  the  use  of  the  galvanic  current,  the 
cathode  being  placed  at  the  back  of  the  nec^k  and  the  anode  along  the 
course  of  the  sympathetic  or  over  the  heart.  Treatment  of  the  tliyniid 
gland  itself  is  rarely  successful,  aiul  the  operative  measures  have  not  been 
very  satisfactory.     Ligation  of  the  arteries  of  the  thyroid  has  been  tried. 


MYXffiDEMA. 

Deflnition. — A  constitutional  affection,  characterized  cliiucally  by  a 
myxuidematous  condition  of  the  subcutaneous  tissues  and  mental  i'ailiin', 
and  anatomically  by  atrophy  of  the  thyroid  gland.  The  disease  was  de- 
scribed by  Sir  William  (JuU  as  a  cretinoid  change,  and  by  Ord  as  a  siurial 
disease,  to  which  he  gave  the  above  name. 

Clinical  Forms. — Three  groups  of  cases  may  be  recognized :  (n) 
Congenital  form,  or  sporadic  civtinisni.  In  these  cases  there  is  congenital 
absence  of  the  thyroid,  and  the  child  is  a  dwarf,  having  a  tliick  neck,  short 
arms  and  legs,  and  prominent  abdomen.     The  face  is  large,  the  lips  are 


DISEASES  OP  THE  TIIYllOID  GLAND. 


715 


tliick,  the  tongue  is  largo  and  usimlly  ])r(>trmlos.     Tlio  mentul  condition 
li  tliat  of  imhoi'ility  or  idiocy. 

(//)  Mi/.i(('fli')iin  J'rojif'r. — In  this,  womon uro  voiy  much  moro  frc(iuontly 
u'u'ftcd  than  men — in  a  ratio  of  one  to  six.    The  di.icase  may  alfcct  sovorul 
nu'iiihcrs  of  a  family,  and  it  may  bf  transnnttcd  thnmgh  the  mother.     In 
sonic  instances  tliere  has  been  first  tiie  appcaraiu'e  of  exojdithalmio  goitre, 
'riidiigli  occurring  most  commonly  iu  women,  it  seems  to  have  no  special 
relation  to  the  eatamenia  or  to  ])regnaney,  thougli  in  one  instance  the 
symptoms  of  myxo'ckfimi  disappeared  during  pregiuincy.    It  is  not  soeom- 
iiiui)  in  tiiis  country  as  in  Knglai\d.     'I'he  symptoms  of  tliis  form,  as  given 
by  Ord,*  are  nuirked  increase  in  tlie  general  bulk  of  the  body,  a  lirm,  in- 
elastic swelling  of  the  skin,  which  does  not  pit  on  ])ressure,  dryness  and 
niiiglmess,  which  tend,  with  the  swelling,  to  obliterate  in  the  face  the  lines 
of  expression,  imperfect  nutrition  of  the  hair,  local  tnuu'faction  of  the  skin 
and  subcutaneous  tissues,  ])articularly  in  the  supraclavicular  region,    Tlu; 
jiliysiognomy  is  altered  in  a  renuirkable  way,  the  features  are  coarse  ami 
broad,  the  lips  thick,  the  nostrils  broad  and  thick,  and  the  mouth  is  en- 
larged.    Over  the  cheeks,  sometimes  the  nose,  there  is  a  reddish  patch. 
There  is  a  striking  sU)wness  of  thought  aiul  of  movement.     The  memory 
becomes  defeiitive,  the  patients  become  irritable  and  suspicious,  and  there 
may  be  headache.     In  some  instiinces  there  are  delusions  and  hallucina- 
tions, heading  to  a  final  condition  of  dementia.     The  gait  is  heavy  and 
slow.     The  temperature  may   be  below  normal.     The  functions  of  tlie 
heart,  lungs,  and  abdominal  organs  are  normal,     lliemorrhage  sometimes 
(iicurs.     Albuminuria  is  sometimes  present,  more  rarely  glycosuria.    Death 
is  usually  due  to  some  intercurrent  disease.     The  thyroiil  gland  is  dimin- 
ished  in  size  aiid  may  become  completely  atrophied  and  converted  into  a 
tiliioiis  iiuiss.     The  subcutaneous  fat  is  abundant  and  in  one  or  two  in- 
stances a  great  increase  in  the  mucin  has  been  fttund. 

The  course  of  the  disease  is  slow  but  progrCvSsive,  and  extends  over  ten 
or  liftccn  years.  T  have  recently  had  uiuler  observaticm  a  case  to  which 
tlie  term  acute  myxcedeina  might  be  applied.  A  young  man,  aged  twenty, 
pivscMted  a  gradual  enlargement  of  the  facts  particularly  of  the  lips  ai\d 
elueks  and  nose,  without  actual  cedema.  The  backs  of  the  hands  were 
iilso  s\v(dlen,  but  did  not  pit.  The  condition  came  on  with  enlargement 
of  the  thyroid,  and,  after  persisting  for  between  three  and  four  months, 
is  now  gradually  subsiding. 

('■)  Opfrutive  Myxwdema  ;  Cticho.ria  Slnniiiprira. — llorsley,  in  a  series 
of  interesting  experiments,  showed  that  complete  removal  of  the  thyroid 
in  monkeys  was  followed  by  the  production  of  a  condition  similar  to  that  of 
myxo'denui  and  often  associatetl  with  spasms  or  tetsmoid  contractures,  and 
followed  by  apathy  and  conni.  When  the  monkeys  were  kept  warm  myx- 
edema was  averted,  and,  instead  of  an  acute  myxcedoma,  the  animals  devel- 

*  Report  on  Myxoetlemn,  Clinicul  Society's  Transactions,  1888. 


rs  >' 


'•  \  U 


'mi> 


716 


DISEASES  OF  THE   BLOOD   AND   DUCTLESS  GLANDS. 


oped  H  condition  which  ch>s(>ly  roHoinblod  cretinism.  An  identical  cundi- 
tion  niiiy  follow  extirpiitiori  of  tlu*  thyroid  in  man.  Kochcr,  of  Hern, 
found  that  after  complete  extirpation  u  cachectic  condition  followtd  in 
many  casen,  the  Hymptom.s  of  which  are  pructiciilly  identical  with  those  df 
niyxa>donui.  The  disease  follows  only  a  (certain  miniher  of  total  ami  u 
much  smaller  i)roportion  of  partial  removals  of  the  thyroid  ghmd.  Of 
4C8  cases,  in  (!9  the  operative  myxcedema  developed.  It  has  heeii  thdii^fht 
that  if  a  small  frafjnndit  of  the  thyroid  remains,  or  if  there  arc  accissory 
glands,  which  in  animals  are  very  common,  these  symptoms  do  not  de- 
volop.  It  is  ])ossil)le  that  in  men,  in  the  cases  of  complete  removal,  the 
accessory  fragments  subserve  the  function  of  the  gland.  Operative  my.x(ju- 
dema  is  very  rare  in  this  country;  the  only  case  of  which  I  know  is  a 
patient  of  M(!({raw's,  (tf  Detroit. 

It  is  evident  that  the  thyroid  gland  supplies  some  essential  secretion 
of  first  importunco  to  normal  metabolism.  AVhat  this  is  or  how  it  acts 
is  at  ])resent  beyond  our  knowledge. 

The  diaijnnsis  of  the  disease  is  easy.  Bright's  disease  is  the  only  con- 
dition  for  which  it  could  be  readily  mistaken,  l)ut  the  absence  of  pitting, 
the  curions  condition  of  the  faci;,  and  the  absence  of  albumen  in  the  urino 
are  features  whicdi  would  readily  distinguish  it. 

irnfortunately,  no  satisfactory  treatment  is  known.  The  patients  snf- 
fer  in  cohl  and  improve  greatly  in  warni  ather.  They  si'.owld,  there- 
fore, be  kept  at  an  even  tcmi)erature,  and  should,  if  possible,  move  to  a 
warm  climate  during  the  winter  mouths. 


SECTION  VII. 


DISEASES  OF  THE  KIDNEYS. 


I.  ANOMALIES  IN   FORM  AND  POSITION. 

Anomalies  in  Form. — Tlioso  niroly  come  within  the  scope  of  the  phy- 
siciiui.  Atropliy  or  congenital  absence  of  one  kidney  is  associated  with 
flivjit  enlargement  of  the  other  organ.  Fused  kidneys  nuiy  have  a  liorae- 
tlioe  shape,  or  both  organs  may  form  a  hirge  mass,  which  is  often  dis- 
])la(v(l,  being  either  in  an  iliac  fossa  or  in  the  middle  line  of  the  abdomen, 
(ir  even  in  the  ])elvis.  Under  these  circumstances  it  may  be  mistaken  for 
a  new  growth.  In  I'olk's  ease  the  organ  was  removed  unch'r  the  l)elief 
tliiit  it  was  a  floating  kidney.*  Tlie  patient  lived  eU'ven  days,  had  com- 
plete anuria,  and  it  was  found  ]u>st  mortem  that  a  single  unsymmetrical 
kidney,  as  this  form  is  culled,  had  l)eeu  removed. 


Movable  Kidxev 

{Floating  Kidney;  Palpable  Kidney;  Ran  mohilis;  Kcpfi roplosis).  ^ 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritonteum 
wliich  passes  in  front  of  it,  and  by  the  blood-vessels.  'J'he  lower  edge 
of  the  left  kidney  is  nearly  two  inches  from  the  iliac  crest,  a  little  Itelow 
the  level  of  the  second  Inmbar  s])ine ;  that  of  the  right  is  usually  from  one 
half  to  three  (puirters  of  an  inch  lower.  Normally  the  kidney  is  firndy 
fixed,  but  under  certain  circumstjinces  one  or  another  organ,  more  rarely 
hotli,  becomes  movable.  In  rare  cases  the  kidney  is  surrounded,  to  a 
srivatir  or  less  extent,  by  the  ])eritonieum,  and  is  anchored  at  the  hilus 
hv  a  inesonephron.  Some  would  limit  the  term  floating  kidney  t<»  this 
coiiilition. 

Movable  kidney  is  almost  always  acquired.  It  is  most  common  in 
wniiicii.  Of  the  GfiT  cases  collected  in  the  literature  by  Kuttner,  r)S4 
Were  in  women  and  only  8.3  in  men.  It  is  more  common  on  the  right 
than  on  the  left  side.  Of  727  cases  analyzed  by  this  author,  it  occurred 
on  the  right  in  .^S.l  cases,  on  the  left  in  81,  and  on  both  sides  in  0.'}.     'I'he 


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»  New  York  Medical  Journal,  1883. 


718 


DISEASES  OP  THE  KIDNEYS. 


'':  fi  . 


greater  fre(|iu'ncy  of  the  condition  in  women  nmy  ho  attributed  to  corn- 
pH'ssion  of  tlR)  lower  tlioracic  zone  by  tif,dit  laeiii^r,  and,  more  inipDrtant 
Htill,  to  tbe  relaxation  of  the  alxhtininal  walls  which  fullnws  rciicnicd 
|>re;^naM('i("<.  'I'his  doi-n  not  aecoiint  for  all  the  eases,  us  niuvabU'  kiihicy 
Is  by  no  means  uneoniinon  in  nullipara'.  Dnimmon*!  believes  that  in  a 
majority  of  tho  eases  tliere  is  a  eonjxenitally  relaxed  condition  of  I  he  |iiri. 
toneal  attachments.  Wasting  of  the  fat  about  the  kidiies  nmy  he  a  eaiisc  in 
some  instances.  'I'raumaand  the  liftinj^  of  heavy  wei;;bts  are  occasidiiailv 
factors  in  its  production.  'I'lie  kidney  is  s<»nietimes  dra;.f,i;ed  d(i\\ii  \,y 
tumor.s.  Tho  ^'reater  fre((ueiu7  on  tho  ri^dit  side  is  |)robalily  assncjated 
with  tho  position  of  tho  kidiu'y  just  bem-ath  the  liver,  and  the  depressiim 
to  which  tho  organ  is  subjectt'd  with  each  descent  of  tht;  diaphra;,nti  in 
inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  whicii  |ii(se!it 
that  combination  of  neurasthenia  with  gastro -intestinal  disturbance  which 
has  boon  described  by  (ileiiard*  as  vnlerophisis. 

To  doterniiiu!  tho  j)resenco  of  a  moval)le  kidney  the  patient  siwiuld  \w 
j)Iaccd  in  the  dorsal  position,  with  the  head  moderately  low  and  the  aii- 
domimil  walls  relaxed.  Tho  left  haiul  i.s  ])luced  in  tho  lumbar  rc;,di>ii 
behind  tlie  eleventh  and  twelfth  ribs;  the  right  hand  in  tho  hypipclinii- 
driac  region,  in  the  nipple  lino,  just  under  tho  eilge  of  the  liver.  Uiinaniial 
palpation  nmy  detect  tho  j)resem!0  of  a  firm,  rouiuled  body  just  below  tlic 
edge  of  the  ribs.  If  nothing  can  bo  felt  tho  patient  should  bo  asked  U\ 
ilraw  a  deep  breath,  when,  if  tho  organ  is  jialpable,  it  is  touched  by  the 
fingers  of  the  right  hand.  Various  grades  of  mobility  may  be  recognized. 
It  may  be  possible  barely  to  feel  tho  lower  edge  on  deep  ]ialpati<)ii — /»///«?- 
bb;  kiihii'ji — or  tho  organ  may  bo  fio  far  displaced  that  on  tlra\viii>:  the 
doopent  breath  tho  fingers  of  tho  right  hand  nuiy  be  in  a  thin  pcrsdii 
slipped  above  tho  upper  end  of  tho  organ,  whicdi  can  bo  readily  held 
down,  but  cannot  bo  pushed  below  tho  level  of  the  nav(d — niont/i/r  kii/iii'i/. 
In  a  third  group  of  cases  tho  organ  is  freely  movable,  aiid  may  even  lie 
felt  just  above  Poupart's  ligament,  or  nuiy  bo  in  the  middle  line  of  tlio 
ubdonuni,  or  can  oven  bo  pushed  over  bc^'ond  this  point.  To  this  tlic 
term  JJodfitii/  kidney  is  ai)])ropriate,  whether  the  organ  has  a  mesoiiephroii 
or  not. 

And,  lastly,  a  dislocated  kidney  may  bocomo  fixed  in  an  ahiKiriiiiil 
position.  This  is  extremely  rare,  and  in  a  very  largo  nund)i'r  of  cases  I 
liave  found  oidy  one  instance  of  tho  kind.  A  woman,  aged  tweuty-nint', 
with  four  children,  had  nervous  symptoms  with  abdominal  ))aiii,  ami  had 
been  much  worried  by  the  discovery  of  a  tumor,  just  to  the  right  of  tlic 
middle  lino,  close  to  tho  navel.  It  was  not  movable,  but  the  distinctly 
reniform  shape  and  the  depression  at  tho  left  margin  indicatcij  that  it 
Wiis  doubtless  a  dislocated  kidney  which  had  become  fixed. 

*  Revue  do  Medecine,  1887 ;  Pourcelot,  Paris  Thesis,  1880. 


ANOMAMKS  IN   FORM   AND  POSITION. 


71!) 


The  nioviiblc!  ki<lm'y  irt  not  puiiifiil  <m  prcssun',  except  wlieii  it  is 
pra'pt'tl  very  firniiy,  when  there  is  u  tliill  pain,  or  Honietiiiies  u  sickeiiin;^ 
si'iisitioii.  Mxariiiimtioii  of  tlie  patient  fruin  lu'liin*!  may  show  a  ilislinct 
lliitti  nin;;  in  the  hinihar  re<;ir)n  on  the  siiU-  in  which  the  kidney  is  tnohih>. 

Symptoma.  — In  a  hirj^e  majority  of  eases  tlie  ecmdition  jrives  no 
trouble,  und  it  id  well,  if  ih^teeted  uecicU'ntally,  not  to  let  the  patient  know 
of  its  presenco.  In  other  insianees  there  is  pain  in  the  himltar  re;.Mon  or 
a  sense  of  dra<r<:;in<^  and  discomfort,  or  there  may  l)e  intercostal  nciiral;.'ia. 
In  a  lar^o  groiij)  the  symptotns  an^  thost;  of  neiirasthcma  with  dyspeptic 
(listnrhanee.  In  women  the  liysterieal  symptoms  may  he  marked,  and  in 
Mien  various  grades  of  hypoeliondriasis.  'I'lie  gastric  distnrliance  is  usu- 
ally a  form  of  nervous  dyspepsia.  Dilatation  of  the  stomach  has  licen  oi)- 
scrvcd,  owing,  as  snggesteil  l)y  Hartels,  to  pressure  of  the  dislocated  kidney 
upnn  the  duodenum.  This  view  has  been  supported  l»y  Oser,  Landau,  and 
Kwalil.  On  the  other  hand,  Litton  holds  that  the  dilatation  of  the  stom- 
ach is  the  cause  of  the  mr)hility  of  the  kidney,  and  he  found  in  40  eases 
of  (l('|tression  and  dilatation  of  the  stonuich  i'i  instances  of  dislocation  of 
the  kidney  on  tlut  right  sid(^  My  own  experience  coincides  with  that  of 
Dnnninond,  who  has  very  exceptionally  found  the  two  conditions  to  co- 
exist. While  not  denying  the  possibility  of  causal  relationship  between 
\\w  two,  it  seems  ])robal)le,  considering  the  fre(|uency  of  lloating  kidney, 
that  the  complication  is  only  a  coinci<lence.  The  association,  however, 
with  a  i/i'presni'fl  stonuich  is  certainly  not  uncommon  in  women,  ('onsti- 
putinn  is  not  infrecpient.  »Some  writers  have  described  ])ressure  upon  the 
gall-tliicts,  with  jaundice,  but  it  is  not  very  likely  to  occur. 

Under  the  name  viiteroptosis,  (llenard  has  described  a  special  symp- 
tom group  characterized  by  nervous  dys[)epsia,  prolapse  of  the  abdon  inal 
orpuis,  ])articularly  the  transverse  colon,  with  looseness  of  the  mesenteric 
and  ju'ritoneal  attachments,  so  that  there  is  a  falling  down  of  the  viscera 
(splaii(!inopt4)sis).  Dilatation  of  the  stomach  and  mobility  of  the  kidiusy 
are  viTv  commonly  associated  with  this  state.  Uleiiard  held  that  he  (;ould 
feel  the  prolapsed  transverse  colon  as  u  narrow  band,  but  lOwald  states 
correctly  that  this  is  the  jjancreas,  wliitdi  in  many  of  these  cases  can  be 
distinctly  jialpatod.  According  to  (ilenard,  the  kink  in  the  colon  causes 
the  ciinstipation,  while  the  depression  of  the  stomach  and  intestines  leads 
to  vascular  disturbance  and  impairment  of  the  motor  and  secretory 
functions. 

Ill  floating  kidney  there  are  attacks  (simulating  gastralgia  or  renal 
colic)  cliaracterized  by  severe  abdominal  pain,  chills,  nausea,  vomiting, 
fever,  and  collapse.  Scarcely  any  mention  is  made  of  such  symptoms, 
which  were  first  described  by  Dietl  in  1804,  aiul  a  more  wide-spread  knowl- 
Pilge  of  their  occurrence  in  connection  with  this  condition  is  tlesirable. 
My  attention  was  called  to  them  in  1880  by  Palmer  Howard  in  the  case 
of  a  stout  lady,  who  suffered  repeatedly  with  the  most  severe  attacks 
of  abdominal  pain  and  vomiting,  which  constantly  reqn.irod  morphia.     A 


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720 


DISEASES  OF  TUE  KIDNEYS. 


tumor  was  discovered  a  little  to  the  right  of  the  navel,  and  tlu;  diiitr. 
iiosis  of  probublo  lu'opiii.sin  was  concurriMl  in  by  Flint  (Sr.)  and  (iiiilhird 
Tliomas.  Tbe  patii'n*  lost  weight  rapidly,  bccamo  cniaciatt'd,  and  in  the 
spring  of  1881  again  went  to  New  York,  where  she  saw  \'an  Hiiren,  who 
diagnosed  a  floating  kidney  and  said  that  these  paroxysms  wen.'  as8o. 
eiated  with  it  in  a  gouty  person,  lie  cut  off  all  stimulants,  reassiind  the 
lady  tha'c  she  had  no  cancer,  and  from  that  time  siie  rapidly  recovered, 
and  the  attacks  liave  l)ccii  few  and  lar  between.  In  this  patient  any  over- 
indulgence in  eating  or  in  d linking  is  stdl  lial)le  tt»  be  f(dlowed  by  a  very 
severe  attack.  These  attacks  may  a)o;)  be  mistaken  for  renal  colic,  ai)'l 
the  operation  (»f  nephrotomy  has  been  performed. 

In  other  instances  the  attacks  of  ])ain  may  l)e  thought  to  l)e  hie  to  in- 
testinal disease  or  to  recurring  a])pendicitis.  The  cause  of  these  pamx- 
ysnud  attacks  is  not  quite  clear.  Dietl  thought  they  were  due  t(»  stiaiigu- 
lation  of  the  kidney  or  to  ttvists  or  kinks  in  the  renal  vessels  due  Id  the 
extrenu!  mobility.  I-uring  the  attacks  the  urine  is  sometinu's  higli-eolored 
and  contains  an  excess  of  uri(!  acid  or  of  the  oxalates.  It  is  st  ited,  tO(», 
that  blood  or  pus  may  be  present.  The  kidney  nniy  be  tender,  swulleii, 
and  less  freely  m.-.able.  Intermittent  hydronephrosis  has  sometimes 
been  associated  with  movable  kidney. 

The  (/idi/iiosis  is  rarely  (l()ul)tful,  as  the  shape  of  the  organ  is  usually 
distinctive  and  the  mobility  imirked.  Tumors  of  the  gall-bladder,  ovarian 
growths,  and  tumors  of  the  bowels  may  in  rare  instances  be  confounded 
vath  it. 

Treatment. — Tiie  kidney  has  heen  extirpated  in  many  instances, 
but  the  oi»eratiiin  is  not  without  risk,  and  there  have  been  several  fatal 
cases.  Stitehiugof  the  kidney — nepdirorrhaphy — asreeomn-nded  by  Ilahii. 
is  the  most  suitable  procedure,  and  statistics  recently  published  by  Keen 
show  that  reliid"  is  alTorded  in  numy  casjs  by  the  procedure.  It  does  imt, 
however,  always  siu:ceed. 

The  treatment  by  trusses  and  bandages  is  not  satisfactory,  tliou<rh 
great  relief  is  sometimes  oldained.  As  a  rule,  bandages,  with  pads  jness- 
ing  to  the  rigiit  of  the  na\el,  are  not  well  borne,  as  the  kidiu^y  is  often 
sensitive.  In  some  instances,  however,  the  greatest  relief  is  expeii- 
enc!e(l  by  this  procedure.  An  air-pad  beneath  the  bandage,  as  reeoin- 
m(Hided  by  .Newman,  is  prol)ably  the  best.  In  other  eases  a  broad  ha'uiii.irt' 
W(dl  i)added  in  the  lower  abiiomiiuil  zone  pushes  up  the  intestines  niiil 
makes  them  act  as  a  support.  In  the  attacks  of  severe  colic  morphia  i> 
required.  When  depen<lent,  as  seems  sometimes  the  ease,  upon  an  excess 
of  uric  acid  or  the  o.valates,  the  diet  must  be  carefully  regulated. 


CIRCULATORY  DISTURBANCES. 


721 


II.  CIRCULATORY   DISTURBANCES. 


Normally  the  secretion  of  urine  is  aceoniplislu'd  by  the  niiiinteniince 
of  a  oertiiin  blood-pressure  within  tiie  jjloineruli  and  by  tii(^  iietivity  of 
the  renal  ei)itheliuin.  Hownian's  views  on  this  (|uesti(in  have  Ikou  <s:on- 
evally  accepted,  and  the  watery  elements  are  held  to  be  liltcrctl  from  the 
gloiiH'ruli;  the  amount  (le})endinfi  on  the  rapidity  and  tl»e  ])ressure  of  the 
blood  current;  the  quality,  whether  normal  or  alinornud,  dependini;  upon 
the  inti^rrity  of  tlie  eapihary  and  {glomerular  epithelium  ;  while  the  jrreater 
j)ortinu  of  the  soli<l  inj^redieiits  are  excreted  by  the  i-piliielium  of  tbe  con- 
voiutfd  tubules.  The  iute<j;rity  of  the  epitludium  c(tverin<f  tiie  capillary 
tufts  within  J^)wmau\s  capsule  is  es.^iential  to  the  production  of  a  normal 
urine.  If  under  any  circumstances  their  nutrition  fiuls,  as  when,  for 
example,  the  rapidity  of  the  blood-curn  i^  is  lowered,  so  that  tliey  are 
deprived  of  the  necessary  amount  uf  oxv^fu,  the  nuiU'rial  whieli  tilters 
tliroufrh  is  no  h)nger  normal  (i.  e.,  water),  but  contains  serum  aibuincn. 
C'ohiilieim  has  shown  that  the  venal  epithelium  is  extremely  sensitive  to 
circulatory  chanjfes,  and  that  eomi)ressiou  of  the  n-ual  artery  for  oidy  a 
few  luiiiutes  cau'^es  serious  disturbance. 

The  circulation  of  the  kidney  is  renuirkably  influenced  by  rcllex 
stiiiudi  coming  from  the  skin.  Exposure  to  cold  causes  heightened 
1)1(10(1- ■•ressure  within  the  kidneys  and  increased  sec^retion  of  urinci.  So 
also  in  the  chills  of  nudaria,  after  which  a  large  amount  of  pale  urine 
may  li"  passed. 

Congestion  of  the  Kidneys. — (l)  Ardi'c  Conypsth)!  :  f/i/pr/uriiiia. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  col'^  or  to  the  action  (>f  poisons  ami  severe  irritants. 
Tiirpeittiiu',  cubebs,  cantharides,  and  copaiba  are  all  stated  to  cause  cx- 
trcuie  liy|)cra'nwa  of  the  or;ran.  The  most  typical  congestion  of  the 
kiiluey  winch  Ave  see  post  mortem  is  that  in  the  early  stage  of  acute 
l'>riglit's  disease,  when  the  orgaTi  nuiy  be  large,  soft,  of  a  dark  eolo'-,  aiul 
on  scetioti  bloo<l  dri|)s  from  it  freely. 

It  has  been  held  tha;  in  all  the  acute  fevers  the  kidneys  are  congested, 
and  thui,  tlM-i  expliiineil  the  scanty,  liigli-c<dored,  and  often  albuminous 
nrine.  On  the  other  hand,  by  HoyV  oncometer,  \\alti'r  Menthdson  has 
slioun  that  the  kidney  in  aeut«  fever  is  in  a  state  of  extreme  ana-mia, 
small,  pale,  iind  bloodless;  and  that  tliis  ana-mia,  increasing  with  the 
liyrcxiaand  interfering  with  the  juitrition  of  the  glomerular  I'piLludiiim, 
iii'i()unt.<  for  the  scanty,  dark-colored  urine  of  fever  ami  for  the  presence 
"f  ulhumen.  In  the  prolonged  fevers,  however,  it  is  probable  that  ridaxa- 
'inn  of  the  arteries  again  takes  place.  Certainly  it  is  rare  to  Iind  jxist 
imirteni  such  a  co'v'ition  of  the  kidney  .-is  is  described  by  Mendidson.  On 
tlu'  contrary,  tiic  kidney  oi  fever  is  comniotdy  swcdien,  the  blood-vesstds 
iirc  coM'i^o.Jited,  and  the  cortex  frequently  shows  truces  of  cloudy  .swcdiing. 
lluwi'ver,  the  eirculutory  disturbances  in  acute  fevers  are  probably  less  im- 


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722 


DISEASES  OF  TilE  KIDNEYS. 


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portant  than  the  irritative  effects  of  either  tlio  specific  ajijents  of  the  dis. 
ease  or  tlie  produfts  ])ro(ln('e(i  in  their  ^rowtli,  or  in  the  altt'rod  inetabdiism 
of  the  tissues.  Tlie  urine  is  diminislied  in  amount,  and  niay  enniain 
albumen  and  tube-casts. 

(^')  f'fisfiive  Covijcstmi ;  Mechanical  Ilijpn'O'mid. — This  is  found  in 
casea  of  clirojiic  disease  of  tlie  heart  or  lunj,',  with  imiu'dcd  circulation, 
and  as  a  result  of  pressure  npon  the  reiuil  veins  l)y  tumors,  the  pre<,'iiiiiit 
uterus,  or  ascitic  lluid  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic 
induration  associated  with  chronic  heart-disease,  the  organs  are  enlarsri'd 
and  firm,  the  capsule  strips  olT,  as  a  rule,  readily,  the  cortex  is  ol'  a  dirp 
red  color,  and  the  ])yramids  of  a  purple  red.  The  section  is  coarse-look- 
ing, the  .iubstaiu'c  is  very  lirm,  and  resists  cutting  and  tearing.  'I'lie  in- 
terstitial tissue  is  increased,  and  there  is  a  small  celled  intiltratioii  be- 
tween the  tubules.  Here  and  there  the  Maljiighian  tufts  have  iKcome 
sclerosed.  Tlie  l)lood-vessels  are  usually  thickened,  and  there  may  be 
more  or  less  granular,  fatty,  ()r  hyaline  changes  in  the  epithelium  of  the 
tubules,  'i'lie  condilion  is  indee(l  a  diffuse  nephritis.  The  urine  is  usu- 
ally reduced,  is  of  high  specific  gravity,  and  contains  nutre  or  less  al'm- 
men.  Hyaliiu'  tube-easts  and  blood-corjuiscles  are  not  uncommon.  In 
uncomplicated  cases  of  the  cyanotic  iiuluration  nra'inia  is  rare.  On  thr 
otlu'r  hand,  in  the  cardiac  eases  with  extensive  arterio-sclerosis,  tln'  kidnevs 
are  more  involved  ami  the  renal  function  is  likely  to  be  disturbed. 


HI.  ANOMALIES  OF  THE  URINARY  SECRETION. 

1.    H.K.M.VTl  IJIA. 

The  following  division  may  be  nnide  of  the  causes  of  ha'maturiu  : 

(1)  (icnrnil  Discuses. — The  malignant  forms  of  the  ai'ute  specific 
fevers,  such  as  snudl-pox,  malaria,  yellow  fever,  etc. ;  .scurvy,  jjuipiirj, 
and  lucmophilia.     Occasionally  in  leukaMuia  luennituria  occurs. 

(2)  Itennl  (Muses. — Acute  congestion  and  inflanunatiou,  as  in  BriirlitV 
disease,  or  the  elTei't  of  toxic  agents,  such  as  turpentine,  f,'arl)olic  add,  and 
cantbarides.  W  hen  the  carbolic  spray  was  in  use  many  surgeons  snlTercd 
from  luennituria  in  conse(pionce  of  this  poison.  Ueind  ini'ari'tion.  us  in 
ideerative  emiocarditi^.  Xew  growths,  in  which  the  bleeding  is  ii-ii:ili\ 
profuse.  Tubende  rarely  causes  lia>maturia,  though  at  the  onset,  wluii 
the  ])npill;\>  are  involved,  there  may  be  blei'ding.  Stone  in  the  kidney  is  a 
freipUMit  clause.  Parasites:  The  ///rr/'m  sdni/iiiin'.s  /loiniiiis  ami  tin' />'//■ 
htn-zia  cause  a  form  of  Inematuria  met  with  in  the  tropics.  The  ei  Iiimt- 
citeeus  is  rartdy  associated  with  haemorrhage. 

(3)  Affi'cf ions  nf  the  I'rinai //  Passar/rs. — Stone  in  the  ureter,  inali^'- 
nant  disease  or  ulceration  of  the  Idaddcr,  the  ))re.sence  of  a  cnlcidiis,  para- 
sites, and,  very  rarely,  ruptured  veins  in  the  bladder.     Bleeding  fnmi  tlu' 


ANOMALIES  OF  THE   URINARY  SECRETION. 


723 


urethra  oooasionally  occurs  in  gonorrhcua  aud  as  a  re8ult  of  the  lodgment 
of  a  calculus. 

(4)  'J)'(iiima/i,s»i. — Injuries  may  produce  l)leeding  from  any  part  of 
tlu'  iiriTiary  passages.  Jiy  a  fall  or  blow  on  the  hack  tiio  kidney  may  be 
ruptured,  and  this  may  be  followed  by  very  free  l)leeding;  less  comtnonly 
the  blood  comes  from  injury  of  the  bladder  or  (jf  the  prostato.  IJlood 
from  the  urethra  is  frequently  due  to  injury  by  the  jjassage  of  a  catheter, 
or  SDinetiuies  to  falls  or  blows. 

.\iid,  lastly,  there  are  cases  in  which  hivnuituria  oocurB  for  a  long  t!in(! 
withiiul  discoverable  cause,  j)articularly  in  yuung  persons.  Tlie  heulUl 
may  not  be  seriously  impaired,  (iull  has  ciiaracterized,  in  a  happy  way,  a 
case  of  this  kiiul  as  one  of  renal  e])istaxis. 

Of  sj)e(iiil  interest  is  the  mahirial  hivmatuvia  vliii'li  ]>rrvails  in  certain 
districts  and  has  already  been  considered  in  the  secUou  on  paludism. 

The  diagnosis  of  iia'maturia  is  usually  easy.  The  color  of  th')  urine 
viiriis  from  a  light  smoky  to  a  bright  red,  or  it  nuiy  have  a  dar  k  porU'r 
cdlor.  Kxiimined  with  the  microscojx',  the  blood-corjiuscles  are  n^adilv 
r('ii)i.Miized,  either  plainly  visil)le  and  retiiining  their  color,  in  whirh  case 
tiny  are  usually  crenated,  or  sim|»ly  as  shadows.  In  aiiimouiacal  urine  or 
iiriius  of  lowsi)eciHc  gravity  the  luemoglobin  is  rapidly  dissolved  from  the 
ror|)iiscles,  but  in  nornuil  urine  they  remain  for  many  Jumrs  unchanged. 

(MJior  tests  are  rarely  necessary.  The  guaiucum  test  consists  of  the 
iuiilition  to  the  urine,  in  a  test-tube,  of  a  drop  or  two  of  the  tincture  of 
giiaiaeiim  and  two  minims  of  ozonic  ether.  A  blue  color  forms  at  the  line 
iif  eentact  of  the  two  fluids  and  ditTuses  iUsclf  through  the  ether. 

The  spectroscopical  examination  of  the  urine  nuiy  slntw  either  tho  sin- 
;:1('  Iiatid  of  reduced  ha'mogloi)in  or  the  double  band  of  oxyhii'moglobin 
liolwirn  the  lines  I)  and  M. 

It  is  important  tf)  distinguish  between  blood  coming  from  the  ])laddor 
and  from  the  kidneys,  though  this  is  not  always  easy.  From  the  i)ladder 
tilt'  blond  may  be  found  oidy  with  the  last  )M>rtions  of  urine,  or  only  at  the 
ti'iniiiiatiou  of  micturition.  In  ha'morrhage  from  the  Icidneys,  the  blood 
and  lu'ine  are  iiitiniattdv  mixed.  Clots  are  more  commonly  foutui  in  the 
IiIimmI  iKdii  the  kidneys,  and  may  form  moulds  of  tho  pelvis  or  of  the  ureter. 
\Mii'ii  tho  seat  of  tlie  bleeding  is  in  tho  bladder,  on  washing  out  this  organ, 
tilt' water  is  more  or  less  blood-tinged  ;  but  if  the  .s(mrc(>  of  tl»*'  bleedin<j  is 
liif.'lior,  the  water  comes  away  t dear.  In  numy  instancies  it  is  dithculi  to 
settle  the  fjiu'stion  by  the  examination  of  the  urine  alone,  amd  the  s\nii- 
toms  and  the  ])hysical  signs  must  also  be  t^ikeii  into  account. 


2.    E.KMOOLOUINl  KIA. 

Ttiis  eonditit>n  is  charact-erized  by  the  pre<en('c  of  blood-pignu'nt  in 
iIk' urine.     The  blood-cells  are  cither  absent  or  in  insigniticant  numbers. 
I'he  Coloring  matter  is  not  hasmatiti,  as  indi<-»t«d  by  the  old  name,  lunnn- 
40 


724 


DISEASES  OF  THE   KIDNEYS. 


tinuria,  nor  in  reality  always  Iwmoglobin,  but  it  is  most  frequently  niotli.T- 
moglobin.  The  urine  has  a  red  or  brownish-red,  sometimes  quit-*.'  l>l;i(k 
color,  and  usually  dej)osits  a  very  heavy  brownish  sediiiu'nt.  Wlicii  the 
ha>nioglobin  oecurs  oidy  in  small  (puintities,  it  may  give  a  lake  or  siiKikv 
color  to  the  urine.  Microscopical  examination  shows  the  presence  of 
granular  jjigment,  sometimes  fragments  of  blood-disks,  epitheUiiiii,  iind 
very  often  darkly  pigmented  urates.  The  urine  is  also  albuminous.  The 
number  of  red  blood-cor2)Uscles  bears  no  proportion  whatever  to  the  in- 
tensity of  the  color  of  the  urine.  Examined  siiectroscopically,  there  are 
either  the  two  absorption  bands  of  oxyha?moglobin,  which  is  rare,  or,  more 
commonly,  tliere  are  the  three  absorption  bands  of  methienioglol)iii,  of 
which  the  one  in  the  red  near  6'  is  characteristic.  Two  cliiiieul  ;,q'(iii|),s 
may  be  distinguished. 

(1)  Toxic  HaBmoglobinuria.— This  is  caused  by  poisons  whiih  pioihice 
rapid  dissolution  of  the  blood-corpuscles,  such  as  chlorate;  of  potasli  in  larfre 
doses,  {)yr()gallic  acid,  i;arbolic  acid,  arseniuretted  liydrogen,  carlxm  diox- 
ide,  naphthol,  and  muscarine ;  also  the  poisons  of  scarlet  fever,  yellow  fever, 
typhoid  fever,  malaria,  and  sy))hilis.  It  has  also  followed  severe  hums.  Ex- 
posure to  excessive  cold  and  violent  muscular  exertion  are  stated  to  produce 
ha»moglobinuria,  A  most  remarkable  toxic  form  occiurs  in  horses,  eoni- 
ing  on  with  great  suddenness  and  associated  with  paresis  of  the  hind  lefrs. 
Death  may  occur  in  a  few  hours  or  a  few  days.  Horses  are  attacked  mdy 
after  being  stjvlled  for  some  days  aiul  then  taken  out  aiul  driven,  partieii- 
hirly  in  cold  weather.  The  affection  is  common  in  horses  in  this  country. 
The  form  of  luvmoglobinuria  from  cold  and  exertion  is  extremely  rare 
No  instance  of  it,  even  in  association  with  frost-bites,  came  under  my  ob- 
servation in  Canada.  Blood  transfused  from  one  mammal  into  another 
causes  dissoluti(m  of  the  corpuscles  with  the  production  of  hivmoifjohinii- 
ria;  and,  lastly,  there  is  the  epidemic  luvmoghbinnria  of  the  ne\v-l»iirn, 
associated  with  jauiuliee,  cyanosis,  and  nervoits  symptoms. 

(2)  Paroxysmal  HsBmoglobinuria. — This  rare  disease  is  chara(  terized 
by  the  occsisional  ])assjige  of  bloody  urine,  in  which  the  coloring  matter 
only  is  present.  It  is  more  frequent  in  males  than  in  females,  and  occurs 
chiefly  in  adults.  It  seems  specially  associated  with  cold  and  exert  inn. 
and  has  often  been  brought  on,  in  a  susceptible  person,  by  the  use  of  a 
cold  toot-bath.  Paroxysmal  luemoglobinuria  has  been  found,  too,  in  |t«'r- 
sons  subject  to  the  various  forms  of  Raynaud's  disease.  Many  regard  the 
relation  between  tliese  two  affection's  as  extremel)  close;  some  hold  tli.it 
they  are  manifestations  of  one  and  the  same  disorder.  Druitt,  the  antln.r 
of  the  well-known  Surgical  Vade-mecum,  has  given  a  gra{>hie  desciiptio'i 
of  his  sufferings,  which  lasted  for  many  years,  and  were  accompuuieil 
with  local  asphyxia  and  local  syncope.  Tiie  connection,  however,  i--  ii"t 
very  common.  In  only  one  of  the  cases  of  Raynaud's  disease  whirli  I 
have  seen  was  paroxysmal  hfemoglobinuria  present,  and  in  it  epileiiti  ■ 
attacks  occurred  at   the  same   time.      The   relation  of   the  di.seaa'  to 


ANOMALIES  OF  THE   URINARY   SECRETION. 


r25 


malariii  is  not  so  dose  as  lias  l)cen  thought  hy  many  writers.  No  doubt  it 
hiis  la-en  frequently  confounded  with  a  nudarial  ha-niaturiu.  Tiie  attacks 
may  como  on  suddenly  after  exj)osure  to  cold  or  as  a  result  of  mental  or 
b(»tlily  exhaustion.  They  may  be  preceded  by  chills  and  pyrexia.  In  other 
instiinccs  the  temperature  is  subnormal.  There  may  be  vomitinff  and 
(liiurliu'a.  Pain  in  the  lumbar  rejifion  is  not  uncommon.  The  luvino- 
gldhiuuria  rarely  persists  for  more  than  a  day  or  two — sometimes,  indeed, 
not  for  a  day.  There  are  instances  in  which,  even  in  the  course  of  a  sin- 
gle (liiy,  there  have  been  two  or  three  paroxysms,  and  in  the  intervals  clear 
uriiio  has  been  j)assed.  Jaundice  has  been  present  in  a  inimber  of  cases. 
According  to  Kalfe,  paroxysmal  luvmoglohinuria  may  alternate  with  gen- 
eral symptoms  of  the  same  character,  but  associated  only  Mith  the  passage 
of  iilltumen  and  an  increased  (luantity  of  urea  in  the  urine.  In  such  cases 
lie  sujiposes  that  the  toxic  agent,  whatever  its  nature,  has  destroyed  only 
a  limited  number  of  the  corjtusv'les,  the  coloring  matter  of  which  is  readily 
dealt  with  by  the  spleen  and  liver,  while  the  globulin  is  excreted  in  the 
urine.     The  cases  are  rarely  if  ever  fatal. 

The  essential  pathology  of  the  disease  is  unknown,  and  it  is  difficult 
to  f(irm  a  theory  which  will  meet  all  the  facts — jnirticularly  the  relation 
with  h'aynaud's  disease,  which  is  rightly  reganled  as  a  vaso-motor  disorder. 
Increased  haemolysis  and  dissolution  of  the  hamioglobin  in  the  blood-serum 
(lia'ni(tgl()binipmia)  precedes,  in  each  inst^mce,  the  appearance  of  the  color- 
ing matter  in  the  urine ;  but,  as  I'onfick  has  shown,  the  amount  of  free 
hu'iuiigldbin  must  reach  a  certain  grade  before  it  is  e.xcreted. 

Treatment. — In  all  forms  of  luematuria  rest  is  essential.  In  that 
produced  by  renal  calculi  the  recumbent  ])osturo  may  suftice  to  check 
the  bleeding.  Full  doses  of  acetate  of  lead  and  opium  should  be  tried, 
then  ergot,  gallic  and  tannic  acid,  and  the  dilute  sulphuric  acid.  The 
oil  of  turpentine,  whidi  is  sometimes  recommended,  is  a  risky  remedy 
ill  hii'iuaturia.  Kxtr.  hanuimelis  virgin,  and  extr.  hydrastis  canad.  are 
also  recommended.  Cold  may  be  applied  to  the  loins  or  dry  cups  in  the 
luniliii'.'  regicm. 

T!if  treatment  of  luvmoglohinuria  is  unsatisfactory.  Nothing  seems 
to  chirk  the  occurrence  of  the  atta"ks.  During  the  paroxysm  the  })aticnt 
should  be  kept  warm  and  given  hot  drinks.  Quiniiu>  is  recommended  in 
largo  (loses,  on  the  supposition — as  yet  unwarranted — that  the  disease  is 
«npi'ia]ly  coniu'ctcd  with  malaria.  If  there  is  a  syphilitic  history  iodide 
''  i"'iassium,  in  full  dose.'^,  may  i)e  trieil.  in  a  warm  climate  the  attacks 
are  much  less  frequent. 


i  .■ 


III.  Alui  MixruiA.. 

The  presence  of  albumen  in  the  urine,  formerly  regarded  as  indicative 

^hight's  disease,  is  now  recognized  as  occurring  under  many  circum- 

•iwinci's  without  the  existence  of  serious  organic  change  in  the  kidney. 


726 


disp:ases  op  the  kidneys. 


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Two  groups  of  cases  may  be  recognized — tliose  in  which  the  kidncy.s  show 
no  course  k'sions,  and  those  in  which  there  uro  evident  anatomical 
cliangos. 

Albuminuria  without  Coarse  Renal  Lesions.— («)  Funvtinnul  So- 
cnlU'd  Physiuhijiral,  Albuminuria. — In  a  uornial  condition  of  the  kiiliicv 
only  tlio  water  and  the  salts  are  allowed  to  pass  from  the  blood.  When 
albuminous  substances  transude  there  is  probably  disturbance  in  tlic  nu- 
trition of  the  epithelium  of  the  capillaries  of  the  tuft,  or  of  the  cills  sur- 
rounding the  glomerulus.  This  statement  is  still,  however,  in  disiuitc, 
and  Seiuitor,  Clrainger  Stewart,  and  others  liold  that  there  is  a  physioloi,'!. 
cal  albuminuria  which  may  follow  muscular  work,  the  ingestion  of  food 
rich  in  albumen,  violent  emotions,  cold  bathing,  and  dysj)opsia.  The  dif- 
ferences of  opinion  on  this  point  are  striking,  and  observers  of  ((jual 
thoroughness  and  reliability  have  arrived  at  directly  opposite  conclusions, 
The  presence  of  albumen  in  the  urine,  in  any  form  and  under  :uiy  di- 
cumstance,  may  l)e  regarded  as  indicative  of  change  in  the  renal  or  irloni- 
erular  epithelium,  a  change,  however,  which  may  be  transient,  sliirlit, 
and  unimportant,  depending  upon  variations  in  the  circulation  or  upon 
the  irritating  effects  of  substances  taken  with  the  food  or  teniiioraiily 
present,  as  in  febrile  states. 

Much  attention  has  been  given  of  late  years  to  the  albuminuria  of 
adolescen(!e,  or  cyclic  albuminuria.,  which  is  also  believed  to  be  a  func- 
tional disorder.  A  majority  of  the  cases  occur  in  young  persons — hoys 
more  commonly  than  girls — and  the  condition  is  often  discovered  acciucnl- 
ally.  The  urine,  as  a  rule,  contains  only  a  very  small  quantity  of  alhii- 
nuMi,  but  in  some  instances  large  quantities  are  present.  The  most  strik- 
ing feature  is  the  variability.  It  may  be  absent  in  tlie  morning  and  only 
present  after  exertion,  or  it  may  be  greatly  increased  after  tukiiiir  food. 
particularly  proteids.  The  quantity  of  urine  may  be  but  little  if  at  all  in- 
creased, the  specific  gravity  is  usually  nornud,  and  the  color  may  In'  hii:li. 
Occasionally,  hyaline  casts  may  be  found,  and  in  some  instances  tliciv 
has  been  transient  glycosuria.  As  a  rule,  the  pulse  is  not  of  high  tension 
and  the  second  aortic  sound  is  not  accentuated. 

Various  forms  of  this  affection  have  been  recognized  by  writers,  sudi 
as  JU'urotic,  dietetic,  cyclic,  intermittent,  and  ])aroxysmal — names  which 
indicate  the  characters  of  the  different  varieties.  A  large  jjropoitinn  of 
the  case's  get  well  after  the  ccmdition  has  ))ersisted  for  a  variable  perioii. 
This  in  itsilf  is  an  evidence  that  the  changes,  whatever  their  nature. 
were  tran.-ieiit  and  slight.  In  tliese  instances  the  albumen  exists  in  small 
qua!itity,  tu})e-casts  are  not  ]>resent,  and  the  arterial  tension  is  not  in- 
creased. In  a  second  group  the  albumen  is  more  persistent,  tin' amount 
is  larger,  th(<ugh  it  may  vary  from  day  to  day,  and  the  pulse  tcn-ioii  \^ 
iiu'reased.  In  such  inst«n«'en  the  persi.stent  albuminuria  j)rohalilv  indi- 
cates actual  organic  change  in  the  kidney. 

{b)  J-'cbrile  Albuminurui.   -  Pyrexia,   by   whatever   cause   iirndiiceil, 


ANOMALIES  OP  TOE  URINARY  SECRETION. 


727 


mav  cauae  slight  albumiiiuria.  Tlio  presence  of  the  albumen  is  due  to 
slifjlit  changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swell- 
iiijr,  which  cannot  be  regarded  as  an  orgunic  lesion.  It  is  extremely 
(■(irmiion,  occurring  in  pneumonia,  dipbtheria,  typhoid  fever,  and  even  in 
tlu'  ft'ver  of  acute  tonsillitis.  The  amount  of  albumen  is  slight,  and  it 
usiiiilly  disappears  from  the  urine  with  the  cessation  of  the  fever. 

(/•)  Hwmii'  ChanijeH. — Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukaemia,  and  profound  anivmia  may  be  associated  with 
slij^lit  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as  bile- 
j)ii,Muout  and  sugar,  may  cause  the  i)assage  of  small  amounts  of  albu- 
men. 

The  transient  albuminuria  of  jiregrumcy  may  belong  to  this  haemic 
group,  although  in  a  majority  of  sucli  cases  there  are  changes  in  tlio  renal 
tissue.  Albumen  maybe  found  sometimes  after  the  inhalation  of  ether  or 
chliu-oform. 

[d)  Albuminuria  occurs  in  certiiin  affections  of  the  nervous  fti/stem. 
This  so-called  neurotic  albuminuria  is  seen  after  an  epileptic,  seizure  and 
in  apoplexy,  tetanus,  exophthalmic  goitre,  and  injuries  of  the  head. 

Albuminuria  with  Definite  Lesions  of  the  Urinary  Organs.— (^0  Con- 
{restioti  of  the  kidney,  either  active,  sudi  as  follows  exposure  to  cold  and 
is  associated  with  the  early  stages  of  nephritis,  or  passive,  due  to  obstructed 
outilow  in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins 
l)y  tiu'  ])regnant  uterus  or  tumors. 

(//)  Organic  disease  of  the  kidneys — acute  and  chronic  Bright's  disease, 
aniy'oid  and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

(r)  Affections  of  the  pelvis,  ureters,  and  bladder,  when  associated  with 
the  t'orination  of  pus. 

Tests  for  Albumen. — Hoth  morning  and  evening  urine  should  be 
cxauiiiu'd,  and  in  doubtful  cases  at  least  three  sjiecimens.  If  turbid,  the 
urine  siiould  be  filtered,  though  turbidity  from  the  urates  is  of  no  moment, 
since  it  disappears  at  once  on  the  application  of  heat. 

H'lif  and  Xitric-dcid  Test. — The  urine  is  boiled  in  a  test-tube  over  a 
spirit-latu}),  ar.d  a  drop  of  nitric  acid  is  then  added.  If  a  cloudiness  occurs 
(wi  hoiliiig,  it  may  be  due  to  phosphates,  which  are  dissolved  on  the  addition 
of  an  acid.     Persistence  of  the  cloudiness  indicates  albumen. 

Jfillrr\<<  Trsf. — A  small  quantity  of  fuming  nitric  acid  is  poured  into  the 
test-tuhe,  and  with  a  pipette  the  urine  is  allowed  to  flow  gently  down  the 
Mv  upon  the  acid.  At  the  line  of  junction  of  the  tw(»  fluids,  if  albumen 
is  presei>t,  a  white  ring  is  formed.  This  contact  method  is  trustworthy, 
and,  {<tY  flio  routine  clinical  work,  is  probai)ly  the  most  satisfactory.  A 
iliiTused  haze,  due  to  mucin,  is  sometinu'S  .seen  just  above  the  white  ring 
•if  ailiumcu.  A  colored  ring  at  the  junction  of  the  acid  aiul  the  urine;  is 
'lilt'  to  I  ho  oxidation  of  the  coloring  matters  in  the  urine. 

^ir  William  Roberts  strongly  recommends  the  maf/nesium-ni/n'c  test. 
•^hie  Volume  of  strong  nitric  acid  is  mi.xed  with  five  volumes  of  the  saturated 


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728 


DISEASES  OP  THE  KIDNEYS. 


Boliition  of  sulphiito  of  niagjiosium.     This  is  usod  in  tho  sumo  wuy  as  (lie 
nitric  acid  in  J  Idler's  tost. 

l*icri(!  acid,  introduced  by  (icorj^o  Johnson,  is  a  delicate  and  \\-iU\\ 
t«st  for  albumen.  A  saturated  solution  is  used  and  em|)loyed  as  in  th,. 
contact  method.  It  has  been  urfjed  a<?ainst  this  test  that  it  throws  dnwn 
the  mucin,  ])ei)tones,  and  certain  vegetable  alkaloids,  but  these  are  dissolved 
by  heat. 

For  minute  traces  of  albumen  tho  trichlora(!ctic  acid  may  b((  used,  or 
Millard's  liuid,  which  is  extremely  delicate  and  ccmsists  of  glacial  i  iirljolic 
acid  (ninety-five  per  cent),  2  drachms ;  })uro  ucetic  acid,  7  drachms ;  Ijiiuor 
potassa?,  2  ounces  G  drachms. 

A  ((uantitative  estinuite  of  tho  albumen  can  l)e  made  by  me.iiis  nf  Hs- 
bacdi's  tube,  but  the  rough  method  of  heating  ajid  boiling  a  certain  <juiiiititv 
of  acidulated  urino  in  a  test-tube  and  allowing  it  to  stand,  is  often  ciii- 
ployed.  The  deptli  of  deposit  can  then  be  compared  with  tlie  whole 
amount  of  urine,  and  tho  proportion  is  expressed  as  a  mere  tra(!e,  almost 
Bolid,  one  fourth,  one  half,  and  so  on.  Tins,  of  course,  does  not  give  an 
ac(nirate  indication  of  the  proportion  of  albumen  in  the  total  (piantity  of 
urine.  For  tho  moro  elaborate  metliods  the  reader  is  referred  to  the  works 
on  I'.riiuilysis. 

The  above  tests  refer  entirely  to  serum  albumen.  Otlier  all)uniiiii)iis 
substances  occur,  such  as  serum  globulin,  peptones,  and  hemialbumosc.  \\\ 
saturating  the  urine  with  magnesium  sulphate,  the  globulin  is  precipitated, 
coagulated,  and  then  readily  separated  from  the  serum  albunu'u. 

Traces  of  peptonen  aro  found  in  the  urine  in  many  acute  diseases  ami 
in  chronic  suppuration.  They  are  not  precipitated  by  heat  or  nitric  acid, 
but  are  thrown  down  by  picric  acid  ami  dissolved  by  heat.  Jf  iiic  iiriiio 
contains  peptones,  a  rose  or  pinkish  tint  is  formed  at  the  junction  of  the 
two  fluids  M'hen  urine  is  allowed  to  flow  gently  into  a  test-tube  coiituiiiiiii,' 
Fehling's  solution.     Peptonuria  has  no  clinical  significance. 

Propej)ton,  or  liemialbumose,  is  not  of  any  j)ractical  importance  It 
was  found  by  Bonco-Jones  in  the  urine  in  osteomalacia,  and  occnrs  oe- 
c)usi(tnally  in  other  afrections. 

Prognosis. — This  depends,  of  course,  entirely  upon  the  cause.  IV- 
brilo  albuminuria  is  transient,  and  in  a  majority  of  the  cases  depending,' 
upon  ha'mic  causes  tho  condition  disappears  and  leaves  the  kidtu ys  iu- 
tjv(!t.  An  occasional  trace  of  albumen  in  a  num  over  forty,  with  nr  witli- 
out  a  few  hyaliiu?  casts,  and  with  increased  tension  and  thick  vessel  walls, 
usually  indicates  (diang'S  in  the  kidneys.  'I'he  persistence  of  a  slight 
amount  of  albumen  in  young  men  without  increased  arterial  tension  is 
loss  serious  as  even  after  continuing  for  years  it  may  disappear.  1  have 
already  s[)()ken  of  the  outlook  in  the  so-called  cyclic  albuminuria. 

I'ractiitally  in  all  (miscs  tlu!  presence  of  albumen  indicates  a  eliaiigo  <ii 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  whicii  if  '^ 
dillicult  to  estimate,  so  tliat  other  considerations,  such  us  the  presence  'h 


ANOMAl.IKS  OF   TIIK   lUINAIlY   SKCIIKTION. 


789 


tul)e-cnsts,  tlio  existence  of  increased  tension,  the  general  condition  of  the 
jiiiticnt,  and  the  iniliicncc  of  di<;estion  upon  the  albumen,  must  be  (we- 
fully  considered. 

The  physician  is  daily  consulted  as  to  the  relati<in  of  albuminuria  and 
WU'  assurance.  As  his  function  is  to  protect  tiie  interests  of  the  company, 
lie  sliould  reject  all  cases  in  whicli  ali)umcn  occurs  in  tlu^  urine.  It  is 
even  doubtful  if  an  exception  shouhl  be  nuith'  in  youiii^  jti-rsons  with 
transient  albuminuria.  Naturally,  companies  lay  j^rcat  stress  upon  the 
jinsi'nce  or  al)sence  of  albumen,  but  in  the  most  serious  and  i'atid  malady 
with  which  they  have  to  deal,  chronic  interstitial  nephritis,  the  albumen  is 
oftei\  absent  or  transient,  even  when  the  disease  is  well  developed.  After 
the  fortieth  year,  from  a  standpoint  of  life  insurance,  the  state  of  the 
arteries  is  fur  more  important  than  the  condition  of  the  urine. 


IV,  Pvi'Ul.v  (/V/.v  in  the  Urine). 

Causes. — (1)  PyeUtix  and  Pi/clntirphritis. — In  larjje  abscesses  nf  the 
kidney,  ])yonephrosis,  the  pus  may  be  intermittent,  and  for  (hiys  or  even 
w('(iks  the  urino  is  free.  In  calculous  aiul  tuberculous  pyelitis  the  i)yuriH 
is  usually  continu(ms,  though  varying  in  intensity.  In  these  cases,  as  u 
rule,  the  pus  is  mixed  with  the  urine,  which  is  acid  in  reaction.  In  the 
I'iirly  stages  of  pyelitis  the  transitional  epithelium  nuiy  be  abuiulant,  but 
is  not  in  any  way  distinctive.  In  the  pyelitis  aiul  jnelonephritis  following 
cystitis  the  urine  is  usually  alkaliiu',  and  contains  more  mucus  ;  micturi- 
tion is  usually  more  frequent,  ami  the  history  })oints  to  a  previous  bladder. 
alTt'ctioii. 

('I)  <li/sfi(t's. — The  urine  is  alkaline,  often  fetid,  the  pus  rojjy,  ami 
tilt'  amount  of  urine  greatly  increased.  'J'he  ropy,  thick  mucus  usually 
I'onu'S  with  the  last  i)ortions  of  the  urine.  1'riple  ph()s])hate  crystals  may 
1)0  present  in  the  fresldy  passed  urine. 

('■'))  Crcfhri/is,  particularly  gonorrluea.  The  pus  apjunirs  first,  is  in 
small  (|iiantities,  aiul  there  are  signs  of  local  inllammation. 

(4)  In  leucort'hoea  the  fpumtity  of  jms  is  usually  snudl,  aiul  large  flakes 
of  vairinal  epithelium  are  numerous.  In  doubtful  cases,  when  leucorrluBa 
is  iircsfiil,  the  urine  should  be  withdrawn  by  a  catheter. 

(.\)  Rupture  of  Abscesses  into  the  Urinary  Pitssiujes. — In  such  cases 
as  iMJvic  or  perityphlitic  abscess  there  have  been  previous  symptoms  of 
pi.'s  fornuition.  A  large  amount  is  jiassed  within  a  short  time,  then  the 
'lisdiarge  stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

I'ns  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On 
settling  there  is  a  heavy  grayish  sediment,  and  the  superiuitant  lluid  is 
usually  turbid.  The  sediment  is  often  tenacious  and  ro])y.  The  reaction 
'•*  K'''i>'rally  alkaline,  and  the  odor  nuiy  be  anuiH)nia('al  even  when  passed, 
r-xatniiuition  with  the  microscope  rOveals  the  presence  of  a  large  number 
of  pus-corpuscles,  which  are  usually,  when  the  pus  comes  from  the  blad- 


'1 

•\. 


R  t 


t  ,  ,t 


*\\ 


:*    .\ 


730 


DISEASES  OF  THE   KIDNEYS. 


der,  well  formed ;  the  protoplasm  is  {jnuiuliir,  and  often  hIiows  niiinv 
trunslueeiit  processes. 

The  oidj'  sediment  likely  to  bo  eotifoniided  with  pun  is  that  of  the 
phosphates;  but  it  is  whiter  and  less  dense,  and  is  distiiiffuishcd  iiiiiiicdi. 
utely  by  niieroscopical  examination. 

With  tiie  pus  there  is  always  more  or  less  epithelium  from  []\{>  lilaiMcr 
and  i)elvis,  but  since  in  these  situations  the  forms  of  (^ells  are  jJracticilK 
identical,  they  alTord  no  infornuition  as  to  tho  locality  from  whi(!h  liic  )mis 
hjis  come. 

Tho  treatment  of  ]tus  in  the  urine  is  considered  under  tho  conditions 
in  which  it  occurs. 

V.   ClIYLURIA — XON-PAUASITIO. 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassoci- 
ated  with  tho  Jilarin  hominin  sanguinis.  The  urine  is  of  an  o])a(|ue  white 
color;  it  resembles  milk  closely,  is  occasionally  mixed  with  blood  (hiiiiiutn- 
chyluria),  and  sometimes  coagulates  into  a  firm,  jelly-liko  mass.  In  other 
instances  there  is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  W 
distin(;tly  blood-tinged.  Under  the  microscope  the  turbidity  seetns  to  lie 
caused  by  numerous  minute  granules — more  rarely  oil  droi)l('ts  .siiiiihir  h> 
those  of  milk.  Traces  of  albumen  are  usually  ])resent.  The  annimit  of 
urine  passed  is  generally  increased,  and  the  chylous  condition  is  iiittTinit- 
tent.  It  nuiy  persist  for  years  without  ileterioratiou  of  health  or  evidence 
of  serious  disease. 

Since  the  discovery  of  tho  Jtlaria  hominis  mnguinis  it  has  been  incor- 
rectly held  by  some  that  all  of  tho  cases  of  chyluria  are  of  this  piirasitic 
nature.  I  had  an  opportunity  in  Montreal  of  making  a  careful  study  of  a 
French-Camidian  wonmn,  a  patient  of  J.  li.  McConnell's,  who  hud  had 
chyluria  for  more  than  thirteen  years.  Tho  urine  was  (piite  milky  in 
color  aiul  occasionally  mixed  with  blood.  Neither  ova  nor  endiryos  were 
found  in  tho  urine  or  in  tho  blood  examined  at  night.  After  her  death 
I  was  enabled  to  make  a  thorough  dissection  of  the  abdominal  lyiii|ih 
vessels,  which  were  found  perfectly  normal.  'J'he  thoracic  duct  was  not 
enlarged,  the  renal  lymphatics  were  not  distended ;  the  kidneys  were  in- 
creased in  size,  but  showed  no  special  changes.  The  most  careful  exami- 
nation of  the  lymph  glands  and  vessels  failed  to  reveal  the  presence  of 
parasites. 

The  pathology  of  the  C(mdition  is  unknown.  No  known  remedies  have 
any  intluence  upon  the  chyluria. 

(For  para.sitic  chyluria  see  Filariasis.) 

VI.  LiTiiuuiA  {Lilhwmia ;  Lithic-acid  Diathesis). 

Tho  amount  of  uric  acid  excreted  daily  depends  greatly  upon  the  liiet. 
ringing  from  half  a  gramme  on  a  vegetable  to  as  high,  oven,  as  twe 


ANOMALIES  OF  THE  URINARY  SECRETION. 


(31 


W8  niiinv 


gnunmcs  on  an  animal  (Vwi.  In  the  urine  of  hcrhivora  it  occurs  only  in 
truces.  In  that  of  caruivora  it  nuiy  bo  abHcnt  alt(tj,'ctlu'r.  On  the  <ither 
hiiiiil,  in  the  urine  of  hirdn  and  reptiles  it  is  the  chief  nitr()<,'enous  iiifj^re- 
dicut.  As  Sir  William  Hoherts  reuuirks,  its  ])rescnce  in  the  human  urine 
is  somewhat  of  an  anomaly,  as  its  place  is  very  much  better  taken  by  urea, 
which  is  easily  solublu  and  better  ada[)ted  to  the  nuimmalian  plan  of  a 
li<|uid  urine.     He  re<;ards  it  as  a  sort  (tf  vestipfial  remnant, 

I'lurr  (Dili  Mode  of  Formation  of  tho  I'rie  Arid. —  It  is  n(  w  very  jjen- 
oniUy  conceded  that  uric  acid  is  formed  in  the  tissues  ami  excieted  by  tho 
kidneys.  It  may  occur  in  traces  in  the  blood  even  in  healtii.  Von  Jaksch, 
who  has  recently  examined  tho  blood  of  109  individmils,  found  no  trace  in 
'.»  healthy  jK'rsons,  nor  was  it  present  in  cases  of  ty])hoid  fever  or  in  lu'rv- 
oiis  alTections  or  in  diseases  of  the  liver  atul  j^astro-intestinal  canal,  except 
when  anaMuia  coexisted.  On  the  other  hand,  it  was  presejit  in  connection 
with  all  those  diseased  processes  in  which  oxidation  was  disturbed,  either 
directly,  as  in  alTections  of  the  lungs,  su(;h  as  ])iunimonia,  or  indirectly,  as 
in  iiiiiemia,  in  which  the  oxygen-carriers  are  deticicut.  According  to 
lliiiir,  the  amount  in  the  blood  rises  and  falls  with  the  degree  of  alkalinity 
(as  HKire  is  held  in  solution),  and  all  circumstances  which  increase  tliis  are 
associated  with  an  increase  in  the  amount  of  uric  acid. 

As  to  the  i)lace  of  formation,  the  experimental  evidence  points  strongly 
to  tile  liver,  ami,  according  to  Minkowski,  it  is  formed  there  by  the  synthe- 
sis of  aiiunonia  and  lactic  acid.  1'he  viinvs,  however,  as  to  its  place  of 
liroiliiction  and  the  antecedents  are  by  no  means  harm(mious.  (iarrod 
still  holds  that  the  kidneys  are  concerned  not  only  with  its  excretion,  but 
with  its  fonnation.  On  the  other  hand,  P^bstein  thinks  that  it  is  chiefly 
Itroduced  in  the  nmsdes  and  in  the  bone  nuirrow.  Nor  is  it  yet  settled 
whether  uric  acid  is  only  an  intermediate  step  in  the  fornuition  of  urea  or 
whether  it  has  an  independetit  origin. 

Mdi/c  of  /'JliiiiiiKi/ioii. — Trie  acid  is  extremely  insoluble,  a  gramme  re- 
'liiiriiig  for  its  solution.,  at  ordinary  temperature,  fourteen  litres  of  water, 
and  about  half  that  amount  at  body  temperature.  In  the  \J>()0  to  2,000 
c.  c.  of  urine  passed  in  the  day  the  uric  acid  could  not  be  disscdved,  but  it 
is  eliiiiinated  in  cond)iruition  as  soluble  salts,  chiefly  as  urates  of  ammoniuni 
and  sodium.  The  power  in  the  blood  of  hohling  the  uric  acid  in  soltition 
depends  ui)on  the  degree  of  alkalinity;  thus  it  has  been  long  kiutwn  that 
the  excretion  of  uric  acid  some  hours  after  breakfast  is  high.  This  is  in 
what  Sir  William  Roberts  calls  "the  alkaline  tide."  llii.g  has  shown  that 
this  excretion  can  bo  increased  or  diminished  by  increasing  or  diminishing 
the  alkalinity  of  the  blood ;  thus,  under  .salicylate  of  soda,  given  in  fifteen 
irrain  doses  three  times  a  day,  the  excretion  of  the  uric  acid  is  increased 
"11  the  first  and  second  days,  and  subsequently  falls  to  tho  normal  amount. 
He  explains  t  lia  by  supposing  that  the  salicylate  finds  a  considerable 
'|iiantity  of  uric  acid  .itored  in  the  liver,  spleen,  and  other  tissues,  gets  this 
into  solution,  and  the  greater  part  of  it  is  passed  in  the  urine.     11  is  obser- 


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Photogrdphic 

Sciences 

Corporation 


33  WEST  MAIN  STREET 

WEB.TER,N.Y.  M5B0 

(716)  •72-4503 


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DISEASES  OF  THE  KIDNEYS. 


vations  indicate  that  alkalies,  such  as  the  phosphate  of  soda  and  cnt- 
pounds  of  salicylic  acid,  increase  markedly  the  excretion  of  this  injured  lent 
in  the  urine,  and  also  increase  the  amount  of  it  in  the  blood,  withdrawing 
it  from  the  spleen  and  liver.  On  the  other  hand,  acids,  lead,  and  iron  in- 
terfere with  the  solubility  of  the  uric  acid  and  with  its  elimination.  A  fact 
of  great  practical  importance  which  he  mentions  is  that  lithia,  "  tIiou,<;li  a 
beautiful  solvent  of  uric  acid  in  a  test-tube,  yet  when  given  to  the  luiniun 
subject  by  mouth  never  reaches  the  uric  acid  at  all,  because  it  at  otice 
forms  an  insoluble  compound  with  the  phosphate  of  soda  in  the  1)100(1, 
thus  removing  from  that  fluid  one  of  the  natural  solvents  of  uric  acid, 
and  diminishing  its  power  of  holding  uric  acid  in  solution."  This  is 
directly  opposed  to  the  prevalent  ideas  of  the  value  of  the  lithia  compounds 
in  the  uric-acid  diathesis. 

The  pathology  of  uric  acid  is  more  a  matter  of  defective  elimiiuition 
than  of  excessive  formation.  In  conditions  of  the  system  associated  with 
persistent  diminished  alkalinity  of  the  blood  the  uric  acid  accumulates  in 
the  liver,  spleen,  and  the  joints.  The  degree  of  alkalinity  of  the  kidney 
structure  possibly,  as  Ilaig  suggests,  may  have  an  influence  in  determin- 
ing how  much  shall  be  excreted  and  how  much  retained,  and,  according  to 
his  views,  it  is  this  small  remnant  or  overflow  which  accumulates  in  the 
blood  and  produces  headache,  high  tension  of  the  pulse,  and  mental  de- 
pression, and  when  dejicsited  in  the  joints  causes  gouty  arthritis  and  the 
uratic  lesions. 

Occurrence  in  the  Urine. — The  uric  acid  occurs  in  combination  ehief.y 
with  ammonium  and  sodium,  forming  the  acid  urates.  In  smaller  (juan- 
tities  are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may 
be  separated  from  its  bases  and  crystallizes  in  rhombs  or  prisms,  wliich 
are  usually  of  a  deep  red  color,  owing  to  the  staining  of  the  urinary  pig- 
ments. The  sediment  formed  is  granular  and  the  groups  of  crystals  look 
like  grains  of  Cayenne  pepper.  It  is  very  important  not  to  mistake  a  de- 
posit of  uric  acid  for  an  excess.  1'he  deposition  of  numerous  grains  in 
the  urine  within  a  few  hours  after  passing  is  more  likely  to  be  due  to  con- 
ditions which  diminish  the  solvent  power  than  to  increase  in  the  quantity. 
Of  the  conditions  which  cause  precipitation  of  the  uric  acid  Roberts  gives 
the  following :  "(1)  High  acidity;  (2)  poverty  in  mineral  salts ;  (;])  low 
pigmentation;  and  (4)  high  percentage  of  uric  acid."  The  grade  of 
acidity  is  probably  the  most  important  element. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the 
so-called  brick-dust  or  lateritious  deposit,  M'hich  has  a  pinkish  color,  due 
to  the  presence  of  urin.iry  pigment.  It  is  composed  chiefly  of  the  acid 
sodium  urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  si)e('ifie 
gravity.  As  the  urates  are  more  soluble  in  warm  solutions  they  fre(juently 
deposit  as  the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily, 
indeed  usually  does  not,  mean  an  excessive  excretion,  but  the  existence  ot 
conditions  favoring  the  deposit. 


ANOMALIES  OP  THE   CRINARY  SECRETION. 


733 


Murchison  introduced  the  term  litlia;mia  to  designate  certain  symptoms 
due,  as  he  supposed,  to  functional  disturbance  of  the  liver.  Not  only  have 
liis  views  been  widely  adopted,  but,  as  is  so  often  the  case  when  we  give 
the  rein  to  theoretical  conceptions  of  disease,  the  so-called  manifestatLons 
of  this  state  have  so  multiplied  that  some  authors  attribute  to  this  cause  a 
considerable  proportion  of  die  ailments  affecting  the  various  systems  of  the 
body.  Thus  one  writer  enumerates  not  fewer  then  thirty-nine  separate 
morbid  conditions  associated  with  lithaimia.  From  what  has  been  said  as 
to  our  knowledge,  or  rather  our  lack  of  knowledge,  of  the  mode  of  forma- 
tion and  elimination  of  uric  acid  it  is  very  evident  that  the  physiology  of 
the  subject  must  be  widely  extended  before  we  are  in  a  position  to  draw 
safe  conclusions.  Thus  it  is  by  no  means  sure  that,  as  Murchison  sup- 
posed, the  essential  defect  is  in  a  functional  disorder  of  the  liver,  disturb- 
ing the  metabolism  of  the  albuminous  ingredients,  nor  is  it  at  all  certain 
that  the  only  offending  substance  is  uric  acid.  Bouchard  contends  that 
the  so-called  lithiasis  has  little  or  nothing  to  do  with  disturbance  in  the 
function  of  the  liver,  and  that  it  has  not  been  shown  that  uric  acid  is  the 
only  or  even  the  chief  agent  in  producing  tiie  symptoms.  In  the  present 
imperfect  state  of  knowledge  it  is  impossible  with  any  clearness  to  dufine 
the  pathology  of  the  so-called  uric-acid  diathesis.  We  may  say  that  cer- 
tain symptoms  arise  in  connection  with  defective  food  or  tissue  metabolism, 
more  particularly  of  the  nitrogenous  elements.  Deficient  oxidation  is 
probably  the  most  essential  factor  in  the  process,  with  the  result  of  the 
formation  of  less  readily  soluble  and  less  readily  eliminated  jiroducts  of 
retrograde  metamorphosis.  This  faulty  metabolism  if  long  continued 
may  load  to  gout,  with  uratic  deposits  in  the  joints,  acute  inflammations, 
and  arterial  and  renal  disease.  In  a  largo  group  of  cases  the  disturbed 
mctiiljolism  produces  high  tension  in  the  arteries  (probably  as  a  direct 
sequence  of  interference  with  the  capillary  circulation)  and  ultimately 
degenerations  in  various  tissues,  particularly  the  scleroses. 

Overeating  and  overdrinking,  when  combined  with  deficient  muscular 
exercise,  lie  at  the  basis  of  this  nutritional  disturbance.  The  symptoms 
which  are  believed  to  characterize  the  uric-acid  diathesis  have  already 
been  briefly  considered  under  the  section  on  irregular  gout,  and  the  ques- 
tion of  diet  and  exercise  has  also  been  there  considered. 


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VII.     OXALURIA. 

Oxalic  acid  occurs  in  the  mine,  in  combination  with  limo,  forming  an 
oxalate  which  is  held  in  solution  by  the  acid  phosphate  of  soda.  About 
.01  to  M  gramme  is  excreted  in  the  day.  It  never  forms  a  heavy  deposit, 
but  the  crystals— usually  octahedra,  rarely  dumb-bell-shaped— collect  in  the 
mucus-cloud  and  on  the  sides  of  the  vessel.  The  amount  varies  extremely 
witli  the  diet,  and  it  is  increased  I-.rgely  when  such  fruits  and  vegetables 
as  tomatoes  and  rhubarb  are  taken.     It  is  also  a  product  of  incomplete  oxi- 


II      .11. rhX 


It  wm 


134 


DISEASES  OF  THE  KIDNEYS. 


dation  of  the  organic  substances  in  the  body,  and  in  conditions  of  increased 
metabolism  the  amount  in  the  urine  becomes  larger.  It  is  stated  also  to 
result  from  the  acid  fermentation  of  the  mucus  in  the  urinary  passages 
and  the  crystals  are  usually  abundant  in  sperrtiatorrhcea. 

When  in  excess  and  present  for  any  considerable  time,  the  condition  is 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crvs- 
tals  may  be  deposited  before  the  urine  if  voided,  and  form  a  calculus. 
It  is  held  by  many  that  there  is  a  special  diathesis  associated  with 
this  state  and  manifested  clinically  by  dyf.pepsia,  particularly  the  nervous 
form,  irritability,  depression  of  spirits,  lassitude,  and  sometimes  marlvcd 
hypochondriasis.  There  may  be  in  addition  neuralgic  pains  and  the  gen- 
eral symptoms  of  neurasthenia.  The  local  and  general  symptoms  are 
probably  dependent  upon  some  disturbance  of  metabolism  of  which  the 
oxaluria  is  one  of  the  manifestation!^  It  is  a  feature  also  in  many  gouty 
persons,  and  in  the  condition  called  lithaimia, 

VIII.  Cystikuria. 

Cystin  does  not  occur  in  normal  urine.  It  is  very  rarely  met  with,  and 
its  chief  interest  is  owing  to  the  fact  that  it  may  form  a  calculus.  It* 
presence  in  tho  urine  has  been  determined  in  many  members  of  the  same 
family,  and  the  condition  appears  sometimes  to  be  hereditary.  As  it  con- 
tains sulphur,  it  is  thought  to  be  formed  from  the  taurin  of  the  bile. 

IX.  Phosphaturia. 

The  phosphoric  acid  is  excreted  from  the  body  in  combination  with 
potassium,  sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alka- 
line phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  of 
lime  and  magnesia.  '■'■The  alkaline  phosphates  exist  in  the  blood  in  the 
form  of  neutral  sodium  and  potassium  phosphates  (hydrogen-di.-odiuni 
phosphates,  IINa^PO^),  but  appear  in  the  urine  as  acid  sodium  and  jio- 
tassium  phosphates  (dihydrogen-sodium  phosphates,  H,!N'aP()J,  ami 
thus  cause  the  acid  reaction  of  that  secretion.  The  change  of  the  neutral 
into  the  acid  salt  is  caused  by  the  decomposition  effected  by  the  act  of 
secretion,  in  which  the  bicarbonates  and  neutral  phosphates  in  the  hlood 
change  into  carbonates  and  acid  phosphates  respectively."     (Ralfo.) 

Of  the  earthy  phosphates,  those  of  lime  are  abundant,  of  magiie^imn 
scanty.  In  urine  which  has  undergone  the  ammoniacal  fermentatidii, 
either  inside  or  outside  the  body,  there  is  in  addition  the  aiuiiioiiid- 
magnesiuui  or  triple  phosphate,  which  occurs  in  triangular  prisms  or  in 
feathefy  or  stellate  crystals,  hence  the  term  given  to  this  form  of  stellai- 
phosphates.  The  earthy  phosphates  occur  as  a  sediment  in  the  urine 
when  the  alkalinity  is  due  to  a  fixed  alkali,  or  under  certain  circumstances 
the  deposit  may  take  place  within  the  bladder,  and  then  the  plins[)liate3 
are  passed  at  the  end  of  micturition  as  a  whitish  fluid,  which  is  popularly 


ANOMALIES  OP  THE  URINARY  SECRETION. 


735 


confounded  with  spermatorrhooa.  The  calcium  ph:)sphate  may  be  pre- 
cipitated by  heat  and  produce  a  cloudiness  which  maybe  mistaken  for  albu- 
men, but  is  at  once  dissolved  upon  making  the  urine  acid.  This  condition 
is  very  frequent  in  persons  suffering  from  dyspepsia  or  from  debility  of  any 
kind.  The  phosphates  may  be  in  great  excess,  rising  in  the  twenty-four 
hours  to  from  7  to  9  grammes  (Tessier),  whereas  the  normal  amount  is  not 
iiiore  than  2 "5  grammes.  And,  lastly,  tbe  phosphates  may  be  deposited  in 
urine  which  has  undergone  decomposition,  in  which  the  carbonate  of  am- 
monia from  the  urea  combines  with  the  magnesium  phosphates,  forming 
the  tri]tie  salt.  This  is  son  iu  cystitis,  and  is  duo  to  the  introduction  of 
a  bacterial  ferment. 

The  clinical  significance  of  an  excess  of  phosphates,  to  which  the  term 
piiospliaturia  is  a;  'ied,  has  been  much  discussed.  It  must  be  remem- 
bered that  a  deposit  does  not  necessarily  mean  an  excess,  to  determine 
which  a  careful  analysis  of  the  twenty-four  hours'  secretion  should  be 
made.  It  has  long  been  thought  that  there  is  a  relation  between  the  ac- 
tivity of  the  nerve-tissues  and  the  output  of  phosphoric  acid ;  but  the 
question  cannot  yet  be  considered  settled.  The  amount  is  increased  in 
viisting  diseases,  such  as  jihthisis,  acute  yellow  atrophy  of  the  liver,  leu- 
kiiMuiii,  and  severe  anoBmia,  whereas  it  is  diminished  in  acute  diseases  and 
during  pregnancy. 

In  a  condition  termed  by  Tessier,  Ralfe,  and  others  phosphatic  dia- 
betes tliere  is  polyuria,  thirst,  emaciation,  and  a  great  increase  in  the 
excretion  of  phosphates,  which  may  be  as  much  as  from  seven  to  nine 
grammes  in  the  day.  The  urine  is  usually  acid,  free  from  sugar,  the  patients 
are  nervous ;  in  some  instances  sugar  has  been  present  in  the  urine,  and 
iu  others  it  subsequently  makes  its  appearance. 


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X.  Indicanuuia. 


The  substance  in  the  urine  which  has  received  this  name  is  the  indoxyl- 
sulpluite  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  agents  are  added  to 
tlie  urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is 
present  only  in  small  quantities  in  healthy  urine.  It  is  derived  from  the 
indol,  a  product  formed  in  the  small  intestine  by  the  decomposition  of  the 
albumen  under  the  influence  of  bacteria.  When  absorbed,  this  is  oxidized 
in  the  tissues  to  indoxyl,  which  combines  with  the  potassium  sul})hate, 
forming  the  above-named  substance. 

'I'lie  quantity  of  indican  is  increased  on  a  milk  diet,  in  all  wasting 
uiscases,  and  whenever  any  large  quantities  of  albuminous  substances  are 
undergoing  rapid  decomposition,  as  in  the  severer  forms  of  peritonitis  and 
enipyenia.  It  is  met  with  also  in  prolonged  constipation  and  in  ileus. 
Indican  has  occasionally  been  found  in  calculi.  Though,  as  a  rule,  the 
uriue  is  colorless  when  passed,  there  are  instances  in  which  the  decompo- 


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736 


DISEASES  OP  THE  KIDNEYS. 


Bition  has  taken  place  within  the  body,  and  a  bhie  color  has  been  noticod 
immediately  after  the  i;rine  was  voided.  Sometimes,  too,  in  alkaline 
urine  on  exposure  there  is  a  bluish  film  on  the  surface. 

To  test  for  indican,  place  four  or  five  c.  c.  of  nitric  or  hydrochloric 
acid  in  a  test-tube;  boil,  anu  add  an  equal  quantity  of  urine.  A  bluish 
ring  develops  at  the  point  of  contact.  Add  ten  c.  c.  of  chloroform  and 
shake  the  test-tube,  and  on  separation  the  chloroform  has  a  violet  or 
bluish  color  due  to  the  presence  of  indican. 


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XI.  Mklanuria. 

In  melanotic  cancer  the  urine,  either  at  the  time  of  voiding  or  after 
exposure  to  the  air,  may  present  a  dark  color.  Tliis  pigment  is  known  as 
melanin,  and  it  may  occur  in  solution  or  in  the  form  of  small  gramik's. 
The  urine  may  be  voided  clear,  and  subsequently,  on  exposure  to  the  uir 
or  on  the  addition  of  oxidizing  substances,  becomes  dark.  In  these  cases 
it  contains  a  chromogen  called  melanogen  which  turns  dark  by  oxidation. 
Von  Jaksch  has  found  that  "  in  urine  containing  melanin  or  its  precursor, 
melanogen,  Prussian  blue  is  formed  by  adding  a  nitropruss'.de,  aqueous 
potash,  and  an  acid.  This  reaction,  however,  does  not  seem  to  depend  on 
the  presence  of  melanin,  as  it  is  not  given  by  that  substance  when  sep- 
arated from  the  urine,  but  apparently  by  some  other  at  present  unknown 
substance,  which  is  present  in  traces  in  normal  urine  and  is  increased  in 
cases  of  melanuria,  and  also  in  those  conditions  where  excess  of  indigo 
occurs  in  the  urine."     (Ualliburton.) 

XII.  Other  Substances. 

Fat  in  the  urine,  or  liptiria,  occurs,  according  to  Halliburton,  first, 
without  disease  of  the  kidneys,  as  in  excess  of  fat  in  the  food,  after  tlie  ad- 
ministration of  cod-liver  oil,  in  fat  embolism  occurring  after  fractures,  in  the 
fatty  degeneration  in  phosphorus  poisoning,  in  prolonged  suppuration  as  in 
phthisis  and  pyasmia,  in  the  lipaemia  of  diabetes  mellitus ;  secondly,  with 
disease  of  the  kidneys,  as  in  the  fatty  stage  of  chronic  Bright's  disease,  in 
which  fat  casts  are  sometimes  present,  and,  according  to  Ebstein,  in  pyo- 
nephrosis ;  and,  thirdly,  in  the  affection  known  as  chyluria.  The  urine  is 
usually  turbid,  but  there  may  be  fat  drops  as  well,  and  fatty  crystals  have 
been  found. 

Lipacicluria  is  a  term  applied  by  von  Jaksch  to  the  condition  in  wliich 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  butyric,  formic, 
and  propionic. 

Acetonuria. — Von  Jaksch  distinguishes  the  following  forms  of  patho- 
logical acetonuria :  The  febrile,  the  diabetic,  the  acetonuria  with  certain 
forms  of  cancer,  the  form  associated  with  inanition,  acetonuria  in  psy- 
choses, and  the  acetonuria  which  results  from  auto-intoxication.  It  is 
doubtful,  however,  whether  the  symptoms  in  these  are  really  due  to  the 


UREMIA. 


737 


acetone.  It  may  be  tlio  substances  from  wliich  this  is  formed,  particu- 
larly the  diacetic  acid  or  the  oxybutyric  acid.  The  odor  of  the  acetone 
may  be  marked  in  the  breath  and  evident  in  the  urine.  Le  Nobel's  test 
has  been  given  in  the  section  on  diabetes. 

Diacetic  acid  is  probably  never  present  in  the  urine  in  health.  With 
a  solution  of  ferric  chloride  it  gives  a  Burgundy-red  color.  A  similar  re- 
action is  given  by  acetic,  formic,  oxybutyric  acids,  and  it  may  be  present 
in  the  urine  of  patients  who  are  taking  antipyrin,  thallin,  and  the  salicy- 
lates. "  If,  however,  the  urine  is  previously  boiled,  diacetic  acid,  if  pres- 
ent, still  gives  the  ferric-chloride  reaction,  but  these  other  substances  do 
not.  Fleischer  fouiul  that  the  substance  which  gives  the  ferric-chloride 
reaction  in  diabetic  urine  is  not  taken  up  by  ether  after  the  urine  has 
been  acidulated  with  sulphuric  acid,  Avliereas  ethyl-diacetic  acid  is  solu- 
ble in  ether."     (Ualliburton.) 

Alcapf anuria. — Aromatic  compounds  occur  in  the  urine  after  the  ad- 
ministration of  carbolic  acid  or  gallic  acid,  and  on  exposure  to  air  becomes 
dark.  In  carboluria  the  substance  causing  the  black  color  is  known  as 
hydrochinon.  Many  years  ago  Boedeker  met  with  cases  in  which  the 
urine  became  dark,  owing  to  the  presence  of  an  aromatic  compound  which 
111  '^•alled  alcapton.  It  has  been  found  in  cases  of  consumption,  and  in 
otli  -  instances  in  which  there  are  no  local  lesions  or  no  general  disease. 
The  urine  may  be  clear  on  passing,  and  then  darken  on  exposure  to  the  air, 
or  on  the  addition  of  liquor  potassaj.  The  substance  is  apparently  without 
clinical  significance  except  in  so  far  as  it,  with  the  other  aromatic  substances, 
is  capable  of  reducing  the  Fehling  solution,  and  may  be  mistaken  for  sugar. 

Choluria  and  glycosuria  have  already  been  considered  under  jaundice 
and  diabetes.* 


IV.  URyCIMIA. 

Under  this  term  is  grouped  a  series  of  manifestations,  chiefly  nervous, 
developing  in  the  course  of  Bright's  disease,  and  due  to  the  retention 
within  the  blood  of  poisonous  materials  which  should  be  eliminated  in 
the  urine. 

Uraemia  is  usually  seen  in  nephritis,  but  may  occur  when  the  ureters 
are  obstructed,  or  when  the  circulation  of  blood  in  the  kidneys  is  im- 
peded, as  in  conditions  of  extreme  engorgement  following  compression  of 
the  renal  vessels  or  in  the  profound  alterations  of  the  blood  in  cholera. 

Two  opposite  views  are  held  with  reference  to  the  production  of 
uraemia :  (a)  That  it  is  due  to  the  accumulation  in  the  blood  of  excre- 
mentitious  material— body  poisons — which  should  be  thrown  off  by  the 

*  For  further  details  concerning  the  urine  the  student  is  referred  to  von  Jaksch's 
Cliniual  T)iagnosis,  Tyson  on  the  Urine,  and  to  Halliburton's  Text-Booic  of  Chemical 
Pliysiology  and  Pathology. 


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DISEASES  OF  THE  KIDNEYS. 


kidneys.  "  If,  howcA'cr,  from  any  cause,  these  organs  make  default,  or  if 
there  be  any  prokingcd  obstruction  to  the  outllow  of  urine,  accumulution 
of  some  or  of  all  the  poisons  takes  place,  and  the  characteristic  symj)t(iiiis 
are  manifested,  buc  the  accumulation  may  be  very  slow  and  the  earlier 
symptoms,  corresponding  to  the  comparatively  small  dose  of  poison,  iiiav 
be  very  slight;  yet  they  are  in  kind,  though  not  in  degree,  as  indicative 
of  uraemia  as  are  the  more  alarming,  which  appear  towards  the  end,  and 
to  which  alone  the  name  uraemia  is  often  given."  (Carter.)  Several  poisons 
having  distinct  actions  have  been  separated  from  the  urine  by  lioiulianl, 
two  of  which  produce  convulsions,  and  one  of  which  is  narcotii;.  Hdii- 
chard's  observations  tend  strongly  to  confirm  the  view  now  generally  lielil. 
that  the  symptoms  are  caused  by  the  retention  of  the  excretory  ])ro(liiets. 
The  nature  of  these  poisonous  ingredients  is  not  yet  known.  It  was  foi'- 
merly  thought  that  the  urea  was  the  offending  substance,  and  it  has  been 
found  increased  in  the  blood  in  uraemia.  Others  hold  that  it  is  the  accu- 
mulation of  carli  juate  of  ammonia.  It  is  more  probable,  however,  that 
there  are  several  toxic  agents  at  work. 

(b)  Traube  suggested  that  the  chief  symptoms  of  uraemia,  particndurly 
the  coma  and  convulsions,  were  due  to  localized  oedema  of  the  brain.  In 
favor  of  this  view  is  the  fact  that  obstruction  of  the  ureters,  as  by  stone, 
does  not  necessarily  produce  uraemia,  even  if  long  continued,  and  in  this 
obstructive  suppression  neither  convulsions  nor  coma  occur.  Then,  too, 
uraemia  may  supervene  in  a  case  of  chronic  Bright's  disease  in  wliich  a 
large  amount  of  urine  is  being  passed  with  a  fair  proportion  of  solids. 
(Edema  of  the  brain  certainly  does  occur  in  some  fatal  cases — it  may  be 
diffuse  or  localized,  but  it  is  not  a  constant  lesion,  and  cannot  explain  all 
the  symptoms  of  uraemia. 

Symptoms. — Clinically,  acute  and  chronic  uraemia  may  be  recog- 
nized, but,  for  convenience  of  description,  it  is  perhaps  best  to  follow  the 
division  of  French  writers  into  cerebral,  dyspnosic,  and  gastro-inledinal 
forms. 

Among  the  cerebral  manifestations  of  uraemia  may  be  described : 

(rt)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has 
shown  no  previous  indications  of  mental  trouble,  and  who  may  not  be 
known  to  have  Bright's  disease.  In  a  remarknlde  case  of  this  kind  wliich 
came  under  my  observation  the  patient  became  suddenly  maniacal  and 
died  in  six  days.  More  commonly  the  delirium  is  less  violent,  but  the 
patient  is  noisy,  talkative,  restless,  and  sleepless. 

{b)  Delusional  Insanity  {Folic  Brighiique). — Cases  are  by  no  means 
uncommon,  and  excellent  clinical  reports  have  been  issued  on  the  subject 
from  several  of  the  asylums  of  this  country,  particidarly  by  Bremer, 
Christian,  and  Alice  Bennett.  Delusions  of  persecution  are  common. 
One  of  my  cases  committed  suicide  by  jumping  out  of  a  window.  The 
condition  is  of  interest  medico-legally  because  of  its  bearing  on  testa- 
mentary capacity.     Profound  melancholia  may  also  supervene. 


UREMIA. 


73D 


(r)  Cunvuhions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  ill  the  head  and  restlessness.  The  attacks  may  be  general  and  iden- 
ti(!il  with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  be 
present.  The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is 
usiKilty  unconscious.  Sometimes  the  temperature  is  elevated,  but  more 
fieiiiicntly  it  is  depressed,  and  mav  sink  rai)idly  after  the  attack.  Local 
or  Jaoksonian  epilepsy  may  occur  in  most  characteristic  form  in  uremia. 
A  remarkable  sequence  of  the  convulsions  is  blindness — uramic  amaurosis 
— wliich  may  persist  for  several  days.  This,  however,  may  occui  apart 
froin  the  convulsions.  It  usually  piisses  off  in  a  day  or  two.  There  are 
no  ophthalmoscopic  changes.  Sometimes  urajmic  deafness  supervenes, 
iind  is  probably  also  a  cerebral  manifestation.  It  may  also  occur  in 
connection  with  persistent  headache,  nausea,  and  other  gastric  symp- 
toms. 

{(})  Coma. — Unconsciousness  invariably  accompfinics  the  general  con- 
vulsions, but  a  coma  may  develop  gradually  without  any  convulsive  seiz- 
ures. Frequently  it  is  preceded  by  headache,  and  the  patient  gradually 
becomes  dull  and  apathetic.  In  these  cases  there  may  have  been  no  pre- 
vious indications  of  renal  disease,  and  unless  the  urine  is  examined  the 
nature  of  the  case  may  be  overlooked.  Twitchings  of  the  muscles  occur, 
particularly  in  the  face  and  hands,  but  there  are  many  cases  of  coma  in 
which  the  muscles  are  not  involved.  In  some  of  these  cases  a  condition 
of  torpor  persists  for  weeks  or  even  months.  The  tongue  is  usually  furred 
ami  tlio  breatli  very  foul  and  heavy. 

(*')  Local  Palsies. — In  the  course  of  chronic  Bright's  disease  hemi- 
l)logia  or  monoplegia  may  come  on  spontaneously  or  follow  a  convul- 
sion, and  post  mortem  no  gross  lesions  of  the  brain  be  found,  but  only 
a  localized  or  diffused  oedema.  These  cases,  which  are  not  very  uncom- 
mon, may  simulate  almost  every  form  of  organic  paralysis  of  cerebral 
origin. 

(/)  Of  other  cerebral  symptoms,  headache  is  important.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and 
associated  with  giddiness.  Other  nervous  symptoms  of  urtemia  are  intense 
itching  of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in 
the  mu.sclos  of  the  calves,  particularly  at  night. 

Urwmic  dyspnwa  is  classified  by  Palmer  Howard  as  follows:  (1)  Con- 
tinuous dyspnoea;  (2)  paroxysmal  dyspnani;  (3)  both  types  alternating; 
and  (4)  Oheyne-Stokes  breathing.  The  attacks  of  dyspna^a  are  most  com- 
monly nocturnal ;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as 
nuich  distress  as  in  true  asthma.  Occasionally  the  breathing  is  noisy  and 
stridulous.  The  Cheyne-Stokes  type  may  persist  for  weeks,  and  is  not 
necessarily  associated  with  coma.  I  have  seen  it  in  a  man  who  travelled 
over  a  hundred  miles  to  consult  a  physician.  In  another  instance  a  pa- 
tient, up  and  about,  could  only  when  at  meals  feed  himself  in  the  apnoea 
period.  Though  usually  of  serious  omen  and  occurring  with  coma  and 
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(illier  symptoms,  recovery  may  follow  even  aftor  persistciico  for  weeks  or 
even  moiitlH. 

The  fjiasfro-iiifrsfiiKil  nianit'csiutioiis  of  imRinia  often  sot  in  witli  uhriipt- 
ncss.  rncontroliiible  voiiiitiii;^  iiiin  eome  on  and  its  caiise  bo  quite  iiti- 
reeognizahlc.  A  younir  marri(!(l  woman  wan  admitted  to  my  wards  in  tho 
Montreal  (ii'neral  Hospital  witli  persistent  vomiting;  of  four  or  live  days' 
duration.  The  urine  was  slii,ditly  albuminous,  but  she  had  notie  of  tho 
usual  signs  of  ura'niia,  and  the  ease  was  not  regarchul  as  otie  of  Bri^jlit's 
disease.  Tiie  vomiting  persisted  and  caused  death,  'i'iio  ])08t-ui(irtem 
showed  extensive  scderosis  of  both  kidneys.  The  attacks  may  be  preceded 
by  nausea  and  may  be  associated  witli  diarrluini.  In  some  instiiiices  tlio 
diarrhtt'a  may  come  on  without  tiie  vomiting;  sometimes  it  is  profuse  mid 
associated  with  an  intense  catarrhal  or  even  diphtheritic  inflanunation  of 
the  colon. 

A  sj)ecial  uraMiiic  stomatitis  has  been  described  (Harie)  in  whirh  tlio 
mucosa  of  the  lij)s,  gums,  and  tongue  is  swollen  and  erythenuitoiis.  Thu 
saliva  nuiy  be  increased,  ami  there  is  dilHtailty  in  swallowing  and  in  mas- 
tication.    The  tongue  is  usually  very  foul  and  the  breath  heavy  and  fctiil. 

Diagnosis. — I'ra'mia  may  be  confounded  with  : 

(a)  Cerebral  lesions,  siu-h  as  hu-morrhage,  meningitis,  or  even  tumor. 
In  apoplexy,  which  is  so  commonly  associated  witli  kiilney  disease  aiul 
stiff  arteries,  the  sudden  loss  of  consciousness,  particularly  if  with  con- 
vulsions, may  simulate  a  unemic  attack  ;  but  the  mode  of  oiisi't,  tli(! 
existence  of  complete  hemiplegia,  with  conjugate  deviation  of  tlie  eves, 
suggest  haemorrhage.  As  already  noted,  there  are  cases  of  ura'inie  lieiiii- 
jilegia  or  monoi)legia  which  cannot  be  separated  from  those  of  organic 
lesion  and  which  post  mortem  show  no  trace  of  coar.se  disease  of  tlio 
brain.  I  know  of  an  instance  in  which  a  consultation  was  held  upon  tlie 
propriety  of  operation  in  a  case  of  hemiplegia  believed  to  be  due  to  ^^iili- 
dural  haemorrhage  which  post  mortem  was  slioM-n  to  be  uracil ic.  Indi'ii), 
in  some  of  these  cases  it  is  quite  impossible  to  distinguish  between  the 
two  conditions.  So,  too,  cases  of  meningitis,  in  a  condition  of  dee[i  coma, 
with  perhaps  slight  fever,  furred  tongue,  and  without  localizing  symptoms, 
may  readily  be  confounded  with  ura-mia. 

(b)  With  certain  infectious  diseases.  ITrannia  may  persist  for  weeks 
or  months  and  the  patient  lies  in  a  condition  of  torpor  or  even  uncon- 
sciousness, with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twilfliiii{r.s 
a  rapid  feeble  pulse,  Avith  slight  fever.  This  state  not  unnaturally  sug<rcsts 
the  existence  of  one  of  the  infectious  diseases.  Cases  of  the  kind  are  not 
uncommon,  and  I  have  known  them  to  bo  mistaken  for  typhoid  fever  and 
for  miliary  tuberculosis. 

(c)  Ura?mic  coma  may  be  confounded  with  poisoning  by  alcohol  or 
opium.  In  opium  poisoning  the  pupils  are  contracted  ;  in  alcohol isni  they 
are  more  commonly  dilated.  In  uraemia  they  are  not  constant ;  they  may 
be  either  Avidely  dilated  or  of  medium  size.     The  examination  of  the  I'vo 


ACUTE  nilKJIIT'S   DISKASK. 


r4i 


■0  for  woi'lc.H  or 

n  witli  abrupt- 
!  bo  quite  iin- 
ly  wanl.s  in  tlio 
ir  or  live  davs' 
(1  none  of  ilu) 
)iie  of  Hri^'lit's 
lO  ])((st-inoi't('m 
my  lie  preci'dcil 
LI  ii\st!in('es  the 
t  is  profiisi'  ami 
niUiinumli'Hi  (if 

v)  ill  \vlii<'U  the 
ic'niatoiis.  The 
ing  aiul  ill  iiias- 
hcavy  and  ft'tid. 

or  oven  tuiimr. 
ncy  disease  and 
rly  if  with  cmi- 
\J  of  onset,  the 
ion  of  th(!  eyes, 
,f  nrivnii"'  heini- 
|th(ise  of  orLniine 
disease  of  the 
|is  lu'hl  upon  the 
)  bo  due  to  sub- 
riiMiiie.     Indeed, 
lish  between  the 
Lii  of  deep  eoimi, 
lizing  syniptoins, 

licrsist  f^ir  weeks 
or  cviMi  luieon- 
Icular  twitehiii.sr?, 
latu rally  sujrjrests 
Itbe  kinil  are  ii'it 
^'phoid  f*'vei'  iiu^l 

ig  bv  ah'olwl  or 
\lcr)lioUsm  they 
Istaiit ;  they  way 
(atiou  of  the  eye 


jrrmmd  should  bo  made  to  (lotoniiino  tho  j)ro.soiioo  or  ubs(>nco  of  albiiiiii- 
miiic  retinitis,  '['iio  urine  should  be  drawn  olT  and  examined.  The  oilur 
of  the  breath  sometitneH  gives  an  important  liint. 

The  condition  of  tho  heart  and  arteries  sliould  also  be  taken  into  uc- 
eoiml.  Sinbleii  ura-niie  eonia  is  more  e(tnim(»n  in  the  (dironi(r  inters' itial 
nephritis.  Tlio  (diaracter  of  the  delirium  in  nleoliolism  is  sonu'tinies  im- 
portant, and  tho  coma  is  not  ao  deep  as  in  uruMiiia  or  opium  poisoning. 
It  may  for  a  time  be  impossiblo  to  determine  whether  the  condition  is 
due  ti)  uni'mia,  i)rofoun(l  aleoholism,  or  Invmorriiage  into  the  j)ons  Varolii. 
The  ireatmeut  will  be  considered  under  chronic  JJright's  disease. 


V.    ACUTE   BRIGHT'S   DISEASE. 

Definition. — Acute  diffuse  nephritis,  due  to  the  action  of  cold  or  (;f 
toxic  agents  upon  the  kidneys. 

In  all  instances  changes  exist  in  the  epithelial,  vascular,  and  inler- 
tuhiilar  tissues,  which  vary  in  intensity  in  different  forms ;  hence  writers 
have  described  a  tubular,  a  glomerular,  and  an  acute  interstitial  nephritis. 
Delatii'ld  recognizes  acufe  exudative  and  acute  productive  forms,  the  latter 
cliaructerized  by  proliferation  of  the  connective-tissue  stroma  and  of  the 
cells  of  the  Malpighian  tufts. 

Etiology. — The  following  are  the  principal  causes  of  acute  iie- 
jihritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  one  of  the  most  common  causes. 
It  is  jiarticularly  prone  to  follow  exposure  after  a  drinking-bout. 

('^)  The  poisons  of  the  specific  fevers,  particularly  scarlet  fever,  less 
coininonly  tyjihoid  fever,  measles,  dii)htheria,  small-pox,  chicken-pox, 
cholera,  yellow  fever,  meningitis,  and,  very  rarel}',  dysentery.  Acute  nephri- 
tis is  not  often  associated  with  8yi)hilis.  In  acute  tuberculosis  nephritis 
is  not  uncommon.     It  may  also  occur  in  septicaemia. 

(3)  Toxic  agents,  such  as  turpentine,  cantharides,  chlorate  of  potash, 
and  earixdic  acid  may  cause  an  acute  congestion  which  sometimes  ter- 
minates in  nephritis.     Alcohol  probably  never  excites  an  acute  nei^hritis. 

(4:)  Pregnancy,  in  which  the  condition  is  thought  by  some  to  result 
from  eonipression  of  the  renal  veins,  although  this  is  not  yet  finally  settled. 
The  condition  may  in  reality  be  due  to  toxic  products  as  yet  undetermined. 

(•J)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive 
lesions  of  tiie  skin,  as  in  burns  or  in  chronic  skin-diseases. 

Morbid  Anatomy. — The  kidneys  may  present  to  tho  naked  eye  in 
mild  cases  no  evident  alterations.  When  seen  early  in  more  severe  forms 
the  organs  are  congested,  swoUeu,  dark,  and  the  section  may  drip  blood. 
In  otlier  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  off 
readily,  and  the  ;3ortex  is  swollen,  turbid,  and  of  a  grayish-red  color,  while 
tlie  pyramids  have  an  intense  beefy-red  tint.     The  glomeruli  in  some  in- 


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DISEASKS  ()!<'  TIIK   KIDNKYS. 


Ktaucos  atiind  out  plainly,  ilocj)!)'  swollen  mid  congostod  ;  in  other  instuiu'i'ji 
thoy  arc  ])ulo. 

The  liist(ilof];y  may  1)0  thus  auniniarized  :  (ti)  (ilomorular  chaiif^c.-i.  In 
a  majority  of  tlu>  cases  of  nephritis  due  to  toxic  a;,'ents,  which  roaeli  lliu 
kidney  through  the  blood-vessels,  the  tufts  sufTor  first,  and  there  is  cilluir 
an  acute  intraivipillary  gloinorulitis,  in  which  the  capillaries  hocomo  filled 
with  cells  and  thrond)i  or  involvement  of  the  epithelium  of  the  tuft  aiui 
of  Bowman's  capsnhi,  the  cavity  of  M'hich  contains  leucocytes  luid  red 
blood-corpuscles.  Hyaline  (h'generalion  of  the  contents  and  of  the  wulLs 
of  the  capillaries  of  the  tufts  is  an  extremely  common  event,  'f  hcsc  pm- 
cesses  are  perhaps  best  marked  in  scarlatiiud  nephritis.  There  niuy  ho 
proliferation  about  H  wman's  capsule.  These  changes  interfere  with  tho 
circuhition  in  the  tufts  and  seriously  inlluence  tho  nutrition  of  the  luinilar 
structures  beyond  tliem. 

(/;)  The  alterations  in  the  tubular  opitheliunx  consist  iu  cloudy  jewell- 
ing, fatty  change,  and  hyaline  degeneration.  In  the  convoluted  liihiilcs, 
the  accumulation  of  altered  cells  with  leucocytes  and  blood-corpusrlw 
(iauses  tlio  enlargement  aiul  swelling  of  tho  organ.  The  ej)itlielial  cells 
lose  their  striatioU;  *'  '  nuclei  are  obscured,  and  hyaline  droplets  of  ton 
accumulate  in  tliem. 

{(■)  Ii'.torstitial  changes.  In  the  milder  forms  a  simple  inllaiuniatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles— exists 
between  the  tubules.  In  severer  casea  areas  of  sniall-celled  infiltration 
occur  about  the  capsules  and  between  the  convoluted  tubes.  'I'hese  clian^'os 
may  be  wide-sj)read  and  uniform  throughout  tho  organs  or  juoro  intense 
iu  certain  regions. 

Symptoms. — Tho  onset  h  usually  sudden,  and  when  the  nephritis 
follows  cold,  dropsy  may  be  noticed  within  twenty-four  hours.  After 
fevers  the  onset  is  less  abrupt,  but  the  patient  gradually  becomes  ])alo  and 
a  puffiness  of  the  faco  or  swelling  of  the  ankles  is  first  noticed.  In  chil- 
dren there  may  at  tho  outset  be  convulsions  Chilliness  or  rigors  initiate 
the  attack  in  a  limited  number  of  cases.  Pain  in  tho  back,  nausea,  and 
vomiting  may  be  present.  Tho  fever  is  variable.  Many  cases  iu  adults 
have  no  rise  in  temperature.  In  young  children  with  nephritis  from  cdM 
or  scarlet  fover  the  temperature  may,  for  a  few  days,  range  from  101°  to 
103°. 

Tho  nu)st  characteristic  symptoms  are  the  urinary  changes.  Thero 
may  at  first  be  suppression,  more  commonly  the  urine  is  scanty  and 
highly  colored  and  contains  blood,  albumen,  and  tube-casts.  Tho  ([uantity 
is  reduced  and  only  four  or  five  ounces  may  bo  passed  in  the  twenty-fom' 
hours;  the  specific  gravity  is  high — 1-025,  or  even  more;  the  c(dor  varies 
from  a  smoky  to  a  deep  porter  color,  but  is  seldom  bright  red.  On  stand- 
ing there  is  a  heavy  deposit ;  microscopically  there  are  blood-(''>"piis('Io.s 
epithelium  from  the  urinary  passages,  and  casts,  hyaline,  blood,  and  epitlu;- 
lial  in  character.    The  albumen  ia  abundant,  forming  a  curdy,  thick  pro- 


otlior  iiist;iti(!i'.'j 


clumtres.    Tlioro 


ACUTK  HKKJIIT'S  dfskask. 


743 


clpihito.  TIjo  total  excretion  of  iirciv  is  reduced,  tliosigh  tlie  jicncntugc 
U  lii},'h. 

Aiianniii  is  im  eiirly  and  marked  symptom.  In  cases  of  extensive 
dropsy,  elTusion  may  take  place  into  tli(>  pleura'  and  peritoa'inim.  'JMiere 
all'  cases  of  scarlatinal  nephritis  in  wliicli  the  droi)sy  of  the  extremities  is 
trivial  and  cITusion  into  tho  pleura'  extensive.  The  lungs  may  hcconie 
(I'di'iiiatous.  In  rare  cases  there  is  u'denui  of  the  glottis.  Kpistaxis  may 
ocrur  or  cutaneous  ecchymoscs  may  develop  in  the  course  of  the  disease. 

The  pulse  may  be  hard,  the  tensiitn  increased,  and  the  secoiul  aortic 
8ound  accentuated.  Occasiotudly  dilatation  of  the  heart  comes  on  rapidly 
iind  may  cause  sudden  death  ((Jooilhart).  The  skin  is  dry  and  it  may  he 
(lillicult  to  induce  sweating. 

rra'mio  symptoms  develop  ii<  a  limited  number  of  cases.  'J'hey  may 
occur  at  the  onset  with  suppression,  niore  commonly  later  in  the  disease. 
Oculiir  changes  are  not  so  common  in  acute  iis  in  cliroTiie  Hright's  disease, 
but  ha'morrhagio  retinitis  may  oc(  ur  and  occasi  wially  papillitis. 

The  course  of  acute  Hright's  disease  varies  ( 'itisiderably.  The  descrip- 
tii)ii  just  given  is  of  the  form  which  most  commi^nly  follows  cold  or  searliit 
fever.  In  many  of  the  febrile  cases  dro^  sy  is  not  a  prominent  symptom, 
and  (he  diagnosis  rests  rather  with  the  examination  of  the  urine.  More- 
o\ci;  the  condition  nuiy  be  transient  and  les.-.  serious.  In  other  cases,  as 
in  the  acute  nephritis  of  typhoid  fever,  there  uuiy  be  luematuria  and  pro- 
nounced signs  of  interference  with  the  renal  function.  The  most  intense 
acute  nephritis  may  exist  without  aiuist'rca. 

In  scarlatinal  nephritis,  in  Avhieh  the  glomeruli  are  most  seriously  af- 
fected, suppression  of  the  urine  may  be  an  early  symptom,  the  dropsy  is 
apt  to  be  extreme,  and  ura'mic  manifestations  are  common.  Acaite 
Bri-rht's  disease  in  children,  however,  may  set  in  very  insidiously  and  be 
associated  with  transient  or  slight  ledema,  and  the  symptoms  may  point 
rather  to  atTec^tion  of  the  digestive  system  or  to  brain-disease. 

Biagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  seri- 
ous involvement  of  the  kidneys  may  be  manifested  only  by  slight  uMlema 
of  the  feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  gen- 
eral health.  The  first  indication  of  trouble  may  be  a  uriemic  convulsion. 
This  is  particularly  the  i-ase  in  the  acute  nephritis  of  j)regnancy,  aiul  it  is 
ugo(]d  rule  for  the  practitioner,  wben  engaged  to  attend  a  case,  invariably 
to  ask  that  during  the  seventh  and  eighth  months  the  urine  should  occa- 
sionally be  sent  for  examination. 

In  nephritis  from  cold  and  in  scark^t  fever  the  .symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned, 
overy  case  in  wliieh  albumen  is  present  must  not  be  called  acute  Bright's 
disease,  not  even  if  tube-casts  be  present.  Thus  the  common  febrile  albu- 
minuria, although  it  represents  the  first  link  in  the  chain  of  events  leading 
to  acute  Bright's  disease,  should  not  be  placeil  in  the  sanu;  category. 

There  are  occasional  cases  of  acute  Bright's  disease  with  anasarca,  ia 


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744 


DISEASES  OP  THE  KIDNEYS. 


which  albumen  is  either  absent  or  present  only  as  a  trace.  This  is  a  rare 
condition.  Tube-casts  are  usually  found,  and  the  absence  uf  albumen  is 
rarely  permanent.     The  urine  may  be  reduced  in  amount. 

"  iie  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  foi-in  of 
Bright's  disease,  but  scarcely  of  such  extreme  value  as  has  been  stated. 
Thus,  the  hyaline  and  granular  casts  are  common  to  all  varieties.  'I'lio 
blood  and  epithelial  casts,  particularly  those  made  up  of  leucocytes,  are 
most  common  in  the  acute  cases. 

Prognosis. — The  outlook  varies  somewhat  with  the  cause  of  the 
disease.  Recoveries  in  the  foim  following  exposure  to  colli  are  iinieli 
more  frequent  than  after  scarlatinal  nephritis.  In  young  children  tlie 
mortality  is  high,  amounting  to  at  least  one  third  of  the  cases.  Serious 
symptoms  are  low  arterial  tension,  the  occurrence  of  ura3mia,  and  effu- 
sion into  the  serous  sacs.  The  persistence  of  the  dropsy  after  tlie  tirst 
month,  intense  pallor,  and  a  large  amount  of  albumen  indicate  the  possi- 
bility of  the  disease  becoming  chronic.  For  some  months  after  the  dis- 
appearance of  the  dropsy  there  may  be  traces  of  albumen  and  a  few  tube- 
casts. 

In  a  week  or  ten  days,  in  a  case  of  scarlatinal  nephritis,  if  the  proirross 
is  favorable,  the  dropsy  diminishes,  the  urine  increases,  the  albumen  less- 
ens, and  by  the  end  of  a  mouth  the  dropsy  has  disappeared  and  the  urine 
is  nearly  free.  In  very  young  children  the  course  may  be  rapid,  and  I 
have  known  the  urine  to  be  free  from  albumen  in  the  fourth  week.  Otlier 
cases  are  more  insidious,  and  though  the  dropsy  may  disappear,  th(>  albu- 
men persists  in  the  urine,  the  anremia  is  marked,  and  the  condition  In- 
comes chronic  or,  after  several  recurrences  of  the  dropsy,  improves  and 
complete  recovery  takes  place. 

Treatment. — The  patient  should  be  in  bed  and  there  remain  until 
all  traces  of  the  disease  have  disappeared.  As  sweating  plays  sucli  au 
important  part  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the 
patient  to  blankets.     lie  should  also  be  clad  in  thin  Canton  fliunel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow- 
root or  oat-meal,  barley  water,  and,  if  necessary,  beef  tea  and  chiekeu 
broth.  It  is  better,  if  possible,  to  confine  the  patient  to  a  strictly  milk 
diet.  As  convalescence  is  established,  bread  and  butter,  lettuce,  water- 
cress, grapes,  oranges,  and  other  fruits  may  be  given.  The  return  to  a 
meat  diet  should  be  gradual. 

The  patient  should  driiik  freely  of  alkaline  mineral  waters,  ordinary 
water,  or  lemonade.  The  fluids  keep  the  kidneys  flushed  and  wash  out 
the  debris  from  the  tubes.  A  useful  drink  is  a  drachm  of  creain  of  tiutar 
in  a  pint  of  boiling  water,  to  which  may  be  added  the  juice  of  half  a  leiiiou 
and  a  little  sugar.  Taken  when  cold,  this  is  a  pleasant  and  satisfactory 
diluent  drink. 

No  remedies,  so  far  as  known,  control  directly  the  changes  Avhii^h  arc 
going  on  in  the  kidneys.     The  indications  are :    (1)  To  give  the  excretory 


ACUTE  BRIGHT'y  DISEASE. 


T45 


nges  which  are 


function  of  the  kidney  rest  by  utilizing  tlic  skin  and  the  bowels,  in  the 
hope  that  the  natural  i)roccsses  may  be  «uflicient  to  elTect  a  cure;  (2)  to 
meet  the  symptoms  as  they  arise. 

.In  a  case  of  si  arlet  fever  it  may  of'casionally  be  possible  to  avert  an 
attack,  the  i)reni(iiiitory  symptoms  of  which  are  marked  increase  in  the 
artorial  tension  and  the  presence  of  bl«)(,d  coloring  matter  in  the  urine 
(Miihomed).  An  active  saline  cathartic  may  completely  relie\e  this  con- 
dition. 

At  the  onset,  when  there  is  pain  in  the  back  or  ha'^maturia,  the  dry  or 
wet  cujis  give  relief.  The  latter  should  not  bo  used  in  children.  A\'arm 
poultices  arc  often  grateful.  In  cases  which  set  in  with  suppression  of 
urine,  these  measures  should  be  adopted,  and  in  addition  the  hot  bath 
with  subse(iuent  i)ack,  copious  diluents,  and  a  free  purge.  The  dropsy  is 
hcst  treated  by  hydrotherapy — either  tlie  hot  bath,  the  wet  pack,  or  the 
hot-air  bath.  In  children  the  wet  })ai!k  is  usually  sati^'factory.  It  is  ap- 
plied by  wringing  a  blanket  out  of  hot  water,  wrajjping  the  child  in  it, 
covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In  this 
the  child  nuiy  remain  for  an  hour.  It  may  be  repeated  daily.  In  the  case 
of  adults,  the  hot-air  bath  or  the  vai)or  bath  maybe  conveniently  given  by 
allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  the  bed-clothes, 
which  are  raised  on  a  low  cradle.  'Mow.  elhcient,  as  a  rul\  is  a  hot  bath  of 
from  ii.'teen  or  twenty  minutes,  after  Avhich  the  patient  is  wrapjied  in 
blankets.  The  sweating  producted  by  these  measures  is  usually  profuse, 
rarely  exhausting,  and  in  a  majority  of  cases  the  dropsy  can  in  tliis  way  be 
relieved.  There  are  some  cases,  however,  in  which  the  skin  does  not  re- 
spond to  the  baths,  and  if  the  symptoms  are  serious,  particularly  if  urjvmia 
supervenes,  jaborandi  or  its  active  principle,  })ilocar]iit'e,  may  be  used. 
The  hitter  may  be  given  hypodermically,  in  doses  of  froin  a  sixth  to  an 
eiglitii  of  a  grain  in  adults,  and  from  a  twentieth  to  a  twelfth  of  a  grain  in 
thiUlren  f"om  two  to  ten  years.  It  is  a  drug  to  bo  used  with  care.  I 
abandoned  its  employment  for  many  years,  after  having  several  cases  of 
serious  collapse.     I^atterly  I  have  resumed  its  use,  often  with  benetit. 

Tlio  bowels  should  be  kept  ojjcn  l)y  a  morning  saline  purge  ;  in  children 
the  fluid  magnesia  is  readily  taken  ;  in  adults  the  sulphate  of  magnesia  nuiy 
be  given  by  Hay's  method,  in  concentra  i  form,  \n  the  morning,  before 
iunthing  is  taken  into  the  stomach.  In  liright's  disease  it  not  infrequently 
causes  vomiting.  The  compound  ])owdcr  of  jalap,  in  half-drachm  doses, 
or,  if  accessary,  elaterium  may  bo  used.  If  the  dropsy  is  not  extreme,  the 
iiriui  not  very  concentrated,  and  ura}mic*symptoms  are  not  present,  the 
tiowe's  shoidd  be  kept  loose  without  active  ])urgation.  If  these  measures 
fail  t »  reduc'^  the  dropsy  and  it  has  become  extreme,  the  skin  nuiy  be 
punctured  Avith  a  lancet  or  drained  by  a  snudl  silver  canuia  (Southey's 
tube),  which  is  inserted  beneath  it.  A  fine  aspirator  needle  may  be 
used,  and  the  fluid  allowed  to  drain  through  a  piece  of  long,  narrow 
rubber  tubing  into  a  vessel  beneath  the  bed.     If  the  dyspncBa  is  marked. 


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746 


DISEASES  OF  THE  KIDNEYS. 


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owing  to  pressure  of  fluid  in  the  pleurae,  aspiration  should  be  performed. 
In  rare  instances  the  ascites  is  extreme  and  may  require  paracentesis,  or  a 
Southey's  tube  may  be  inserted  and  the  fluid  gradually  withdrawn.  If 
uraemic  convulsions  occur,  the  intensity  of  the  paroxysms  may  be  liiiiited 
by  the  use  of  chloroform  ;  to  an  adult  a  pilocarpine  injection  should  be  ut 
once  given,  and  from  a  robust,  strong  man  twenty  ounces  of  blood  may  bo 
withdrawn.  In  children  the  loins  may  be  dry  cupped,  the  wet  pack  used, 
and  a  brisk  purgative  given.  Bromide  of  potassium  and  chloral  sometimes 
prove  useful. 

Vomiting  may  be  relieved  by  ice  and  by  restricting  the  amount  of  food. 
Drop  doses  of  creosote,  iodine,  and  carbolic  acid  may  be  givr^n.  Tlie  dilute 
hydrocyanic  acid  with  bismuth  is  often  effectual. 

The  question  of  the  use  of  diuretics  in  acute  Bright's  disease  is  not  yi.>t 
settled.  The  best  diuretic,  after  all,  is  water,  which  may  be  taken  freely 
with  the  citrate  of  potash  or  the  benzoate  of  soda,  salts  which  are  held  to 
favor  the  conversion  of  the  urates  into  less  irritating  and  more  easily  ex- 
creted compounds.  Digitalis  and  strophanthus  are  useful  diuretics,  and 
may  be  employed  without  risk  when  the  arterial  tension  is  low  and  tin; 
cardiac  impulse  is  not  forcible.  I  have  never  seen  any  injiirious  elTects 
from  their  employment  after  the  early  symptoms  had  lessened  in  intensity. 

For  the  persistent  albuminuria,  I  agree  with  Roberts  and  Roscnstciii 
that  we  have  no  remedy  of  the  slightest  value.  Nothing  indieiites  iikhv 
clearly  our  helplessness  in  controlling  kidney  metabolism  than  inability  to 
meet  this  common  symptom.  Astringents,  alkalies,  nitroglyocrin,  ami 
mercury  have  been  recommended. 

For  the  ana»miji  ihvays  associated  with  acute  Bright's  disease  iron 
should  be  employeu.  It  should  not  bo  given  until  the  acute  symptoms 
have  subsided.  In  the  adult  it  may  be  used  in  the  form  of  the  perchlorido 
in  increasing  doses,  as  convalescence  proceeds.  In  children,  the  syrup  of 
the  iodide  of  iron  or  the  syrup  of  the  phosphate  of  iron  are  bettor  ])reparii- 
tions.  The  dilatation  of  the  heart  is  best  treated  with  digitalis,  strophan- 
thus, and  strychnia. 

In  the  convalescence  from  acute  Bright's  disease,  care  should  he  taktii 
to  guard  the  patient  against  cold.  The  diet  should  still  consist  chiefly  "f 
milk  and  a  return  to  mixed  food  should  be  gradual.  A  change  of  air  i.s 
often  beneficial,  particularly  a  residence  in  a  warm,  equable  climate. 


VI.  CHRONIC   BRIGHT'S  DISEASE. 

Here,  too,  in  all  forms  we  deal  with  a  diffuse  process,  involving  epi- 
thelial, interstitial,  and  glomerular  tissues.  Clinically  two  groups  are  rec- 
ognized— (r?)  the  chronic  parenchymatous  nephritis,  which  fnllow.s  tin' 
acute  attack  or  comes  on  insidiously,  is  characterized  by  marknl  dro]'>v, 
and  post  mortem  by  the  large  tvhite  kidney:     In  the  later  stains  of  tliw 


.  be  performed. 


aniovint  of  food. 
vrm.    The  dilute 


vhich  are  liold  U 


CHRONIC  BRIGHT'S    DISEASE. 


i47 


process  the  kidney  may  be  smaller — a  condition  known  as  the  small  white 
kidney ;  (b)  chronic  interstitial  nephritis,  in  wliicli  dropsy  is  not  common 
iiud  the  cardio-vascular  changes  are  pronounced,  Delatield  recognizes  n 
chronic  diffuse  nephritis  with  exudation  and  a  (.'hronic  productive  diffuse 
nephritis  without  exudation,  the  latter  corresponding  to  the  contracted 
kidney  of  autliors. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Bright's  dis- 
ease, but  in  reality  it  is  a  degcnci'ation  which  may  accompany  any  form 
of  nephritis. 

CniioNic  Pauexciiym.'v.tols  Nephritis 

(Chronic  Desquamative  and  Chronic  Tubal  Nephritis:  Chronic  Diffuse  Nephritis  with 

Exudation). 

Etiology. — In  many  cases  the  disease  follows  the  acute  nephritis  of 
cold,  scarlet  fever,  or  pregnancy.  More  frequently  than  is  usually  stated 
the  disease  has  an  insidious  onset  and  occurs  independently  of  any  acute 
attack.  The  fevers  may  play  an  important  r6lc  in  certain  of  these  cases. 
Rosenstein,  Bartels,  and,  in  this  country,  I.  E.  Atkinson  have  laid  special 
stress  upon  malaria  as  a  cause.  No  instance  of  the  kind  has  fallen  under 
my  observation  during  the  past  seven  years,  in  which  time  seve/al  hun- 
dred cases  cf  malaria  have  been  under  my  treatment.  Beerard  alcohol 
arc  believed  to  lead  to  tliis  form  of  nephritis.  In  chronic  supp.;ratiou, 
syphilis,  and  tuberculosis  the  diffuse  parenchymatous  nephritis  is  not  un- 
eommou,  and  is  usually  associated  with  amyloid  disease.  Males  are  rather 
more  subject  to  the  atTection  than  females.  It  is  met  with  most  commonly 
in  young  adults,  and  is  b}'  no  means  infrequent  in  children  as  a  sequence 
of  sciu'latinal  nephritis. 

Morbid  Anatomy. — Several  varieties  of  this  form  have  been  recog- 
nized. The  most  common  is  the  Ictrae  v)hitc  kidnpy  of  Wilks,  in  which 
the  organ  is  enlarged,  the  capsule  is  thin,  and  the  surface  white  Avith 
the  stellate  veins  injected.  On  section  the  cortex  is  swollen  and  yellowish 
white  in  color,  and  often  ])resents  npaque  areas.  The  pyramids  may 
be  deeply  congested.  On  microscopical  examination  it  is  seen  that  the 
epithelium  is  granular  and  fatty,  and  the  tubules  of  the  cortex  are  dis- 
tended, and  contain  tube-casts.  Hyaline  changes  arc  also  present  in  the 
epithelial  cells.  The  glomeruli  are  large,  the  capsules  thickened,  the 
capillaries  show  hyaline  changes,  and  the  epithelium  of  the  tuft  and  of 
the  capsule  is  extensively  altered.  The  interstitial  tissue  is  everywliere 
increased,  though  not  to  an  extreme  degree. 

The  second  variety  of  this  form  results  from  the  gradual  increase  in 
the  connective  tissue  and  the  subsequent  shrinkage,  forming  Avliat  is  called 
the  xmall  irliife  Jcldhnj  or  the  pale  granular  kidney.  It  is  doubtful 
whetlier  this  is  always  precerled  by  the  large  white  kidney.  Some  observers 
hold  that  it  may  be  a  primary  independent  form.     The  capsule  is  tbick- 


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DISEASES  OP  THE  KIDNEYS. 


ened  and  the  surface  is  rough  and  granular.  On  section  the  resip'.ance 
is  greatly  increased,  tlie  cortex  is  reduced  and  presents  numerous  opa(|ue 
white  or  whitish-yellow  foci,  consisting  of  accumulations  of  fatty  epithe- 
lium in  the  convoluted  tubules.  This  combination  of  contracted  kidiiev 
witii  the  areas  of  marked  fatty  degeneration  has  given  the  name  of  small 
granular,  fatty  kidney  to  this  form.  The  interstitial  changes  are  marked, 
many  of  the  glomeruli  are  destroyed,  the  degeneration  of  epithelium  in  the 
convoluted  tubules  is  wide-spread,  and  the  arteries  are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the 
chronic  hionorrhafjic  nephritis^  in  which  the  organs  are  enlarged,  yellow- 
ish white  in  color,  and  in  the  cortex  are  many  brownish-red  areas,  due  to 
luemorrhage  into  and  about  the  tube.^.  In  other  respects  the  changes  arc 
identical  witli  those  in  the  large  white  kidney. 

Of  changes  in  the  otiier  organs  the  most  marked  are  thickening  of  the 
blood-vessels  and  hypertrophy  of  the  left  heart. 

Symptoms. — Following  an  acute  nephritis,  the  disease  may  present, 
in  a  niodilied  way,  the  symptoms  of  that  affection.  ).  many  cases  it  sets 
in  insidiously,  and  after  an  attack  of  dyspepsia  or  a  period  of  failing  health 
and  loss  of  strength  the  patient  becomes  pale  and  puffiness  of  the  eyelids 
or  swollen  feet  are  noticed  in  the  morning. 

The  symptoms  are  as  follows :  The  urine  is,  as  a  rule,  diminished  in 
quantity,  often  scanty.  It  has  a  dirty-yellow,  sometimes  smoky,  culor 
aiul  is  hirbid  from  the  presence  of  urates.  On  staiuling,  a  heavy  seilimeiit 
falls,  in  which  are  found  numerous  tube-casts  of  various  forms  and  sizes, 
hyaline,  both  large  and  small,  epithelial,  granular,  and  fatty  casts.  Leuco- 
cytes are  abundant ;  red  blood-corpuscles  are  frequently  met  with,  aiul 
epithelium  from  the  kidneys  and  pelves.  The  albumen  is  abundant  luui 
may  amount  to  one  half  or  one  third  of  the  urine  boiled.  It  is  more 
abundant  in  the  urine  passed  during  the  day.  The  specific  gravity  uiiiy 
be  high  in  the  early  stages — from  1'0:20  to  1*025 — though  in  the  later 
stages  it  is  lower.     'I'he  urea  is  always  reduced  in  ((uantity. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form  of  Briiiht's 
disease.  The  face  is  pale  and  puffy,  and  in  the  morning  the  eyelids  are 
edematous.  The  anasarca  is  general,  and  there  may  be  involvement  of 
tlie  serous  sacs.  In  these  chronic  cases  associated  with  large  white  kidney 
there  is  of  ti^n  a  distinctive  appearance  in  the  face  ;  the  complexion  is  i)asty, 
the  pallor  marked,  and  the  eyelids  are  a'dematous.  The  dropsy  is  peoiil- 
iarly  obstinate.  Urasmic  symptoms  are  common,  though  convulsions  are 
perhaps  less  freouent  than  in  the  interstitial  nephritis. 

The  tension  of  the  pulse  is  usually  increased ;  the  vessels  ultimately 
become  stiff  and  the  heart  hypertrophied,  though  there  are  instaiues  of 
this  form  of  nephritis  in  which  the  heart  is  not  enlarged  The  aortic 
second  sound  is  accentuated.  Retinal  changes  though  less  frequent  than 
in  the  chronic  interstitial  nephritis,  occur  in  a  considerable  number  of 
cases. 


.-r^^^rm 


CHRONIC  BRIGHT'S  DISEASE. 


749 


,he  resiF'.ance 
erous  opiuiue 
fatty  cpithc- 
•actcd  kivliifv 
lame  of  small 
s  are  mavked, 
thelium  in  the 
ly  thickoncd. 
known  as  the 
iarged,  ycUow- 
l  areas,  due  to 
lie  clianges  are 

ckening  of  the 


Gastro-intestinal  symptoms  are  common.  Vomiting  is  frequently  a 
disti'ossiiig  and  serious  symptom,  and  diarrhcea  may  be  profuse.  Ulcera- 
tion of  the  colon  may  occur  and  prove  fatal. 

It  is  sometimes  impossible  to  determine,  even  by  the  most  careful  ex- 
iiniination  of  the  urine  or  by  analysis  of  the  symptoms,  wlii-ther  the  con- 
(liti())i  of  the  kidiiey  is  that  of  the  large  wliite  or  of  the  small  white  form. 
In  cases,  liowever,  whicdi  have  lasted  for  several  years,  Avith  the  progressive 
increase  in  the  renal  connective  tissue  and  the  cardio-vascular  changes, 
the  clinical  picture  may  approach,  in  certain  respects,  that  of  the  con- 
tracted kidney.  The  urine  is  increased,  with  low  specific  gravity.  It  is 
often  turbid,  may  contain  traces  of  blood,  the  tube-casts  are  numerous 
and  of  every  variety  of  form  and  size,  and  the  albumen  is  abundant. 
Dropsy  is  usually  present,  though  not  so  extensive  as  in  the  early  stages. 

The  pro[/msis  is  extremely  grave.  In  a  case  which  has  persisted  for 
more  tluui  a  year  recovery  rarely  takes  place.  Death  is  caused  either  by 
great  ellusion  with  a-dema  of  the  lungs,  by  urannia,  or  by  secondary  inllam- 
ination  of  the  sei'ous  membranes.  Occasionally  in  children,  even  when 
the  disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recov- 
ery takes  place. 

Treatment. — Essentially  the  same  treatment  should  be  carrieil  out 
as  in  acute  Bright's  disease.  Milk  or  butter-milk  should  constitute  the 
eliief  article  of  food.  The  dropsy  should  be  treated  by  hydrotheraj)y. 
Iron  preparations  should  be  given  freely.  The  acetate  of  potash  and 
(li,i,'italis  are  useful  in  increasing  the  How  of  urine.  Basham's  mixture 
given  in  plenty  of  water  will  be  found  beneficial. 


m 


Chronic  Interstitial  Nepiiriv..?. 

(Contracted  Kidney;  Granular  Kidney ;  Cirrhosis  of  the  Kidney ;  Gouty  Kidney; 

Renal  Sclerosis). 

Sclerosis  of  the  kidney  is  met  with  (a)  as  an  occasional  sequence  of 
the  large  white  kidney,  forming  the  so-called  j)ale  granular  or  secondary 
contracted  kidney ;  (b)  as  an  independent  primary  affection ;  (c)  as  a 
sequence  of  arterio-sclerosis. 

Etiologfy. — The  primary  form  is  chronic  from  the  outset,  and  is  a 
slow,  creeping  degeneration  of  the  kidney  substance — in  many  respects 
only  an  anticipation  of  the  gradual  changes  which  take  place  in  the  organ 
in  extreme  old  age.  In  many  cases  no  satisfactory  cause  can  be  assigned. 
In  others  there  are  hereditary  influences,  as  in  the  remarkable  family 
studied  by  Dickenson,  in  which  a  pronounced  tendency  to  chronic  Bright's 
disease  occurred  in  four  generations.  Families  in  which  the  arteries  tend 
to  degenerate  early  are  more  prone  to  interstitial  nephritis.  Syphilis  is 
hold  by  some  to  be  a  cause.  xVlcohol  probably  plays  an  important  part, 
particularly  in  conjunction  with  other  factors.  Dietetic  influences  are  at 
Work  in  many  cases.  Some  believe  excessive  use  of  meat  is  injurious,  since  it 


*, 


■■■@i 


750 


DISEASES  OF  THE  KIDNEYS. 


increases  the  materials  out  of  which  uric  acid  is  formed.  By  many  a  func- 
tional disorder  of  the  liver,  leading  to  lithfemia,  is  regarded  as  the  most 
eflicient  factor.  It  is  quite  possible  that  in  persons  who  habitually  eat 
and  drink  too  much  tha  work  throAvn  upon  this  organ  is  excessive,  and 
the  elaboration  of  certain  materials  so  defective  that  in  their  excretion 
from  the  general  circulation  they  irritate  the  kidneys. 

Actual  gout,  which  in  England  is  a  common  cause  of  interstitial  ne- 
phritis, is  not  an  important  factor  here.  On  the  other  hand,  the  nutri 
tional  disorder  known  as  lithjemia  is  very  common,  either  with  or  witlioiit 
dyspepsia.  Lead,  as  is  well  known,  may  produce  renal  sclerosis,  1)iit  it 
is  a  minor  factor  in  comparison  with  other  causes.  It  is  doubt i'lil  if 
climate  has  any  influence.  Purdy  regards  the  cold,  moist  regions  of  the 
Northeastern  States  as  specially  favorable  to  the  disease. 

Among  factors  which  may  account  for  the  prevalence  of  chronic 
Bright's  disease  in  the  better  classes  in  this  country  may  be  mentioned 
the  intense  worry  and  strain  of  business,  combined,  as  they  often  are, 
with  habits  of  hurried  and  over  eating  and  a  lack  of  proper  exercise. 
Males  are  more  commoidy  attacked  than  females.  Under  twenty-five 
years  of  age  it  is  a  rare  disease  ;  between  twenty-five  and  forty  a  few  well- 
marked  cases  occur ;  between  forty  and  sixty  it  is  common. 

Morbid  Anatomy. — The  kidneys  are  usually  small,  and  togctlur 
may  weigh  no  more  than  an  ounce  and  a  half.  The  capsule  is  thick  ami 
adherent ;  the  surface  of  the  organ  irregular  and  covered  with  small  nod- 
ules, which  have  given  to  it  the  name  of  granular  kidney.  In  strij)j)ingo(I 
the  capsule,  portions  of  the  kidney  substance  are  removed.  Small  cysts 
are  frequently  seen  on  the  surface.  The  color  is  usually  reddish,  dftcn  ii 
very  dark  red.  On  section  the  substance  is  tough  and  resists  cuttinir; 
the  cortex  is  tbin  and  may  measure  no  more  than  a  couple  of  millimetres. 
The  pyramids  are  less  wasted.  The  small  arteries  are  greatly  thickened 
and  stand  out  prominently.     The  fat  about  the  pelvis  is  greatly  increased. 

Microscopically  there  is  seen  a  marked  increase  in  the  connective  tis- 
sue and  degeneration  and  atrophy  of  the  secreting  structures,  glomeniliir 
and  tubal,  the  former  being  most  predominant  and  giving  the  main  cluir- 
actcrs  to  the  lesion.     The  following  are  the  most  important  changes : 

(a)  An  increase  in  the  fibrous  elements,  widely  distributed  throughout 
the  organ,  but  more  advanced  in  the  cortex,  particularly  in  the  ti.ssue  be- 
tween the  medullary  rays.  In  the  pyramids  the  distribution  of  new  jrrowtli 
is  less  piitchy  and  more  diffuse."  In  the  early  stages  of  the  process  there 
is  a  small-celled  infiltration  between  the  tubes  and  around  the  ghmieruli. 
and  finally  this  becomes  fibrillated  and  is  seen  encircling  the  tubnles  ainl 
Bowm.an's  capsules,  around  the  latter  often  forming  concentric  layers. 

(b)  The  changes  in  the  glomeruli  are  striking,  and  in  advanced  cases 
a  very  considerable  number  of  them  have  undergone  complete  atrotdiy  and 
are  represented  as  densely  encapsulated  hyaline  structures.  The  atrophv 
is  partly  due  to  cl.anges  in  the  capillary  walls  and  multiplication  of  cell'* 


CHR0NIC5  BRIG  FIT'S  DISEASE. 


751 


<f  many  a  f  luic- 
ed  as  the  nuist 
liabituiilly  out 
!  excessive  and 
their  excretion 

interstitial  iio- 
lantl,  the  mitri 
with  or  without 
sclerosis,  hut  it 
;  is  douhtful  if 
t  regions  of  tlie 

mce  of  chronic 
y  he  mentioned 
they  often  are, 
proper  exercise, 
uler  twenty-five 
forty  a  few  well- 
a. 

all,  and  together 
sule  is  thick  ami 
with  small  noil- 
In  stripping  oil 
'ed.     Small  cysts 
reddish,  often  ii 
resists  euttiii!:; 
of  millimetres, 
rreatly  thickened 
n-eatly  increased, 
le  connective  tis- 
tnres,  glomenilar 
<y  the  main  cliar- 
,nt  changes : 
nitcd  throughout 
in  the  tissue  be- 
(m  of  new  growtli 
;he  process  there 
d  the  glomeruli. 
the  tnbules  and 
entric  layers. 
in  advanced  cases 
plete  atrophy  and 
'es.     The  atroiiby 
plication  "f  eell> 


between  the  loop.s,  partly  to  extensive  hyaline  degeneration,  and  in  part, 
no  doubt,  to  the  alterations  in  the  afferent  vessels.  The  normal  glomeruli 
usually  show  some  thickening  of  the  capsule  and  increase  in  the  cells  of 
the  tufts. 

('•)  The  tubules  show  diatiges  iu  the  epitlielium,  which  vary  a  good 
deal  in  different  localities.  Where  the  connective-tissue  growth  is  most 
advanced  they  are  greatly  atrophied  and  tlie  epithelium  may  be  repre- 
sented by  small  cubical  cells.  In  other  instances  the  epithelium  has 
entirely  disappeared.  On  the  other  hand,  in  the  regions  represented  by 
the  projecting  granules  the  tubules  are  usually  dilated,  and  the  epithelium 
shows  hyaline,  fatty,  and  granular  changes.  Very  many  of  them  contain 
dark  masses  of  epithelial  debris  and  tube-casts.  In  the  interstitial  tissue 
aiul  in  the  tubules  there  may  be  pigmentary  changes  duo  to  haemorrhage. 
The  dilatation  of  the  tubules  may  reach  an  extreme  grade,  forming  definite 
cysts. 

((/)  The  arteries  show  an  advanced  sclerosis.  The  intima  is  greatly 
thickened  and  there  are  changes  in  the  adventitia  and  in  the  media,  con- 
sisting in  increase  in  the  thickness  due  to  proliferation  of  the  connective 
tissue,  in  the  latter  coat  at  the  expense  of  the  muscular  elements. 

The  view  most  generally  entertained  at  present  is  that  the  essential 
lesion  is  in  the  secreting  tissues  of  the  tubules  and  the  glomeruli,  and  that 
the  connective-tissue  overgrowth  is  secondary  to  this.  Greenfield  holds 
that  the  primary  change  is  iu  most  instances  in  the  glomeruli,  to  which 
both  tlie  degeneration  in  the  epithelium  of  the  convoluted  tubules  and  the 
increase  in  the  intertubular  connective  tissue  are  secondary. 

Associated  with  contracted  kidney  are  general  arterio-sclerosis  and 
hypertrophy  of  the  heart.  The  changes  in  the  arteries  have  already  been 
described  in  the  section  on  arterio-sclerosis.  The  hypertrophy  of  the  heart 
is  almost  constant.  I  do  not  remember  ever  to  have  seen  a  well-marked 
instance  of  contracted  kidney  without  some  hypertrophy  of  the  left  ven- 
tricle, and  the  enlargement  may  reach  an  extreme  grade.  The  varia- 
tions depend,  no  doubt,  in  part  upon  the  extent  of  the  diffuse  arterial 
degeneration,  and  there  are  instances  in  which  the  term  cor  hovimun  may 
ho  applied  to  the  enlarged  organ.  In  such  ca.ses  the  hypertrophy  is  not 
confined  to  the  left  ventricle,  but  involves  the  entire  heart.  The  explana- 
tion of  this  hypertrophy  has  been  much  discussed.  It  was  at  first  held  to 
he  due  to  the  increased  work  thrown  upon  the  organ  in  driving  the  impure 
hlood  through  the  cai)illary  system.  Basing  his  opinion  upon  the  sup- 
posed muscular  increase  in  the  smaller  arteries,  Johnson  regarded  the 
hypertrophy  as  effort  to  overcome  a  sort  of  stop-cock  action  of  tliese  ves- 
sels, which,  under  the  influence  of  the  irritating  ingredient  in  the  blood, 
eontracted  and  increased  greatly  the  peripheral  resistance.  Traube  be- 
lieved that  the  obliteration  of  a  large  number  of  capillary  territories  in 
the  kidney  materially  rai.scd  the  arterial  pressure,  and  in  this  way  led  to 
the  hypertrophy  of  the  heart ;  an  additional  factor,  he  thought,  was  the 


752 


DISEASES  OP  THE  KIDNEYS. 


diminished  excretion  of  water,  which  also  heightened  the  pressure  within 
the  blood-vessels. 

In  oui  present  knoAvledge  the  most  satisfactory  explanation  is  that 
given  by  Colinheim,  which  is  thus  clearly  and  succinctly  put  by  Faggc  : 
"  lie  gives  reasons  for  thinking  that  the  activity  of  the  circulation  throu<;li 
the  kidneys  at  any  moment — in  other  words,  the  state  of  the  smaller  renal 
arteries  as  regards  contraction  or  dilatation — depends  not  (as  in  tlie  ease 
of  the  tissues  generally)  upon  the  need  of  those  organs  for  blood,  l)ut 
solely  upon  the  amount  of  material  for  the  urinary  secretion  that  the  cir- 
culatory fluid  happens  then  to  contain.  This  suggestion  has  boarings 
.  .  .  upon  the  development  of  hypertrophy  in  one  kidney  when  the  otlicr 
has  been  entirely  destroyed.  But  another  consequence  deducible  from  it  is 
that  when  parts  of  both  kidneys  have  undergone  atrophy,  the  blood-flow 
to  the  parts  that  remain  must,  cmteris  paribus.,  be  as  great  as  it  would 
have  been  to  the  whole  of  the  organs  if  they  had  been  intact.  But  in 
order  that  such  a  quantity  of  blood  should  pass  through  the  restricted 
capillary  area  now  open  to  it,  an  excessive  pressure  must  obviously  be 
necessary.  This  can  be  brought  to  bear  only  by  the  exertion  of  more  than 
the  normal  degree  of  force  on  the  part  of  the  left  ventricle,  combined  with 
the  maintenance  of  a  corresponding  resistance  in  all  other  districts  of  the 
arterial  system.  And  so  one  can  account  at  once  for  the  high  arterial 
pressure  and  for  the  cardio-vascular  changes  that  are  secondary  to  it." 

Symptoms. — Perhaps  a  majority  of  the  cases  are  latent,  and  are  not 
recognized  until  the  occurrence  of  one  of  the  serious  or  fatal  complica- 
tions. Even  an  advanced  grade  of  contracted  kidney  may  be  com[)atil)le 
with  great  mental  and  bodily  activity.  There  may  have  been  no  symptoms 
whatever  to  suggest  to  the  patient  the  existence  of  a  serious  malady.  In 
other  cases  the  general  health  is  disturbed.  The  patient  complains  of 
lassitude,  is  sleepless,  has  to  get  up  at  night  to  micturate ;  the  digestion  is 
disordered,  the  tongue  is  furred  ;  there  are  complaints  of  headache,  failing 
vision,  and  breathlessness  on  exertion. 

So  complex  and  varied  is  the  clinical  picture  of  chronic  Bright',  dis- 
ease that  it  will  be  best  to  consider  the  symptoms  under  the  various 
systems. 

Urinnry  System. — The  amount  of  urine  is  usually  increased,  and  from 
two  to  four  litres  may  be  passed.  Frequently  the  patient  has  to  g(>t  up 
two  or  three  times  during  the  night  to  empty  the  bladder,  and  there  is  in- 
creased thirst.  It  is  for  these  symptoms  occasionally  that  relief  is  sought. 
It  is  to  be  remembered,  however,  that  frequent  micturition  at  night  may 
be  associated  with  irritability  of  the  prostate  and,  in  certain  cases,  with 
hyperacidity  of  the  urine.  The  secretion  is  clear,  the  mucus  cloud  is 
well  marked,  but  there  is  no  definite  sediment.  The  color  is  a  light  yellow, 
and  the  specific  gravity  ranges  from  1-005  to  1'013.  Traces  of  allninien 
are  found,  but  may  be  absent  at  times,  particularly  in  the  early  morning 
urine.     It  is  often  simply  a  slight  cloudiness,  and  may  be  apparent  onlj 


CHRONIC  BRKHirS  DISEASE. 


753 


iressure  within 


with  the  more  delicate  tests.  Tlie  sediment  is  scanty,  and  in  it  a  few  hya- 
line or  grannlar  casts  are  found.  The  quantity  of  the  .«()Iid  constituents 
of  tlie  urine  is,  as  a  rule,  diminished,  though  in  some  instances  the  urea 
may  be  excreted  in  full  amount.  In  attacks  of  dyspepsia  or  bronchitis, 
or  in  the  later  stages  when  the  heart  fails,  the  quantity  of  albumen  iiuiy 
bo  greatly  increased  and  the  urine  diminished.  Occasionally  blood  occurs 
in  the  urine,  and  there  may  even  be  haematuria  (S.  West). 

Circuhttory  System. — The  })ulse  is  hard,  the  tension  increased,  and 
the  vessel  wall,  as  a  rule,  thickened.  As  alrci'dy  mentioned,  a  distinction 
must  be  made  between  increased  tension  and  thickening  of  the  arterial 
wall.  The  tension  may  be  plus  in  a  normal  vessel,  but  in  chronic  liright's 
disease  it  is  more  common  to  find  the  tension  is  increased  and  the  artery 
stitf. 

A  pulse  of  increased  tension  has  the  following  characters:  (a)  It  is 
hard  and  incompressible,  requii-ing  a  good  deal  of  force  to  overcome  it ;  {!>) 
it  may  be  impossible  to  obliterate  the  pulse  wave  by  any  pressure  on  tlu- 
vessel ;  {c)  it  is  persistent,  and  in  the  intervals  between  the  beats  the  ves- 
sel feels  full  and  can  be  rolled  beneath  the  finger.  These  characters  may 
be  present  in  a  vessel  the  walls  of  which  are  little,  if  at  all,  increased  in 
thickness.  To  estimate  the  latter  the  pulse  wave  should  be  obliterated  in 
the  radial,  and  the  vessel  wall  felt  beyond  it.  In  a  perfectly  ncjrmal  ves- 
sel the  arterial  coats,  under  these  circumstances,  cannot  be  differentiated 
from  the  surrounding  tissue ;  Avhereas,  if  thickened,  the  vessel  can  bo 
rolled  beneath  the  finger.  Persistent  high  tension  is  one  of  the  earliest 
and  most  important  symptoms  of  interstitial  ne])hritis.  The  cardiac  feat- 
ures are  equally  important,  though  often  less  obvious.  IIypertro])hy  of 
tlie  left  ventricle  occurs  to  overcome  the  resistance  offered  in  the  arteries. 
The  eidargement  of  the  heart  ultimately  becomes  more  general.  The 
apex  is  displaced  downward  and  to  the  left ;  the  impulse  is  forcible  and 
may  be  heaving.  In  elderly  persons  with  emphysema,  the  displacement 
of  the  apex  may  not  be  evident.  The  first  sound  at  the  apex  nniy  be 
duplicated ;  more  commonly  the  second  sound  at  the  aortic  cartilage  is 
aecentuated,  a  very  characteristic  sign  of  increased  tension.  The  sound 
in  extreme  cases  may  have  a  bell-like  quality.  In  many  cases  a  systolic 
murmur  develops  at  the  apex,  ])robably  as  a  result  of  relative  insufficiency. 
It  may  be  loud  and  transmitted  to  the  axilla.  Finally  the  hypertro])hy 
fails,  the  heart  becomes  dilated,  gallop  rhythm  is  present,  and  the  general 
condition  is  that  of  a  chronic  heart-lesion. 

Respiratory  System. — Sudden  anlema  of  the  glottis  may  occur.  Ef- 
fusion into  the  pleura?  or  sudden  a^dema  of  the  lungs  may  prove*  fatal. 
Acute  pleurisy  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  fre- 
quent accompaniment,  particularly  in  the  winter.  Sudden  attacks  of 
oppressed  breathing,  particularly  at  night,  are  not  infrequent.  This  is 
often  a  ura;mic  symptom,  but  is  sometimes  cardiac.  The  patient  may  sit 
U]i  in  bed  and  gasp  for  breath,  as  in  true  asthmii.     Cheyne-Stokes  breath- 


I 


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J   , 


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i 


764 


DISEASES  OP  THE   KIDNEYS. 


!.    ; 


iii;T  niay  bo  prosont,  most;  commonly  toward  tho  close,  but  the  psitiont 
may  bo  walking  about  and  even  attending  to  bis  occupation. 

Diyestivc  System. — Dyspepsia  and  loss  of  appetite  arc  common.  Severe 
and  uneontrollablo  vomiting  may  bo  tlio  first  symptom.  Tliis  is  usimllv 
regarded  as  a  manifestation  of  uraemia,  but  it  may  bo  present  without  any 
other  indications,  and  I  have  kiuiwn  it  to  prove  fatal  without  any  Kuspi- 
fion  that  chronic  13 right's  disease  was  present.  Severe  and  even  fatal 
tliarrhoea  may  develop.  Tho  tongue  may  bo  coated  and  tho  breath  luavy 
and  urinous. 

Nervous  System. — Various  cerebral  manifestations  have  alreudy  Ixcii 
mentioned  under  ura'inia,  and  tjjoy  are  among  the  most  important  of  the 
features  of  chronic  Briglit's  disease.  Cerebral  apoj)]exy  is  closely  related  to 
interstitial  nephritis.  The  luemorrhago  may  take  place  into  the  mciini<;('s 
or  the  cerebrum.  It  is  usually  associated  with  marked  changes  in  the 
vessels.     Neuralgias,  in  various  regions,  are  not  uiu!ommon, 

SjXicial  Senses. — Troubles  in  vision  may  be  the  first  symptom  of  the 
disease.  It  is  remarkable  in  how  many  cases  of  interstitial  nephritis  tho 
condition  is  diagnosed  first  by  the  ophthalmi(!  surgeon.  Tho  flunie-sliaped 
lifccmorrhages  arc  the  most  common.  Less  frequent  is  dilfuso  retinitis  or 
papillitis.  Sudden  blindness  may  supervene  without  retinal  changes— 
uremic  amaurosis.  Auditory  troubles  are  by  no  means  infrequent  in  clironic 
Bright's  disease.  Hinging  in  the  ears,  with  dizziness,  is  not  unconinion. 
Various  forms  of  deafuoss  may  occur. 

Skm. — CEdoma  is  not  common  in  interstitial  nephritis.  Slight  jniflR- 
ness  of  the  ankles  may  be  present,  but  in  a  majority  of  the  eases  dropsy 
does  not  supervene.  When  extensive,  it  is  almost  always  the  result  of 
gradual  failure  of  the  hypertrophied  heart.  The  skin  is  often  dry  and 
pale,  and  sweats  are  not  common.  In  some  instances  the  sweat  may  de- 
posit a  white  frost  of  urea  on  the  surface  of  the  skin.  Eczema  is  a  com- 
mon accompaniment  of  chronic  interstitial  nephritis.  Tingling  of  the 
fingers  or  numbness  and  pallor — tho  dead  fingers — are  not,  as  some  sup- 
pose, in  any  way  peculiar  to  Bright's  disease.  Intolerable  itching  of  the 
skin  may  bo  present,  and  cramps  in  the  muscles  are  by  no  means  rare. 

Ilicmorrhages  are  not  infrequent ;  thus,  opistaxis  may  occur  and  prove 
serious.  Purpura  may  develop.  Broncho-pulmonary  hiBmorrhngos  are 
said,  by  some  French  writers,  to  be  common,  but  no  instance  of  it  has 
come  under  my  observation.  Ascites  is  rare  except  in  association  with 
cirrhosis  of  the  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  dis- 
ease, one  of  the  many  intercurrent  affections  of  which  may  have  jtroved 
fatal.  The  early  stages  of  interstitial  nepbritis  are  not  recognizaMc.  I" 
a  patient  with  increased  pulse  tension  (particularly  if  the  vessel  wall 
is  sclerotic),  with  the  apex  beat  of  the  heart  dislocated  to  the  left,  the 
second  aortic  sound  ringing  and  accentuated,  the  urine  abundant  and  of 
low  specific  gravity,  with  a  trace  of  albumen  and  an  occasional  hyaline  or 


CHRONIC   BRIGITT'S  DISEASE. 


frramilar  cast,  tho  diagnosis  of  interstitial  nephritis  may  be  safely  made. 
Of  all  the  indications,  that  offered  by  the  pulse  is  the  most  importajit 
IVrsistcnt  high  tension  with  thic.-kening  of  tho  arterial  wall  in  a  man  nn- 
iler  lifty  means  that  serious  mischief  has  already  taken  place,  that  cardio- 
vascular changes  are  certaiidy,  aiul  renal  most  ])robably,  present.  It  is 
iiiiliDitant  in  the  diagnosis  of  this  condition  not  to  rest  content  with  a 
!iiiif,de  examination  of  the  urine.  lioth  the  evening  and  the  morning  secre- 
tion should  be  studied.  The  sediment  should  be  collected  in  a  conical 
glass,  and  in  looking  for  tube-casts  a  large  surface  should  be  examined 
witli  a  tolerably  low  power  aiul  little  light.  The  arterio-sclerotio  kidney 
may  exist  for  a  long  time  without  the  occurrence  of  albumen,  or  the  albu- 
nu'U  may  be  in  very  small  quantities.  In  many  cases  it  is  impossible  to 
(litTtrentiate  the  j)rimary  interstitial  nephritis  from  an  arterio-sderotic 
kidney,  nor  clinically  is  it  of  any  special  value  so  to  do.  In  persons 
iiiuler  forty,  with  very  high  tension,  great  thickening  of  the  superficial  ar- 
teries, and  marked  hypertrophy  of  the  heart,  tho  renal  are  more  likely  to 
be  secondary  to  the  arterial  changes. 

Prognosis. — Chronic  Bright's  disease  is  an  incurable  affection,  and 
tho  anatomical  conditions  on  which  it  depends  are  quite  as  much  beyond 
the  reach  of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial 
nephritis,  however,  is  compatible  with  the  enjoyment  of  life  for  many 
years,  and  it  is  now  ujiiversally  recognized  that  increased  tension,  thick- 
ening of  the  arterial  walls,  and  polyuria  with  a  small  quantity  of  albumen, 
neither  doom  a  man  to  death  within  a  short  time  nor  necessarily  interfere 
with  the  pursuits  of  an  active  life  so  long  as  proper  care  be  taken.  I 
know  patients  who  have  had  high  tension  and  a  little  albumen  in  the 
inii\e  with  hyaline  casts  for  ten,  twelve,  and,  in  one  instance,  fifteen  years. 
Serious  indications  are  the  development  of  nra»mic  symptoms,  dilatation  of 
the  heart,  tho  onset  of  serous  effusions,  the  development  of  Cheyno- 
Stokes  breathing,  persistent  vomiting,  and  diarrha>a. 

Treatment. — Patients  without  local  indications  or  in  whom  the  con- 
ilition  has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet 
life  without  mental  worry,  with  gentle  but  not  excessive  exercise,  and  rcsi- 
flonee  in  an  equable  climate,  should  be  recommended.  In  addition  they 
i^hnuul  bo  told  to  keep  the  l)owels  regular,  the  skin  active  by  a  daily  tepid 
hath  with  friction,  and  the  urinary  secretion  free  by  drinking  daily  a 
definite  amount  of  either  distilled  water  or  some  pleasant  mineral  water. 
Aleohol  should  be  strictly  prohibited.     Tea  and  coffee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be 
wfirned  not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day. 
Care  in  food  and  drink  is  probably  the  most  important  element  in  the 
treatment  of  these  early  cases. 

A  patient  in  good  circumstances  may  be  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  cli- 
48 


I 


villi 


I 


III 


706 


DISEASES  OF  THE  KIDNEYS. 


mate,  like  tliut  of  Houtlit'rn  ('aliforniu.  'riitTo  is  no  doubt  of  the  viiliic  in 
thoso  (!!i.s('H  of  rc'inoval  from  the  cliangctihlc,  irroyulur  wouthur  wlucli  nie- 
vailH  in  t\\v  toniporato  rci^'ioiis  from  Noviimbcr  until  April. 

At  this  {icriod  modiciiicH  arc  not  ro(|iiiri'd  unlcsH  for  cortain  siiccial 
symptoms.  I'ationts  derive  much  benefit  from  an  annual  visit  to  certain 
mineral  H[»rin<(s,  such  as  Poland,  Bedford,  Saratoga,  in  this  eountry,  ami 
Vichy  and  others  in  Euroj)e.  Mineral  waters  have  no  curative  inlliicncc 
upon  chronic  Hright's  disease;  they  simply  help  the  interstitial  circiiiatinii 
and  keep  the  drains  flushed.  In  this  early  stage,  when  the  patient's  cdn- 
dition  is  good,  the  tensicm  not  higb,  anil  the  quantity  of  albumen  small, 
medicines  are  not  indicated,  since  no  remedies  are  known  to  have  the  sljirht- 
cst  influence  upon  the  progress  of  the  disease.  Sooner  or  later  syinptnins 
arise  which  demand  treatment.  Of  these  the  following  are  the  most  im- 
portant : 

(rt)  Greathj  Iiicrrnsed  Arterial  Tensmi. — It  is  to  bo  remembered  that 
a  certain  increase  of  tension  is  not  only  necessary  but  unavoidalile  in 
chronic  Hright's  disease,  and  probably  the  most  serious  danger  is  too 
great  lowering  of  the  blood  tension.  The  hapi>y  medium  must  be  souf^lit 
between  sucdi  heightened  tension  as  throws  a  serious  strain  upon  the lieaii 
and  risks  rupture  of  the  vessels  and  the  low  tension  which,  under  tluse 
circumstances,  is  specially  liable  to  bo  associated  with  serous  effusions.  In 
cases  with  persistent  high  tension  the  diet  should  be  light,  an  occasional 
saline  purge  should  be  given,  and  sweating  promoted  by  means  of  hot  aii' 
or  the  hot  bath.  If  these  measures  do  not  suffice,  nitroglycerin  may  lie 
tried,  beginning  witli  one  minim  of  the  one  per  cent,  solution  three 
times  a  day,  and  gradually  increasing  the  dose  if  necessary.  Patients 
vary  so  much  in  susceptibility  to  this  drug  that  in  each  case  it  UiUst  be  tested, 
the  limit  of  dosage  being  that  at  which  the  patient  experiences  the  ])liysio- 
logical  effect.  As  much  as  ton  minims  of  the  one  per  cent,  solution  may 
be  given  three  times  a  day.  In  many  cases  I  have  given  it  in  much  large; 
doses  for  weeks  at  a  time.  I  have  never  seen  any  ill  effects  from  it,  Jf 
the  dose  is  excessive  the  patients  comphiin  at  once  of  flushing  or  houdache. 
Its  use  may  be  kept  up  for  six  or  seven  weeks,  then  stopped  for  a  week 
and  resumed.  Its  vahio  is  seen  not  only  in  the  reduction  of  the  tension, 
but  also  in  the  striking  manner  in  which  it  relieves  the  headache,  dizzi- 
ness, and  dyspnoea. 

(b)  More  or  less  ancnmia  is  present  in  advanced  cases,  which  is  best 
met  by  the  use  of  iron.  Weir  Mitchell,  who  has  had  a  unique  experience 
in  certain  forms  of  chronic  Bright's  disease,  gives  the  tincture  of  the  per- 
chloride  of  iron  in  large  doses — from  half  a  drachm  to  a  drachm  three 
times  a  day.  He  thinks  tl«tt  it  not  only  benefits  the  anaemia,  but  that  it 
also  is  an  important  means  of  reducing  the  arterial  tension. 

(c)  Many  patients  with  Bright's  disease  present  themselves  for  treat- 
ment with  signs  of  cardiac  dilatation ;  there  is  a  gallop  rhythm  or  the  heart 
sounds  have  a  foetal  character,  the  breath  i^  short,  the  urine  scanty  and 


AMYLOID   DISKASK. 


757 


lii;,'lily  iilbuiiiinous,  iind  tlicro  arc  ai^jfiis  (»f  local  (IrojtHy,  In  tlicsc  cusi'b 
till'  trcatiiu'iit  niUHL  bo  dirccti'd  to  the  lioart.  A  inorninj;  ditso  of  huU.s  or 
pulomul  may  bo  given,  and  digitalis  in  U'n-ininini  doHon,  three  or  f(<ur 
times  u  day.  Strychnia  may  bo  uaed  with  benefit  in  this  condition.  lu 
Hoinc  instiincos  other  cardiac  teenies  may  bo  necessary,  but  as  a  rule  the 
(liifitalis  acts  promptly  and  well. 

{(I)  l'r(P)iiic  Si/tnpfums. — Even  before  marked  manifestations  are  present 
there  may  be  extromo  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.  Headache  is  not  often  complained  of,  though  intense 
frontal  headache  may  be  an  early  symptom  of  ura'mia.  In  this  condition, 
too,  the  patient  may  complain  of  palpitation,  feelings  of  numbness,  and 
sometimes  nocturnal  cramps.  For  these  symptoms  the  salino  i)urgatives 
should  be  ordered,  aiul  hot  baths,  so  as  to  induce  eoj)iou8  sweating,  ^'itro- 
fjl yccrin  also  may  bo  freely  used  to  reduce  the  tension.  For  tlu^  ura'uiic 
convulsions,  if  severe,  inhalations  of  chloroform  may  bo  used.  If  the  pa- 
titMit  is  robust  and  full-blooded,  from  twelve  to  twenty  ounces  of  blood 
should  bo  removed.  The  patient  should  bo  freely  sweated,  and  if  the 
convulsions  tend  to  recur  chloral  may  bo  given,  either  by  the  mouth  or 
per  rectum,  or,  better  still,  morr/nia.  Ura-'inic  coma  must  be  treated  by 
active  purgation,  and  sweating  thnuld  be  promoted  by  the  use  ot  pilocar- 
piuo  or  the  hot  bath.  For  the  restlessness  and  delirium  morphia  is  indis- 
pensable. Hinco  its  re(!ommendation  in  ura,'mic  states  8onu>  years  ago, 
by  iStophen  MaciKenzie,  I  have  used  this  remedy  extensively  aiul  can 
speak  of  its  groat  value  in  these  cases.  I  have  never  seen  ill  ellects  or  any 
tendency  to  coma  follow. 


VII.    AMYLOID   DISEASE. 


.1    i 


Amyloid  (lardaceous  or  waxy)  degeneration  of  tho  kidneys  is  simply  an 
event  in  the  process  of  chronic  Briglifs  disease,  most  comraoidy  in  the 
chronic  ])arenchymatous  nephritis  following  fevers  or  of  cachectic  states. 
It  has  no  claim  to  bo  regarded  as  one  of  the  varieties  of  Bright's  disease. 
Tlic  affection  of  the  kidneys  is  generally  a  part  of  a  wide-spread  amyloid 
degeneration  occurring  in  prolonged  suppuration,  as  in  disease  of  the  bone, 
in  syphilis,  tubercidosis,  and  less  commonly  in  association  with  leukt»?mia, 
Ifud  poisoning,  and  gout. 

Anutoniically  the  amyloid  kidney  is  largf  and  pale,  the  surface  smooth, 
and  the  venae  stellatje  well  marked.  On  section  the  cortex  is  large  and 
may  show  a  peculiar  glistening,  infiltrated  appearance,  and  the  glomeruli 
are  very  distinct.  The  pyramids,  in  striking  contrast  to  the  cortex,  are  of 
a  deep  red  color.  A  section  soaked  in  dilute  tincture  of  iodine  shows  spots 
of  a  walnut  or  mahogany  brown  color.  The  Malpighian  tufts  and  the 
straight  vessels  may  be  most  affected.  In  lardaceous  disease  of  the  kid- 
neys the  organs  are  not  always  enlarged.     They  may  be  normal  in  size  or 


t^«i 


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758 


DISEASES  OF  THE  KIDNEYS. 


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small,  pale,  and  granular.  The  amyloid  change  is  first  seen  in  the  Mal- 
pighian  tufts,  and  then  involves  the  afferent  and  efferent  vessels  and  ilie 
straight  vessels.  It  may  be  confined  entirely  to  them.  In  later  stages  of 
the  disease  the  tubules  are  affected,  chiefly  the  membrane,  rarely,  if  ever, 
the  cells  themselves.  In  addition,  the  kidneys  always  show  signs  of  diffuso 
nephritis.  The  Bowman's  capsules  a''e  thickened,  there  may  be  glomeruli- 
tis,  and  the  tubal  epithelium  is  swollen,  granular,  and  fatty. 

Symptoms. — The  renal  features  alone  may  not  indicate  the  presence 
of  this  degeneration.  Usually  the  associated  condition  gives  a  hint  of  the 
nature  of  the  process.  The  urine,  as  a  rule,  shows  important  cliuiiges ; 
the  quantity  is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity. 
The  albumen  is  usually  abundant,  but  it  may  be  scanty,  and  in  rare  in- 
stances absent.  Possibly  the  variations  in  the  situation  of  the  amyloid 
changes  may  account  for  this,  since  albumen  is  less  likely  to  be  present 
when  the  change  is  confined  to  the  vasse  rectae.  In  addition  to  ordiiiiirv 
albumen,  globulin  nuiy  be  present.  The  tube-casts  are  variable,  usually 
hyaline,  often  fatty  or  finely  granular.  Occasionally  the  amyloid  rea(iioii 
oan  be  detected  in  the  hyaline  casts.  Dropsy  is  present  in  many  instances, 
particularly  when  there  is  much  ana?mia  or  profound  cachexia.  It  is  not, 
however,  an  invariable  symptom,  and  there  are  cases  in  which  it  does  not 
develop. 

Increased  arterial  tension  and  cardiac  hypertrophy  are  not  usually 
present,  except  in  those  cases  in  which  amyloid  degeneration  occurs  in  the 
secondary  contracted  kidney ;  under  which  circumstances  there  may  bo  ura'- 
niia  and  retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other  foinis. 

Diagnosis. — By  the  condition  of  the  urine  alone  it  is  not  possible  to 
recognize  amyloid  changes  in  the  kidney.  Usually,  however,  there  is  no 
difficulty,  since  the  Bright's  disease  comes  on  in  association  with  syphilis, 
prolonged  suppuration,  disease  of  the  bone,  or  tuberculosis,  and  there  is 
evidence  of  enlargement  of  the  liver  and  spleen.  A  suspicious  circum- 
stance is  the  existence  of  polyuria  with  a  large  amount  of  albumen  in  the 
urine,  or  when,  in  these  constitutional  affections,  a  large  quantity  of  clear, 
pale  urine  is  passed,  even  without  the  presence  of  albumen. 

The  prognosis  depends  rather  on  the  condition  with  wliicli  the  nephri- 
tis is  associated.    As  a  rule  it  is  grave. 

The  treatment  of  the  condition  is  that  of  chronic  Bright's  disease. 


Vm.  PYELITIS 

(Consecutive  Nephritis;  Pyelonephritis ;  Pi/onephrosis). 

Definition.— Inflammation  of  the  pelvis  of  the  kidney  and  the  con- 
ditions which  result  from  it. 

Etiology. — Pyelitis  is  induced  by  many  causes,  among  which  the 
following  are  the  most  important :  (a)  The  irritation  of  calculi— a  very 


i:| 


ic  Bright's  disease. 


onephrosis). 

ic  kiducy  and  llio  con- 


PYELITIS. 


759 


frequent  cause,  (b)  Tubercle,  (c)  The  infectious  pyelitis  which  develops 
in  typhoid  fever,  pneumonia,  scarlet  fever,  diphtheria,  small-pox,  and  other 
fevers.  Here  an  acute  inflammation  of  the  pelvis  of  the  kidney  may  occur, 
sometimes  haeraorrhagic  in  character,  more  frequently  diphtheritic,  (d) 
The  i)re8ence  of  decomposing  urine,  following  pressure  upon  the  ureter  by 
t.unors  or  bladder-disease.  By  far  the  most  frequent  form  of  pyelitis  is 
tliiit  which  is  consecutive  to  cystitis,  from  whatever  cause.  In  these  cases 
the  inflammation  may  not  be  confined  to  the  pelvis,  but  pass  to  the 
kiihioy,  inducing  pyelonephritis,  (e)  Occasional  causes  are  cancer,  hyda- 
tids, the  ova  of  certain  parasites,  and,  according  to  some,  the  irritation  of 
tlie  saccharine  urine  of  diabetes,  and  the  irritation  of  turpentine  or  cubebs. 
{ f)  A  primary  pyelitis  or  pyelonephritis  has  been  described  as  coming  on 
iit'tcT  cold  or  overexertion,  but  such  cases  are  extremely  rare. 

Morbid  Anatomy . — In  the  early  stages  of  pyelitis  the  mucous  mem- 
bniue  is  turbid,  somewhat  swollen,  and  may  show  ecchymoses.  The  urine 
in  tlie  pelvis  is  cloudy,  and,  on  examination,  numbers  of  epithelial  cells  are 
seen.  .  In  the  form  associated  Avith  the  infections  fevers  there  is  usually  a 
gniyish  pseudo-membrane,  either  limited  to  an  iufundibulum  or  involving 
it  ((reat  part  of  the  pelvis. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
bnme,  which  has  been  called  by  some  catarrhal  pyelitis.  More  commoidy 
the  mucosa  is  roughened,  grayish  in  color,  thick,  and,  on  microscopical 
examination,  the  tissues  are  seen  to  be  infiltrated  with  leucocytes.  Un- 
der these  circumstances  there  is  almost  always  more  or  less  dilatation 
of  the  calyces  and  flattening  of  the  papillaj.  Following  this  condition 
there  may  be  (a)  extension  of  the  suppurative  process  to  the  kidney  it- 
self, forming  a  pyelonephritis;  (b)  a  gradual  dilatation  of  the  calyc^cs 
with  atrojjhy  of  the  kidney  substance,  and  finally  the  production  of  the 
coiulition  of  pyonephrosis,  in  which  the  entire  organ  is  represented  by  a 
sac  of  pus  with  or  without  a  thin  shell  of  renal  tissue,  (c)  After  the  kid- 
ney structure  has  been  destroj'cd  by  suppuration,  and  the  obstruction  at 
the  oriiico  of  the  pelvis  persists,  the  fluid  portions  may  be  absorbed,  tlu^ 
[ms  becomes  inspissated,  so  that  the  organ  is  represented  by  a  series  of 
siKundi  containing  grayish,  putty-like  nfasses,  which  may  become  imprcg- 
luited  with  lime  salts. 

Tuberculous  pyelitis,  as  already  described,  usually  starts  upon  the  apices 
(if  tlie  pyramids,  and  may  at  first  be  limited  in  extent.  I^ltimately  the 
coiulition  i)roduced  may  be  similar  to  that  of  calculous  pyelitis.  Pyone- 
j)hrosia  is  quite  as  frequent  a  sequence,  Avhilo  the  final  transformation  of 
the  pus  into  a  putty-like  material  impregnated  with  salts,  forming  the 
so-(>;ill('d  scrofulous  kidney,  is  even  commoner. 

The  pyelitis  consecutive  to  cystitis  is  usually  bilateral,  and  the  kidney 
is  apt  to  be  involved,  forming  the  so-called  surfficdl  kidney — acute  sup- 
purative nephritis.  There  are  lines  of  suppuration  extending  along  the 
pyramids,  or  small  abscesses  in  the  cortex,  often  just  beneath  the  capsule; 


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DISEASES  OP  THE  KIDNEYS. 


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or  there  may  be  wedge-shaped  abscesses.  The  pus  organisms  either  pass 
up  the  tubules  or,  as  Steven  has  shown,  pass  by  tlie  lymphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any 
symptoms,  even  when  the  jirocess  is  extensive.  In  mild  grades  there  is 
pain  in  the  back  or  there  may  be  tenderness  on  deep  pressure  on  the  af- 
fected side.  The  urine  is  turbid,  contains  a  few  mucous  and  pus  eelli!i,  and 
occasionally  blood-corpuscles.  The  urine  is  acid,  and  there  may  be  a  trace 
of  albumen. 

Before  the  condition  of  pyuria  is  established  there  may  be  attacks  of 
pain  on  the  affected  side  (not  amounting  to  the  severe  agony  of  renal  colic), 
rigors,  high  fevctr,  and  sweats.  Under  these  circumstances  the  uiinc, 
which  may  have  been  clear,  becomes  turbid  or  smoky  from  the  presence  of 
blood,  and  may  contain  large  numbers  of  mucus  cells  and  transitional  ejii- 
thelium.  Tliese  cases  are  not  common,  but  I  have  twice  had  opportunity 
of  studying  such  attacks  for  a  prolonged  period.  In  one  patient  tlio  or- 
currence  of  the  rigor  and  fever  could  sometimes  be  predicted  from  the 
change  in  the  condition  of  the  urine.  Such  cases  occur,  I  believe,  iu  as- 
sociation with  calculi  in  t'le  pelvis. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the 
urine  in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous, 
as  may  be  readily  demonstrated  by  comparing  scrapings  of  the  mucosa  of 
the  pelvis  and  of  the  bladder.  In  both  the  epithelium  belongs  to  wliat  is 
called  the  transitional  variety,  and  in  both  regions  the  same  conical,  fusi- 
form and  irregular  colls  with  long  tails  are  found. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  bcconio 
chronic  and  suppurative,  the  symptoms  are : 

(1)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter 
may  be  temporarily  blocked,  normal  urine  is  passed  for  a  time,  and  then 
there  is  a  sudden  outflow  of  the  pent-up  pus  and  the  urine  becomes  puru- 
lent. Coincident  with  this  retention,  a  tumor  mass  may  be  felt  on  the 
side  affected.  The  pus  has  the  ordinary  characters,  but  the  transitional 
epithelium  is  not  so  abundant  at  this  stage  and  comes  from  the  bhiddn'  or 
from  the  pelvis  of  the  healthy  side.  Occasionally  in  rajiidly  advanciui,' 
pyelonephritis  portions  of  the  kidney  tissue,  particularly  of  the  apices  of 
the  pyramids,  may  slough  away  and  appear  in  the  urine ;  or,  as  in  a  re- 
markable specimen  shown  to  me  by  Tyson,  solid  cheesy  moulds  of  the 
calyces  are  passed.  Casts  froui  the  kidney  tu])ules  are  sometimes  present, 
The  reaction  of  the  urine  is  at  first  acid,  and  may  remain  so  even  when 
the  pus  is  passed  in  large  quantities.  If  it  remains  any  time  in  the  Mad- 
der or  if  cystitis  exists  it  becomes  ammoniacal.  Micturition  may  be  very 
frequent  and  irritability  of  the  bladder  may  be  present. 

(2)  Intermittent  fever  associated  with  rigors  is  usually  present  in  cases 
of  suppurative  pyelitis.  The  chills  may  recur  at  regular  intervals,  and 
the  cases  are  often  mistaken  for  malaria.     Owon-Rees  called  attention  to 


)'(  : 


PYELITIS. 


7G1 


s,  has  become 


tlie  frequent  occurrence  of  these  rigors,  which  form  a  characteristic 
feature  of  both  calculous  and  tuberculous  pyelitis.  Ultimately  the  fever 
assumes  a  hectic  type  and  the  rigors  may  cease. 

(3)  The  general  condition  of  the  patient  usually  indicates  prolonged 
supi)uration.  There  is  more  or  less  wasting  with  anaiiuia  and  a  progressive 
failure  of  health.  Secondary  abscesses  may  develop  and  the  clinical  pict- 
ure becomes  that  of  jiytemia.  In  some  instances,  particularly  of  tubercu- 
lous pyelitis,  the  clinical  course  may  resemble  that  of  typhoid  fever.  There 
arc  instances  of  pyuria  recurring,  at  intervals,  for  many  years  without 
impiiivment  of  the  bodily  vigor. 

(4)  Physical  examination  in  chronic  pyelitis  usually  reveals  tender- 
ness on  the  affected  side  or  a  definite  swelling,  which  may  vary  much  in 
size  and  ultimately  attain  largo  dimensions  if  the  kidney  becomes  enor- 
mously distended,  as  in  pyonephrosis. 

(5)  Occasionally  nervous  symptoms,  which  may  be  associated  with 
dyspna^a,  supervene,  or  the  termination  may  bo  by  coma,  not  uidike  that 
of  diabetes,  '^riicse  have  been  attributed  to  the  absorption  of  tlie  decom- 
posing materials  in  the  urine,  and  has  been  called  ammoniannia.  A  form 
of  paraplegia  has  been  described  in  connection  with  some  cases  of  abscess 
of  the  kidney,  but  whether  duo  to  a  myelitis  or  to  u  peripheral  neuritis 
has  not  yet  been  determined. 

In  suppurative  nephritis  or  surgical  kidney  folloAving  cystitis,  the  pa- 
tient complains  of  pain  in  the  back,  tlie  fever  becomes  high,  irregular,  and 
associated  with  chills,  and  in  acute  cases  a  typhoid  state  develops  in  which 
death  occurs.  , 

Diagnosis. — Between  the  tuberculous  and  the  calculous  forms  of 
pyelitis  it  may  be  ditficult  or  impossible  to  distinguish,  except  by  the  de- 
teetion  of  tubercle  bacilli  in  tlie  pus.  Tliis  has  been  done  on  several  occa- 
sions, but  many  slides  must  be  examined,  for  the  bacilli  are  usually  scant}'. 
From  perinephric  abscess  pyonephrosis  is  distinguished  by  the  more 
definite  character  of  the  tumor,  the  absence  of  a'dematous  swelling  in 
the  lumbar  region,  and,  most  importar  t  of  all,  the  history  of  the  case. 
Tlie  urine,  too,  in  ])erinephric  abscess  may  l)e  free  from  pus.  There 
are  eases,  however,  in  Avhich  it  is  difficult  indeed  to  make  a  satisfactory 
diagnosis.  A  patient  whom  I  saw  with  Fussell  had  had  cystitis  through 
her  pregnancy,  subsequently  pus  in  the  urine  for  several  months,  and  then 
a  large  fiuctuating  abscess  developed  in  tlie  right  lumbar  region.  It  did 
not  seem  possible,  either  before  or  during  the  operation,  to  determine 
whether  the  case  was  a  simple  pyonephrosis  or  whether  there  had  been  a 
perinephric  abscess  caused  by  the  pyelitis. 

Suppurative  pyelitis  and  cystitis  are  frequently  confounded.  I  have 
known  three  instances  of  the  former  in  which  perineal  section  was 
performed  on  the  supposition  of  the  existence  of  an  intractable  cystitis. 
The  two  conditions  may,  of  course,  coexist  and  prove  puzzling,  but  the 
history,  the  acid  character  of  the  pus  in  many  instances,  the  less  frequent 


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DISEASES  OF  THE  KIDNEYS. 


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occurrence  of  ammoniaeal  decomposition,  the  local  signs  in  one  lumbar 
region,  and  the  absence  of  pain  in  the  bladder  should  be  sufficient  to  dif- 
ferentiate the  aflfections.  In  women,  by  catheterization  of  the  ureters,  it 
may  be  definitely  determined  whetlier  the  pus  comes  from  the  kidneys  or 
from  the  bladder. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  recover. 
Tuberculous  pyelitis  may  termiiuite  favorably  by  inspissation  of  tho  jius 
and  conversion  into  a  putty -like  substance  with  dejiosition  of  lime 
salts.  AVhen  pyonephrosis  develops  the  dangers  are  increased.  Porfora- 
tion  may  occur,  the  patient  may  be  worn  out  by  the  hectic  fever,  or  ainv- 
loid  disease  may  develop. 

Treatment. — In  mild  cases  fluids  should  be  taken  freely,  particularly 
the  alkaline  mineral  waters,  to  which  the  citrate  of  potash  may  be  acUled. 

The  treatment  of  the  calculous  form  will  bo  considered  later.  Practi- 
cally there  are  no  remedies  which  have  much  influence  upon  the  pyuria. 
Astringents  in  no  way  control  the  discharge,  nor  have  I  seen  the  sliij;litost 
benefit  from  buchu,  copaiba,  sandal-wood  oil,  or  uva  ursi.  Tonics  sliould 
be  given,  a  nourishing  diet,  and  milk  and  butter-milk  may  be  taken  freely. 
When  the  tumor  has  formed  or  even  before  it  is  perceptible,  if  the  symp- 
toms are  serious  and  severe,  the  kidney  should  be  explored,  and,  if  neces- 
sary, nephrotomy  should  be  performed. 


IX.    HYDRONEPHROSIS. 


Definition. — Dilatation  of  the  pelvis  and  calyces  of  the  kidney  with 
atrophy  of  its  substance,  caused  by  the  accumulation  of  non-i)uriilent 
fluids  the  result  of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  ab- 
normality in  the  ureter  or  urethra.  I'he  tumor  produced  may  1)l'  largo 
enough  to  retard  i.ibor.  Sometimes  it  is  associated  with  other  malforma- 
tions. There  is  •■.  condition  of  moderate  dilatation,  apparently  coutreuital, 
which  is  not  connected  with  any  obstruction  in  the  ducts.  A  case  of  the 
kind  was  shown  at  the  Philadelphia  Pathological  Society  by  Dalaiul. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidney  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgement  of  a  calcuhus  or  to 
a  cicatricial  stricture  following  ulcer. 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induco  hydro- 
nephrosis, ^lore  commonly,  pressure  upon  the  ureter  from  without,  luir- 
ticularly  tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bauds 
compress  the  ureter.  Obstruction  within  the  bladder  may  result  from 
cancer,  from  hypertrophy  of  the  prostate  with  cystitis,  and  in  th(>  urethra 
from  stricture.  It  is  stated  that  slight  grades  of  hydronephrosis  have 
been  foi'nd  in  patients  with  excessive  polyuria. 


HYDRONEPHROSIS. 


763 


In  whatever  way  produced,  when  tlie  ureter  is  blocked  the  secretion  ac- 
cunmlates  in  the  pelvis  and  infundibula.  Sometimes  anute  inflammation 
follows,  but  more  oommojily  tlie  slow,  gradual  pressure  causes  atrophy  of 
the  papilla?  with  gradual  distention  and  wasting  of  the  organ.  In  acquired 
cases  from  pressure,  even  when  dilatation  is  extreme,  there  may  usually  be 
seen  a  thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kid- 
nev  is  represented  by  a  large  cyst,  which  may  perha])s  show  on  its  inner 
surface  imperfect  septa.  The  fluitl  is  thin  and  yellowish  in  color,  and 
contains  traces  of  urinary  salts,  urea,  uric  acid,  and  sometimes  albumen. 
The  secretion  may  be  turl)id  from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  but  may  be 
fohowed  by  atrojihy  of  the  kidney.  It  ivppears  that  when  the  obstruction 
is  intermittent  or  not  complete  the  greatest  dilatation  is  apt  to  follow. 
Tlie  sac  may  be  enormous,  and  cause  an  abdominal  tumor  of  the  largest 
size.  The  condition  has  even  been  m;sluken  for  ascites.  Enlargenu'nt  of 
the  other  kidney  may  compensnte  for  tlu-  defect.  Hypertrophy  of  the  left 
side  of  the  heart  usually  follows. 

Symptoms. — When  small,  it  n\r.y  not  be  noticed.  The  congenital 
cases  when  bilateral  usually  prove  fatal  ^vithin  a  few  days ;  when  unilateral, 
the  tumor  may  not  be  noticed  for  some  time.  It  increases  progressively 
and  has  all  the  characters  of  a  tumor  in  the  renal  region.  In  adult  life 
many  of  the  cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus 
and  enlargement  of  the  prostate,  etc..  give  rise  to  no  symptoms. 

There  are  remarkable  instances  of  intcrmitteyit  hydronephrosis  in 
which  the  tumor  suddenly  disappears  witli  the  discharge  of  a  large  quan- 
tity of  clear  fluid.  The  sac  gradually  refills,  and  the  process  may  be 
repeated  for  years.  In  these  cases  t"ii.>  obstruction  is  unilateral ;  a  cicatri- 
cial stricture  exists,  or  a  valve  is  pre  sent  in  the  ureter,  or  the  ureter  enters 
the  upper  part  of  the  pelvis. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydronephrosis, 
a  tumor  occupying  the  renal  region,  When  of  moderate  size  it  is  readily 
recon;nized,  but  when  large  it  may  be  confounded  with  ovarian  or  other 
tumors.  In  young  cliildren  it  may  be  mistaken  for  sarcoma  of  the  kidney 
IT  of  the  retroperitoneal  glands,  the  common  causes  of  alidominal  tumor 
in  early  life.  Aspiration  alone  would  enable  us  to  differentiate  be- 
tween hydronephrosis  aTid  tumor.  The  large  hydronephrotio  sac  is  fre- 
quently mistaken  for  ovarian  tumor.  The  latter  is,  as  a  rule,  more  mobile, 
and  rarely  fills  the  deeper  portion  of  the  lumbar  region  so  thoroughly, 
riie  ascending  colon  can  often  be  detected  passing  over  the  renal  tumor, 
iind  examination  per  vaginam,  particularly  under  ether,  will  give  impor- 
tant indications  as  to  the  condition  of  the  ovaries.  In  doubtful  cases  the 
«ic  should  be  aspirated.  The  fluid  of  the  renal  cyst  is  clear,  or  turbid 
from  the  presence  of  cell  elements, rarely  colloid  in  character;  tlic  specific 
h'l'avity  is  low ;  albumen  and  traces  of  urea  and  uric  acid  are  usually  ]n-esent; 
ii'id  the  epithelial  elements  in  it  may  be  similar  to  those  found  in  the  pel. 


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764 


DISEASES  OF  THE  KIDNEYS. 


vis  of  the  kidney.  In  old  sacs,  however,  the  fluid  may  not  be  characteiistic, 
since  the  urinary  salts  elisappear,  but  in  one  case  of  several  years'  duration 
oxalate  of  lime  and  urea  were  found. 

Perhaps  tlie  greatest  difficulty  is  offered  by  the  condition  of  hydro- 
nephrosis in  a  movable  kidney.  Here,  the  history  of  sudden  disajijiuar- 
ance  of  the  tumor  with  the  passage  of  a  large  quantity  of  clear  fluid  would 
be  a  point  of  great  importance  in  the  diagnosis.  In  those  rare  instuiices 
of  an  enormous  sac  tilling  the  entire  abdomen,  and  sometimes  mi.stiikon 
for  ascites,  the  character  of  the  fluid  might  be  the  only  point  of  diffoiviice. 
The  tumor  of  pyonephrosis  may  be  practically  the  same  in  physical  char- 
acteristics. Fever  is  usually  present,  and  pus  is  often  found  in  the  urine. 
In  these  cases,  when  in  doubt,  exploratory  puncture  should  be  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  "When 
single,  the  condition  may  never  produce  serious  trouble,  and  the  inter- 
mittent cases  may  persist  for  years.  I'he  latter  are  the  most  hopeful, 
and  Frederick  Taylor  mentions  an  instance  in  which,  after  the  lli'tli  or 
sixth  subsidence,  in  the  course  of  two  years,  a  calculus  was  discharged. 
Occasionally  the  cyst  ruptures  into  the  peritonaeum,  more  rarely  through 
the  diaphragm  into  the  lung.  A  remarkable  case  of  this  kind  is  at  present 
under  the  care  of  my  colleague,  Ilalsted.  A  man,  aged  twenty-one,  had, 
from  his  second  year,  attacks  of  abdomiiuil  pain  in  which  a  swelling  would 
appear  between  the  hip  and  costal  margin  and  sul)side  with  the  i)a>sago 
of  a  large  amount  of  urine.  In  January,  1888,  the  sac  discharged  through 
the  right  lung.*  Reaccumulations  have  occurred  on  several  occasions 
since,  and  on  June  9,  1891,  the  sac  was  opened  and  drained. 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  fluid 
never  reaccumulate.  In  bilateral  hydronephrosis  there  is  a  danger  that 
urseraia  may  supervene.  There  are  instances,  too,  in  which  bloeking  of 
the  ureter  on  the  sound  side  by  calculus  has  been  followed  by  uneinia. 
And,  lastly,  the  sac  may  suppurate,  and  the  condition  change  to  one  of 
pyonephrosis. 

Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not 
cause  serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of 
moderate  size,  the  obstruction  has  been  overcome  by  shampooing.  If 
practised,  it  should  be  done  with  great  care.  When  the  sac  reaches  a  large 
size  aspiration  may  be  performed  and  repeated  If  necessary,  rnneture 
should  be  made  in  the  flank,  midway  between  the  ilium  and  the  last 
rib.  If  the  fluid  reaccumulates  and  the  sac  becomes  large,  it  may  be  in- 
cised and  drained,  or,  as  a  last  resort,  the  kidney  may  be  removed. 


*  Sowers,  New  York  Medical  Record,  1888. 


NEPHROLITHIASIS. 


X.  NEPHROLITHIASIS  {Renal  Calculus). 


765 


Definition. — The  formation  in  tlie  kidney  or  in  its  pelvis  of  con- 
crctiniis,  by  the  deijosition  of  certain  of  the  solid  constituents  of  the  nriiie. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the 
seiianition  of  the  urinary  salts  jjroduces  a  condition  to  which,  unfortu- 
iiatclv,  the  term  infarct  has  been  applied.  Three  varieties  may  be  recog- 
nized :  (1)  The  uric-acid  infarct,  usually  met  with  at  the  a])iccs  of  the 
pyramids  in  new-born  children  and  during  the  first  weeks  of  life.  It  is 
roiulily  recognized  as  a  yellowish  linear  streak  in  the  pyramids  and  is  of 
no  siLniificance ;  (2)  the  urate  of  soda  infarct,  sometimes  associated  with 
unite  of  ammonia,  which  forms  whitish  lines  at  the  apices  of  the  i)yramid3 
ami  is  met  with  chiefly,  but  not  always,  in  gouty  persons ;  and  (;))  tho 
lime  infarcts,  forming  very  opaque  white  lines  in  the  pyramids,  usually  in 
oil  people. 

In  the  pelvis  and  calyces  concretions  of  the  folloAving  forms  occur :  {a) 
Small  gritty  particles,  renal  sand,  ranging  in  size  from  the  individual 
{frains  of  the  uric-acid  sediment  to  bodies  one  or  two  millimetres  in  diame- 
tji'.  These  may  be  passed  in  tho  urine  for  long  periods  without  producing 
■my  symptoms,  since  they  are  too  fine  to  be  arrested  in  their  downward 
paasa !.',('. 

(//)  Larger  concretions,  ranging  in  size  from  a  small  pea  to  a  bean,  and 
lither  solitary  or  multiple  in  the  calyces  and  jielvis.  It  is  the  smaller  of 
tlu'.se  calculi  which,  in  their  passage,  produce  the  attacks  of  renal  colic. 
They  may  be  rounded  and  smooth,  or  present  numerous  irregular  projec- 
tions. 

(r)  Tho  dendritic  form  of  calculus.  The  orifice  of  the  ureter  may  bo 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  the 
concretion,  which  forms  a  more  or  less  distinct  mould.  These  are  the  rc- 
raarkablo  coral  calculi,  which  form  in  the  pelvis  complete  moulds  of  in- 
fiindibula  and  calyces,  the  latter  even  presenting  cup-like  depressions  cor- 
responding to  the  apices  of  the  papillae.  Some  of  these  casts  in  stone  of 
the  renal  pelvis  are  as  beautifully  moulded  as  Hyrtl's  corrosion  jirepara- 
tions. 

Chemically  the  varieties  of  calculi  are :  (1)  Uric  acid,  by  far  the  most 
important,  which  may  form  the  renal  sand,  the  small  solitary,  or  the  large 
dendritic  stones.  They  are  very  hai'd,  the  surface  is  smooth,  and  the  color  '^ 
fcildish.  The  larger  stones  are  usually  stratified  and  very  dense.  Usually 
the  uric  acid  and  the  urates  are  mixed,  but  in  children  stones  composed  of 
urates  alone  may  occur. 

(v)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.  They  arc  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  Phosphatic  calculi  are  composed  of  the  phosphate  of  lime  and  the 
itomonio-magnesiurn  phosphate,  sometimes  mixed  with  a  small  amount  of 


m 


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166 


DISEASES  OF  THE  KIDNEYS. 


I 


I     H 


■    11 


carbonato  of  lime.     They  are  T\ot  common,  Kince  tho  phosphatic  ^ults  iiro 
oftcner  deposited  about  the  uric;  acid  or  the  oxahite  of  lime  stoiuvs. 

(4)  I{are  forms  of  calculi  are  made  up  of  cystine,  xanthine,  carbonutc 
of  lime,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  '1  hcv  niav 
be  produced  by  ah  excess  of  a  sparingly  soluble  abnormal  ingreditiil,  siich 
as  cystine  or  xanthine ;  moro  frequently  by  the  presence  of  uric  acid  in  a 
very  acid  urine  which  favors  its  deposition.  Sir  William  Koberts  thus 
briefly  states  the  conditions  which  lead  to  the  formati()n  of  the  urif-aciil 
concretions :  high  acidity,  poverty  in  salines,  low  ])igmentation,  uiui  liijrh 
percentage  of  uric  acid.  The  presence  of  albumen  and  mucus  may dottr- 
mine,  as  Ord  suggests,  the  deposition  of  the  \iric  acid  and  thus  form  tin: 
starting  point  of  a  stone.  Ova  of  parasites,  blood-clot,  casts,  and  sluvds  of 
epithelium  may  form  the  nuclei  of  stones. 

Renal  calculi  are  most  common  in  the  early  and  later  periods  of  life. 
They  arc  modcnitely  frequent  in  this  country,  but  there  do  not  appear 
to  be  special  districts,  corresj)onding  to  the  "stone  counties"  in  England. 
Men  are  more  often  affected  than  women.  Sedentary  occupations  mm 
to  predispose  to  stone. 

The  effects  of  the  calculi  are  varied.  It  is  by  no  means  uncommon  t<i 
find  a  dozen  or  more  stones  of  various  sizes  in  the  calyces  without  any 
destruction  of  the  mucous  membrane  or  dilatation  of  the  pelvis.  A  tur- 
bid urine  fills  the  pelvis  in  which  there  are  numerous  cells  from  the 
epithelial  lining.  There  are  cases  of  this  sort  in  which,  apparently,  the 
stones  may  go  on  forming  and  are  passed  for  years  without  seriously  im- 
pairing the  health  and  without  inconvenience,  except  the  attacks  of  renal 
colic.  Still  more  remarkable  are  the  cases  of  coral-like  calculi,  which 
may  occupy  the  entire  pelvis  and  calyces  without  causing  pyelitis,  but 
which  gradually  lead  to  more  or  less  induration  of  the  kidney.  The  must 
serious  effects  are  when  the  stone  excites  a  suppurative  pyelitis  and 
pyonephrosis. 

Symptoms. — Patients  may  pass  gravel  for  years  without  luiving  an 
attack  of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter,  in 
other  instances,  the  formation  of  calculi  goes  on  year  by  year  and  the  pa- 
tient has  recurring  attacks  such  as  have  been  so  graphically  described  by 
Montaigne  in  his  own  case.  A  patient  may  pass  an  enormous  number  of 
calculi.  Some  years  ago  I  \vas  consulted  by  a  commercial  traveller,  aii 
extremely  vigorous  man,  who  for  many  years  had  repeated  attacks  of 
renal  colic,  aiul  had  passed  several  hundred  calculi  of  various  sijios.  Ih' 
collection  filled  an  ounce  bottle.  A  patient  may  pass  a  single  calculus, 
and  never  be  troubled  again.  The  largo  coral  calculi  may  excite  no 
symptoms.  In  a  remarkable  specimen  of  the  kind,  pvesGnttd  to  the 
McGill  ]\Iedical  Museum  by  J.  A.  Macdonald,  tho  patient,  a  middle-aged 
woman,  died  suddenly  with  urcemic  symptoms.  There  was  no  pyelitis 
but  the  kidneys  were  sclerotic.      ;. 


I   ■  Wf,. 


NEPHROLITHIASIS. 


767 


Urnid  colic  ensues  wlieii  u  stone  enters  the  ureter.  Au  attack  may 
set  ill  abruptly  witliout  a])parent  cause,  or  may  follow  a  strain  in  lift- 
iiijr.  It  is  characterized  l)y  agonizing  pain,  which  starts  in  the  Hank  of 
the  iiltVcted  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle  and 
along  the  inner  side  of  the  lliigli.  The  pain  may  also  radiate  through 
thu  ul)(lonicn  and  chest,  and  he  very  intense  in  the  hack.  In  severe  at- 
tacks there  are  nausea  and  vomiting  and  the  patient  is  collapsed.  The 
perspiration  breaks  out  upon  the  face  and  the  i)ulse  is  feeble  and  quick. 
A  chill  may  precede  the  outbreak,  and  the  tem})erature  nuiy  rise  as  higli 
103'.  No  one  has  more  grai)hically  described  an  attack  of  "  the  stone  "  than 
.Montaigne,*  who  was  a  sufferer  for  many  years  :  "  Thou  art  seen  to 
sweat  with  pain,  to  look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to 
blood,  to  sutler  strange  contortions  and  convulsions,  by  starts  to  let  tears 
drop  from  thine  eyes,  to  urine  thick,  black,  and  frightful  water,  or  to  have  it 
siipprossod  by  some  sharp  and  craggy  stone,  that  cruelly  ])ricks  and  tears 
thee."  The  symptoms  persist  for  a  variable  period.  In  short  attacks 
thoy  do  not  last  longer  than  an  hour ;  in  other  instances  they  continue 
for  aday  or  more,  with  temporary  relief.  Micturition  is  frecjuent,  occa- 
sionally })ainful,  and  the  urine,  as  a  rule,  is  bloody.  There  arc  instances 
ill  which  a  large  amount  of  clear  urine  is  passed,  probably  from  the  other 
Ividiicy.  In  rare  cases  the  secretion  of  urine  is  completely  suppressed, 
even  wlien  the  kidney  on  the  opi)osite  side  is  normal,  and  death  may 
occur  from  urajmia.  This  most  frequently  ha])pens  when  the  second  kid- 
ney is  extensively  diseased,  or  when  only  a  single  kidney  exists.  A  number 
of  cases  of  this  kind  liavo  been  recorded.  The  condition  has  been  termed, 
by  Sir  William  Roberts,  obstructive  suppression.  It  is  met  with  also  when 
cancer  compresses  both  ureters  or  involves  their  orifices  in  the  bladder.  The 
patient  may  not  appear  to  be  seriously  ill  at  first,  and  urnemic  symptoms 
may  not  develop  for  a  week,  when  twitching  of  the  muscles,  great  rest- 
lessness, and  sometimes  drowsiness  supervene,  but,  strange  to  say,  neither 
convulsions  nor  coma.  Death  takes  place  usually  within  twelve  days 
from  tlie  onset  of  the  obstruction. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
lias  come.  Examination  during  the  attack  is  usually  negative,  ^'ery 
rarely  the  kidney  becomes  palpable.  Tenderness  on  the  affected  side  is 
I'ommon.  In  very  thin  persons  it  may  be  possible,  on  examination  of  the 
abdomen,  to  feel  the  stone  in  the  ureter ;  or  the  patient  may  complain  of 
a  grating  sensation. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite 
and  characteristic  symptoms,  of  which  the  following  are  the  most  im- 
Iiortant : 

(1)  Pain,  usually  in  the  back,  which  is  often  no  more  than  adullsorc- 

*  Essays,  Book  III,  13. 


;f;#- 


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ii: 


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7C8 


DISEASES  OF  THE  KIDNEYS. 


ness,  but  whic'h  may  be  severe  nncl  come  on  in  piiroxysms.  It  is  usiuilly  du 
the  side  ulletited,  but  may  be  referred  to  tbe  opposite  kidney,  and  tlnic  arc 
instances  in  wbieh  the  pain  has  been  conlined  to  the  sound  side.  I'liins 
of  a  siniihir  nature  may  occur  in  movable  kidneys,  and  there  arc^  scmtuI 
instances  on  record  in  whieli  surgeons  have  incised  tlie  kidney  fur  stoiu' 
and  found  none. 

(2)  J/wmaluria. — Although  this  occurs  most  frequently  when  the 
stone  becomes  engaged  in  the  ureter,  it  nuiy  also  come  on  when  the  stoius 
are  in  the  pelvis.  The  bleeding  is  seldom  profuse,  as  m  cancer,  but  in 
some  instances  may  persist  for  a  long  time.  It  is  aggravated  hy  exertion 
and  lessened  by  rest.  Frequently  it  oidy  gives  to  the  urine  a  siiuiky  iiiu'. 
The  u"ine  may  be  free  for  days,  and  then  a  sudden  exertion  or  a  i)ii)l(iii}:nl 
ride  may  cause  smokiness,  or  blood  may  be  passed  in  considerable  t|uaiitilits. 

(3)  Pyelitis. — (a)  There  may  be  attacks  of  severe  pain  in  the  lnuk, 
not  amounting  to  actual  colic,  which  are  initiated  by  a  heavy  chill  I'ollcwnl 
by  fever,  in  which  the  temperature  may  reach  104"  or  105°,  fdllowed  liv 
profuse  sweating.  The  urine,  which  has  been  clear,  nuiy  become  turliiil 
and  smoky  and  contain  blood  and  abundant  epithelium  from  tlie  inlvis. 
Attacks  of  this  description  may  recur  at  intervals  for  montlis  (ir  even 
years,  and  are  generally  mistaken  for  malaria,  unless  special  utteiitinii  is 
paid  to  the  urine  and  to  the  existence  of  the  i)ain  in  the  back.  This  iviial 
intermittent  fever,  due  to  the  presence  of  calculi,  is  identical  with  the 
hepatic  intermittent  fever,  due  to  gall-stones,  and  in  both  it  is  important 
to  remember  that  the  most  intense  paroxysms  may  occur  without  any  evi- 
dence of  suppuration. 

{b)  More  frequently  the  symptoms  of  purulent  pyelitis,  which  have 
already  been  described,  are  j)resent;  pain  in  the  renal  region,  reeiiriiii;; 
chills,  and  pus  in  the  urine,  with  or  without  indications  of  pyoneiihrosis. 

(4)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  wliieh  \)\\i 
occurs  continuously  or  intermittently  in  the  urine  for  many  years.  On 
many  occasions  between  1875  and  1884  I  examined  the  urine  of  a  phy- 
sician who  had  passed  calculi  when  a  student  in  1847,  and  has  had  pius  in 
the  urine  at  intervals  ever  since.  There  was  no  tumor.  lie  luul  never  had 
a  second  attack  of  colic.  In  spite  of  the  prolonged  sui)purati(tii  )k'  luis 
had  remarkable  mental  and  bodily  vigor. 

Patients  with  stone  in  the  kidney  are  often  robust,  higli  livers,  ami 
gouty.  Attacks  of  dyspepsia  aje  not  uncommon,  or  they  may  have  s^evere 
headaches. 

Diagnosis. — Renal  may  be  mistaken  for  intestinal  colic,  ijarticiihuly 
if  the  distention  of  the  bowels  is  marked,  or  for  biliary  colic.  Tiie  situa- 
tion and  direction  of  the  pain,  the  retraction  and  tenderness  of  the  testKlc, 
the  occurrence  of  haematuria,  and  the  altered  character  of  tlu'  urine  are 
distinctive  features.  Attention  may  again  be  called  to  the  fact  that  at- 
tacks simulating  renal  colic  are  associated  with  movable  kidney,  or  even, 
it  has  been  supposed,  without  mobility  of  the  kidney,  with  the  accunni 


NEIMIROLITlllASlM. 


769 


riiaiiy  years. 


lation  of  the  oxuliitos  or  uric  ucitl  in  tlu^  pelvis  of  tlio  kidney.  The  diaj,'- 
uoji.s  between  a  ntone  in  ilio  kidney  and  stone  in  tiie  bladder  is  not  always 
rasy,  though  in  the  latter  the  pain  is  particularly  about  the  neck  of  tho 
liliuldcr,  and  not  linuted  to  one  side,  important  jioints  aro  tho  reaction 
(»f  till"  uriiu',  which  in  stone  in  the  blaibler  is  almost  invariably  alkaline, 
and  the  al)un(lance  of  mucus  witli  the  pus.  It  is  stated  that  certain  dilTi'r- 
ouc'cs  occur  in  the  sym])tonis  produced  by  dilferent  sorts  of  calculi.  Thc! 
lar},'e  uric-ucid  calculi  less  frecpicntly  itroduco  severe  symptoms.  On  tho 
other  hand,  as  the  oxalate  of  lime  is  a  rougher  cah'ulus,  it  is  apt  to  ])ro- 
(liiic  more  pain  (often  of  a  radiating  character)  than  the  litiiic-acid  form, 
ami  to  cause  ha'morriuige.  In  both  these  forms  the  urine  is  acid.  Tho 
jihosphatic  calculi  are  stated  to  produce  tho  most  intense  pain,  and  tho 
uriiu'  is  commonly  alkaline. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced 
1)V  the  hot  bath,  which  is  sometimes  sutlicieiit  to  relax  the  sjjasm.  When 
the  pain  is  very  intense  morphia  should  bo  given  hy2)odermically,  and  in- 
halations of  chloroform  may  be  necessary  until  the  effects  of  tho  anodyne 
are  manifest.  Local  applications  are  sometimes  grateful — hot  poultices, 
or  eldtlis  wrung  out  of  hot  water.  Tho  patient  may  drink  freely  of  hot 
leiiioiiade,  soda  water,  or  barley  Avater.  (Jccasicnudly  change  in  posture 
will  give  great  relief,  and  inversion  of  the  patient  is  said  to  be  followed  by 
inuiiediate  cessation  of  the  pain. 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  rpiiet  life, 
avoiiHiig  sudden  exertion  of  all  sorts.  Tho  essential  feature  in  tho  treat- 
ment is  to  keep  the  urine  abundant  and,  in  a  majority  of  the  cases,  alka- 
line. The  patient  should  drink  daily  a  large  but  definite  quantity  of 
mineral  waters  *  or  distilled  water,  which  is  just  as  satisfactory.  The 
eitrato  or  bicarbonate  of  potash  may  be  added.  Tho  aching  jniins  in  the 
back  are  often  greatly  relieved  by  this  treatment.  Many  i)atients  find 
benefit  from  a  stay  at  Saratoga,  Bedford,  Poland,  or  other  mineral  springs 
in  this  country,  or  at  Vichy  or  Ems  in  Europe. 

Tho  diet  should  be  carefully  regulated,  and  similar  to  that  indicated  in 
the  early  stages  of  gout.  Sir  William  Roberts  recommends  what  is  known 
as  the  solvent  treatment  for  uric-acid  calculi.  The  citrate  of  jjotash  is 
fliven  ill  large  doses  of  half  a  drachm  to  a  drachm  every  three  hours  in  a  tum- 
blerful of  water.  This  should  bo  kept  up  for  several  months.  I  have  had 
no  suecess  with  this  treatment,  nor,  when  one  considers  tho  character  of  the 
urie-aeid  stones  usually  met  with  in  tho  kidney,  does  it  seem  likely  that 
any  solvent  action  could  be  exercised  upon  them  by  changes  in  tho  urine. 
This  treatment  should  be  abandoned  if  the  urine  becomes  ammonia(;al. 

The  surgical  treatment  of  stone  in  the  kidney  has  advanced  rajiidly  in 
the  hands  of  Morris  and  others.    It  should  he  resorted  to  only  when  the 


*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  tho  waters 
'jf  Corseiia,  declared  by  Montaigne  to  be  "  powerful  enough  to  break  stones." 


;  'I. '. 


t  ' 


'1 


.iL 


770 


DISEASES  OP  THE   KIDNEYS. 


attacks  of  pain  aro  of  such  froquoncy  as  to  ijitorfcro  with  tho  occMipiUi„ri 
of  the  j)atk'nt,  or  wlu'ii  pyelitis  or  ijyclonopliritis  Iuih  boon  excited.  Stuiic 
ill  tiic  kidney  is  not  inconsi.stent  witli  a  long  lifo  and  with  tho  enjoynaiit 
of  a  fair  meaBuro  of  health. 


XI.  TUMORS  OF  THE   KIDNEY. 

These  arc  benign  and  malignant.  Of  the  benign  tunior.s,  the  most 
common  are  the  small  nodular  fibromata  which  occur  frequently  in  tlif 
l>yn\,m\ih,  i\\(i  aberrant  aUrenah  v{\\k\\  (jirawitz  has  described,  and  occii- 
sionally  lipoma,  anf/ioma,  or  hjmphadcnoma.  The  ademnnala  niiiy  lie 
congenital.  In  one  of  tny  cases  the  kidneys  were  greatly  eidarged,  cdii- 
taincd  small  cysts,  and  uumerous  adenomatous  structures  thruiiyhoiit 
both  organs. 

Malignant  growths— ra/icer  or  sarcoma — may  bo  cither  primary  or 
secondary.  The  sarcomata  arc  the  most  common,  either  alveolar  sarcoiiiii 
or  the  remarkable  form  containing  striped  muscular  fibres— rhabdo-myoiim, 
Carcinoma  is  less  frequeiit,  and  is  of  the  enccphaloid  variety. 

Primary  m?i6-er— meaning  by  this,  malignant  disease— is  not  uiiooin- 
mon,  and  the  statistics  given  by  some  writers  do  not  represent  the  fiv- 
quency  with  which  it  is  met  with,  at  any  rate,  in  this  country.  Vircliuw 
gives  the  ratio  to  cancer  in  other  parts  as  one  half  of  one  per  cent. 

The  tumors  attain  a  very  large  size.  In  one  of  my  cases  tho  left  kidney 
wciglied  twelve  pounds  and  almost  filled  the  abdomen.  In  children  tluy 
may  reach  an  enormous  size.  Morris  states  that  in  a  boy  at  the  iliildk'.si'X 
Hospital  tho  tumor  weighed  thirty-one  pounds.  *  They  grow  rapidly,  iuu 
often  soft,  and  hixmiorrhage  frequently  takes  place  into  thcin.  lu  tlie 
sarcomata  invasion  of  the  pelvis  or  of  the  renal  vein  is  common.  The 
rhabdo-myomas  rarely  form  very  large  tumors,  and  death  occurs  shortly 
after  birth.  In  one  of  my  cases  the  child  lived  to  the  age  of  tluce  yeiirs 
and  a  ]v,\]f.  The  tumor  grew  into  the  renal  vein  and  inferior  cava.  A 
detached  fragment  passed  as  an  embolus  into  the  pulmonary  artery,  ami  ii 
portion  of  it  blocked  the  '.ricu;?pid  orifice. 

Symptoms. — The  following  are  the  most  important:  (1)  llaMiia- 
turia.  This  may  be  the  first  indication.  The  blood  is  fluid  or  clotted, 
and  there  may  be  very  characten-istic  moulds  of  the  pelvis  of  the  kidney  ami 
of  the  ureter.  It  would  no  doubt  be  possible  for  such  to  form  in  the  luenia- 
turia  from  calculus,  but  I  have  never  met  with  a  case  of  blood-casts  of  the 
pelvis  and  of  the  ureter,  either  alone  or  together,  except  in  cancer.  It  is 
rare  indeed  that  cancer  elements  may  be  recognized  as  in  the  urine. 
Of  the  numerous  specimens  which  I  have  examined,  in  not  one  have  1 
found  elements  which  could  be  clearly  distinguished  from  the  iniiUifoini 
transitional  epithelium  constantly  present  in  these  cases. 

(3)  Pain  is  an  uncertain  symptom.     In  several  of  the  largest  tumors 


TUMORS  OF  TIIK   KIDNKV, 


'•••1 


wliicli  luivo  como  undiir  giy  obsorvation  there  hiwboen  uodiseomfort  from 
bciriiuiin;,'  to  close.  When  present,  it  is  of  u  (lni{^{;iu<^,  dull  elmraeter,  sit- 
luit'il  in  the  Hunk  and  nuliatinj?  down  the  thigh.  The  piissugc  of  tho 
clots  may  (^anse  great  pain 

(:i)  Progressive  enuuMation.  The  loss  of  flesh  is  usiudly  marke(i 
and  advances  rapidly.  'I'here  may,  however,  be  a  very  large  tumor  with- 
out emaciation. 

Physical  Sig^ne. — In  almost  all  instances  tumor  is  present.  When 
sniiill  and  on  the  right  side,  it  may  be  very  movable;  in  some  instances, 
occupying  a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian 
tumor.  Tlie  large  growths  fill  the  flank  and  gradually  extend  toward  the 
middle  liiu',  occupying  the  right  or  left  half  of  the  abdomen.  Inspection 
may  show  two  or  three  hemispherical  projections  corresponding  to  dis- 
ti'iided  sections  of  the  organ.  In  children  the  abdomen  may  reach  an 
ciionnous  size  and  the  veins  are  prominent  and  distended.  On  bimanual 
palpiition  tlio  tumor  is  felt  to  occupy  the  lumbar  region  and  can  usually 
l)t!  lifted  slightly  from  its  bed  ;  in  some  cases  it  is  very  movable,  even  when 
liirj;i';  in  others  it  is  fixed,  firm,  and  solid.  Tho  respiratory  movements 
liiive  but  slight  influence  upon  it.  Rapidly  growing  renal  tumors  are 
Hoft,  and  on  palpation  may  give  a  sense  of  fluctuation.  A  point  of  con- 
sidcnible  importance  is  the  fact  that  the  colon  crosses  the  tumor,  and  can 
usually  be  detected  without  difficulty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either 
renal  or  retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  can- 
cer) is  more  central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only 
toward  the  end,  a  differential  diagnosis  may  be  impossible ;  but  as  a  rule  the 
sarcoma  is  loss  movable.  It  is  to  be  remembered  that  these  tumors  may 
invade  tho  kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distin- 
fjuished,  as  the  edge  is  very  distinct  and  the  notch  or  notches  well  marked  ; 
it  descends  during  nnipiration,  and  the  colon  lies  behind,  not  in  front  of 
it.  On  tlio  right  side  growths  of  the  liver  are  occasionally  confounded 
with  renal  tumors ;  but  such  instances  are  rare,  and  there  can  usually  be 
(ieteeted  a  zone  of  resonance  between  the  upper  margin  of  the  renal  tumor 
and  the  ribs.  Late  in  the  disease,  however,  this  is  not  possible,  for  the 
renal  tumor  is  in  close  union  with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and 
may  simulate  cancer  of  the  ovary  or  fibroid  of  the  uterus.  The  great 
mobility  upward  of  the  renal  growth  and  the  negative  result  of  examina- 
tion of  the  pelvic  viscera  are  the  reliable  points. 

Medicinal  treatment  is  of  no  avail.  When  the  growth  is  small  and  the 
patient  in  good  condition  removal  of  the  organ  may  be  undertaken,  but 
the  percentage  of  cases  of  recovery  is  very  small. 


ii 


♦  r-4'        i 


>j 


u  ^il 


i  m 


0 


772 


DISEASES  OP  THE  KIDNEYS. 


XII.    CYSTIC  DISEASE  OF  THE  KIDNEY. 


8?    11;' 


Tlie  following  varieties  of  oysts  arc  met  with  : 

(1)  Tlie  small  cysts,  already  described  in  connection  witli  the  clirnnic 
nepliritis,  which  result  from  dilatation  of  obstructed,  tubules  or  of  How- 
man's  capsules. 

(2)  Solitary  oysts,  ranging  in  size  from  a  marble  to  an  orange,  or  even 
larger,  a'  e  occasionally  found  in  kidneys  which  present  no  other  (!]iaii(]f(s. 
Tliey  never  give  rise  to  symptoms,  though,  in  exceptional  cases,  tlu'v  niuy 
form  tumors  of  considerable  size.  They,  too,  in  all  probability,  result 
from  obstruction. 

(3)  The  congenital  cystic  kidneys.  In  this  remarkable  condition  tlic 
kidneys  are  represented  by  a  conglomeration  of  cysts,  varying  in  size  fnnii 
a  pea  to  a  marble.  The  crgans  arc  greatly  enlarged,  and  togetlior  may 
weigh  six  or  more  pounds.  In  the  foetus  they  may  attain  a  size  siilliciont 
to  impede  labor.  Little  or  no  renal  tissue  may  be  noticeable,  altlioiigh  in 
microscopical  sections  it  is  seen  that  a  considerable  amount  remains  in 
the  interspaces.  The  cysts  contain  a  clear  or  turbid  iluid,  soniotimcs 
reddish  brown  or  even  blackish  in  color,  and  may  be  of  a  colloidal  consist- 
ence. Albumen,  blood  crystals,  cholesterin,  with  triple  phosphates  ami 
fat  drops  are  found  in  the  contents.  Urea  and  uric  acid  are  rarely  pres- 
ent. 'JMie  cysts  are  lined  by  a  flattened  epithelium.  It  is  not  vet  accu- 
rately known  )iow  these  cysts  origiiuitc.  Tliat  it  is  a  defect  in  (ievclop- 
meut  rather  than  a  pathological  change  is  suggested  by  the  fact  that  it  is 
often  in  the  embryo  associated  with  other  anomalies,  particularly  imper- 
forate anus.  Both  Shattock  and  Bland  Sutton,  who  have  studied  the 
question  carefully,  believe  fhat  the  anomaly  of  development  is  in  the  fail- 
ure of  complete  differentiation  of  the  Wolffian  bodies,  which  are,  as  it  were, 
mixed  with  the  kidneys  and  give  rise  to  the  cysts. 

In  a  large  majority  of  the  cases  death  occurs,  either  i)i  riiero  or  slioitly 
after  birth  ;  but  instances  are  met  with  at  all  ages  up  to  fifty  or  sixty  iiiui 
I  see  no  reason  to  suppose  that  these  arc  not  instances  of  persistence  of 
the  congenital  form. 

In  the  adult  the  tumors  may  l)e  felt  in  the  lumbar  region  as  laijre 
rounded  masses. 

The  symptoms  are  those  of  chronic  interstitial  nephritis.  JLkiV  of  tl'C 
cases  have  presented  no  indications  whatever  until  a  sudden  i.Uack  of 
urtemia;  others  have  died  of  heart-failure.  A  rare  termination  !n  a  case 
at  the  University  Hospital,  Philadelphia,  was  the  rupture  of  one  of  ttn' 
cysts  and  the  production  of  a  perinephritic  abscess.  The  card  in-vascular 
changes  induced  are  similar  to  those  of  interstitial  nephritis.  'I'lif  '('f* 
ventricle  is  hypertropliied  and  the  arterial  tension  is  greatly  increased. 
The  condition  is  compatible  with  excellent  health.  The  dan.iicrs  arc 
those  associated  with  chronic  Bright's  disease.  It  is  iniportiint  to  re- 
member that  the  conglomerate  cystic  kidney  is  almost  invariaMy  bilut- 


'.r'l 


PERINEPHRIC  ABSCESS. 


773 


end.  One  kidney  may  be  somewhat  larger  and  more  cystic  than  the 
other. 

The  diagnosis  can  sometimes  be  made.  Great  enlargement  of  both 
(ir<'iins,  with  hypertrophy  of  the  left  heart  and  increased  arterial  tension, 
woiihl  suggest  the  condition. 

Olierative  interference  is  not  justifiable.  I  know  an  instance  in 
whicli  one  kidney  was  removed  and  the  patient  died  within  twenty-four 
hours. 

(4)  Occasionally  the  kidneys  and  liver  present  numerous  small  cysts 
Rcattercd  through  the  substance.  The  spleen  also  may  be  involved.  The 
oysts  in  the  kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set 
as  in  tlie  conglomerate  form,  though  in  these  cases  the  condition  is  prob- 
ably the  result  of  some  congenital  defect.  There  are  cases,  however,  in 
wliicli  the  kidneys  are  very  large.  It  is  more  common  in  the  lower  ani- 
mals than  in  man.  I  have  seen  several  instanced  of  it  in  the  hog ;  in  one 
c;ise  the  liver  weighed  forty  pounds,  and  was  converted  into  a  niiiss  of  sim- 
ple cysts.  The  kidneys  were  less  involved.  Charles  Kennedy  *  states  that 
he  has  found  references  to  twelve  cases  of  combined  cystic  disease  of  tliB 
liver  and  kidneys. 

The  echinococcus  cysts  will  be  spoken  of  under  tlie  section  on  para- 
sites. 


ril'ii^ 


*     >i 


t      I 


i 


ir  region  as  h"',-'' 


XIII.  PERINEPHRIC  ABSCESS. 

Suppuration  in  the  connective  tissue  about  the  kidney  may  follow 
(1)  blows  and  injuries;  (2)  the  extension  of  inflammation  from  the  pelvis 
of  the  kidney,  the  kidney  itself,  or  the  ureters;  (3)  perforation  of  tho 
liowi'l,  most  commonly  the  appendix,  in  some  instances  the  colon ;  (4) 
extension  of  suppuration  from  the  spine,  as  in  caries,  or  from  the  pleura, 
us  in  empyema ;  (5)  as  a  sequel  of  the  fevers,  particularly  in  children. 

In  the  post-mortem  examination  of  a  case  of  perinephric  abscess  tho 
kiilney  is  found  surrounded  by  i)uh,  ])articularly  at  the  posterior  ])art, 
though  the  pus  may  lie  altogether  in  fi-ont,  between  the  kidney  and  the 
peritoiiivum.  Usually  the  abscess  cavity  is  large  and  extensive.  The  ])us 
i>  often  offensive  and  may  have  a  distinctly  fajcai  odor  from  contact  with 
the  liu-jfc!  bowel.  It  may  burrow  in  various  directions  and  may  burst  into 
the  pleura  and  be  discharged  through  tlic  lungs.  A  more  frequent  direc- 
ti'iu  is  down  the  psoas  muscle,  when  it  appears  in  the  groin,  or  it  may 
iMss  along  the  iliacus  fascia  and  appear  at  Poupart's  ligament.  It  may 
perforate  the  bowel  or  rupture  into  the  peritonieum,  and  in  some  instances 
it  has  penetrated  the  bladder  or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  pcrinejihritis 
"1  which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  witii  numi   - 

*  Laborutory  Rpporls  of  tlie  Royal  College  of  Physicians,  Edinburgh,  vol.  iii. 


<  mi 


774 


DISEASES  OP  THE  KIDNEYS. 


in 


ous  bands  of  fibrous  tissue,  and  is  stripped  off  from  the  proper  capsule 
with  the  greatest  difficulty.  Such  a  condition  probably  produces  no  symp- 
toms. 

Symptoms. — There  may  be  intense  pain,  aggravated  by  pressure,  in 
the  lumbar  region.  In  otlier  instances,  the  onset  is  insidious ;  there  is  no 
pain  in  the  renal  region,  but  on  the  first  examination  signs  of  deep-seated 
suppuration  may  be  detected.  On  the  affected  side  there  is  usually  pain, 
which  may  be  referred  to  the  neighborhood  of  the  liip-joint  or  radiate 
down  the  thigh  and  be  associated  with  retraction  of  the  testis.  Sometinios 
the  pain  is  referred  even  to  the  knee-joint,  as  in  hip-disease.  Tlie  patient 
lies  with  the  thigh  flexed,  so  as  to  relax  the  psoas  muscle,  and  in  waikini,' 
throws,  as  far  as  possible,  the  weight  on  the  opposite  leg.  According  to 
Gibney,  the  patient  keeps  the  spine  immobile,  assumes  a  stooping  posture 
in  walking,  and  has  great  difficulty  in  voluntarily  adducting  the  tliigh. 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the 
pelvis  or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has 
formed  there  are  usually  chills  with  irregular  fever  and  swea^^s.  Ou  ex- 
amination, deep-seated  induration  is  felt  between  the  l.'^s^  nu  }  Llie  crest 
of  the  ilium.  Bimanual  palpation  may  reveal  a  disLi  ■  .  .  /r  muss. 
CEdema  or  puffiness  of  the  skin  is  frequently  present. 

The  diagnosis  of  perinephric  abscess  is  usually  easy,  and  in  any  case 
when  doubt  exists  the  aspirator  needle  should  be  used.  We  can  not  always 
differentiate  the  primary  forms  from  those  due  to  perforation  of  ilie  kid- 
ney or  of  the  bowel.  This,  however,  makes  but  little  difference,  for  the 
treatment  is  identical.  It  is  usually  possible  by  the  history  and  examina- 
tion to  exclude  disease  of  the  vertebra.  In  (ihildren  the  condition  is  often 
mistaken  for  disease  of  the  hip-joint,  but  the  pain  is  higher,  and  there  is 
an  entire  absence  of  fulness  and  tenderness  over  the  hip-joint  itself. 

From  whatever  cause  produced,  the  indications  for  treatment  arc  iden- 
tical— early,  free,  and  permanent  drainage. 


tm 


il 


m. 


p. 


SECTION  VIII. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


I.  DISEASES  OF  THE  NERVES. 

1.  NEURITIS  {Inflammation  of  the  Nerve  Fibres). 

Neuritis  may  be  localized  in  a  single  nerve,  or  general,  involving  a 
hirge  number  of  nerves,  in  wliich  case  it  is  usually  known  as  imiUiple 
murilis  or  jjoJi/ neurit  is. 

Etiology. — Localized  neuritis  arises  from  (a)  cold,  wbieli  is  a  very 
frequent  cause,  as,  for  example,  in  the  facial  nerve.  This  is  sometimes 
known  as  rheumatic  neuritis.  (/;)  Traumatism — wounds,  blows,  direct 
pressure  on  tlic  nerves,  the  tearing  and  stretcliing  which  follow  a  disloca- 
tion or  a  fracture,  and  the  hypoderinio  injection  of  ether.  Under  this 
section  come  also  the  professional  iialsies,  due  to  pressure  in  the  exercise 
of  certain  occupations,  (c)  Extension  of  inflammation  from  neighboring 
parts,  as  in  a  neuritis  of  the  faciiU  nerve  due  to  caries  in  the  temporal  bone, 
or  in  that  met  with  in  syphilitic  disease  of  the  bones,  disease  of  the  joints, 
und  ooca^iionally  in  tumors. 

Multiple  ueut'itis  has  a  very  complex  etiology,  the  causes  of  which 
may  be  classified  as  follows  :  (a)  The  poisons  of  infectious  diseases,  as  in 
leprosy,  diphtheria,  typhoid  fever,  small-pox,  scarlet  fever,  and  occiusion- 
iilly  in  other  forms ;  {It)  tlie  organic  poisons,  comprising  the  diffusiblo 
stimulants,  such  as  alcohol  and  ether,  bisulpiude  of  carbon,  and  naphtha, 
and  the  metallic  bodies,  such  as  lead,  arsenic,  and  mercury ;  (c)  eachcctic 
conditions,  such  as  occur  in  ana3mia,  cancer,  tuberculosis,  or  marasmus 

•  I  liny  cause ;  (d)  the  endemic  neuritis  or  beri-beri ;  aiul  (e)  lastly, 
tiiire  lire  cases  in  which  none  of  the;'.o  factors  ])revail,  but  the  disease  sets 
in  suddenly  after  overexertion  or  exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflamma- 
tion the  nerve  is  usually  swollen,  infiltrated,  aiul  red  in  color.  The  in- 
flammation may  be  chiefly  periiumral  or  it  may  piuss  into  the  deeper 
portion — interstitial  neuritis — in  which  form  there  is  an  accumulation  of 
lymphoiil  elements  between  the  nerve  bundles.  The  nerve  fibres  them- 
selves may  not  appear  involved,  but  there  is  an  increase  in  the  nuclei  of 


1 


^1    i 


11 


^11 


**>     m'l 


fW'  '^ 


776 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  sheath  of  Scliwann.  The  myelin  is  fragmented,  the  nuclei  of  the  in- 
ternodul  cells  are  swollen,  and  the  axis  cylinders  present  varicosities  or 
undergo  granular  degeneration.  Ultimately  the  nerve  fibres  may  ])i'  com- 
pletely destroyed  and  replaced  by  a  fibrous  connective  tissue  in  uhicli 
much  fat  is  sometimes  deposited — the  lipomafous  neuritis  of  Leyden. 

In  other  instances  the  condition  is  iavmeA  parenchymatous,  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  WalUiiaii 
degeneration,  which  follows  when  the  nerve  is  cut  off  from  its  cfiitiv. 
The  medullary  substance  and  the  axis  cylinders  are  chiefly  involved,  llic 
interstitial  tissue  being  but  little  altered  or  only  affected  secondarily.  The 
myelin  becomes  segmented  and  divides  into  small  globules  and  graiuilos, 
and  the  axis  cylinders  become  granular,  broken,  subdivided,  and  ulti- 
mately distippear.  The  nuclei  of  the  sheath  of  Schwann  prolil'onite  umi 
u'^nuitely  the  fibres  are  reduced  to  a  state  of  atrophic  tubes  witlumtii 
tr,.  :  *  *^' 0  normal  structure.  The  muscles  connected  with  the  degenerated 
nervi  dly  show  marked  atrophic  changes,  and  in  some  instaiipcs  the 

change  .  .  the  nerve  sheath  appears  to  extend  directly  to  the  inteis^titial 
tissue  of  the  muscles — the  neuritis  fa^ciafis  of  Eichhorst. 

Symptoms,  (a)  Localized  Neuritis.— As  a  rule  the  constitutional 
disturbances  are  slight.  The  most  important  symptom  is  pain  of  a,  bor- 
ing or  stabbing  character,  usually  felt  in  the  course  of  the  nerve  and  in 
tho  parts  to  which  it  is  distributed.  The  nerve  itself  is  sensitive  to  iircjs- 
ure,  probably,  as  ^yeir  Mitchell  suggests,  owing  to  the  irritation  of  its  nervi 
nervorum.  The  skin  may  bo  slightly  reddened  or  even  codeniatoiis  over 
the  seat  of  the  inflammation.  Mitchell  has  described  increase  in  tho  tisii- 
pcrature  and  sweating  in  thp  affected  region,  arul  such  trojihic  disturhanws 
as  effusion  into  the  joints  and  herpes.  The  function  of  the  nuiscle  to 
which  the  nerve  fibres  are  distributed  is  impaired,  motion  is  painful, 
and  there  may  be  twitchings  or  contractions.  The  tactile  sensation  uf 
the  part  may  be  somewhat  deadened,  even  when  the  pain  is  gicatly  in- 
creased. In  tho  more  chronic  cases  of  local  neuritis,  such,  for  instance,  ii- 
follow  the  dislocation  of  the  humerus,  the  localized  pain,  which  at  first  may 
bo  severe,  gratlually  disaj)pears,  though  some  sensitiveness  of  the  liracliial 
plexus  may  persist  for  a  long  time,  and  the  nerve  cords  may  be  fidt  tolv 
swollen  and  firm.  'J'he  pain  is  variable — sometimes  intense  and  distrcs- 
ing;  at  others  not  causing  much  inconvenience.  Numbness  and  I'orniicii- 
tion  may  be  present  ami  tlie  tactile  sensation  may  be  greatly  impainJ 
The  motor  disturbances  are  marked.  Ultimately  there  is  extreme  atrophy 
of  the  muscles.  Contractures  may  occur  in  the  fingers.  The  skin  nmy  hi' 
reddened  or  glossy,  the  subcutaneous  tissue  oedematous,  and  the  luitritimi 
of  tho  nails  may  be  defective. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  iipwiird- 
the  so-called  ascending  or  migrating  neuritis — and  involve  the  lar;rt'i' 
nerve  trunks,  or  even  reach  the  spinal  cord,  causing  subacuto  myelitis 
^(Gowers).     Tiius,  in  u  cose  reported  by  James  Stewart,  a  girl  of  fourteeQ 


NEURITIS. 


1  ^ 


had  severe  pain  in  tlie  big  toe  of  the  left  foot,  which  graduully  extended 
up  Ihe  leg  and  resisted  all  treatment  until  a  portion  of  the  sciatio  nerve 
was  removed.  A  year  later  she  had  pain  in  the  little  finger  of  the  left 
liuiul,  which  gradually  ascended  along  the  ulnar  nerve  and  required  for 
its  rt'lief  division  and  stretching.  It  has  been  suggested  that  the  paralysis 
si'condary  to  visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascend- 
iiijf  neuritis.  The  inflammation  nuiy  extend  to  the  nerves  of  the  other 
side,  either  through  the  spinal  cord  or  its  membranes,  or  without  any  in- 
volvuinent  of  the  nerve  centres,  the  so-called  symi)athetic  neuritis.  The 
eluctrical  changes  in  localized  neuritis  vary  a  great  deal,  depending  upon 
the  extent  to  whitili  the  nerve  is  injured.  The  lesion  may  be  so  slight 
that  tlie  nerve  and  the  muscles  to  which  it  is  distributed  may  react  nor- 
mally to  both  currents ;  or  it  may  bo  so  severe  that  the  typical  reaction  of 
degeneration  develops  within  a  few  days,  i.  e.,  the  nerve  does  not  respond 
to  stinudation  by  either  current  while  the  muscle  reacts  only  to  the  gal- 
vanic current  and  in  a  peculiar  manner.  The  contraction  caused  is  slow 
and  lazy,  instead  of  sharp  and  (juick  as  in  the  normal  muscle,  and  the  AnC 
contraction  is  usually  stronger  than  the  CO  contraction.  Between  these 
two  extremes  there  are  many  diiferent  grades  and  a  careful  electrical 
examination  is  most  important  as  an  aid  to  diagnosis  and  prognosis.* 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight 
traumatic  neuritis  may  pass  oif  in  a  day  or  two,  while  the  severer  cases, 
such  as  follow  unreduced  dislocation  of  the  humerus,  may  persist  for 
months  or  never  be  completely  relieved. 

{b)  Multiple  Neuritis.— This  presents  a  complex  symptomatology.  The 
folhjwing  are  the  most  important  groups  of  cases : 

(1)  Acute  Febrile  Polyneuritis. — The  attack  follows  exposure  to  cold 
or  overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  on- 
set resembles  that  of  an  acute  infectious  disease.  There  may  be  a  definite 
chill,  pains  in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  thought 
to  be  acute  rheumatism.  The  temperature  rises  rapidly  and  may  reach 
103"^  or  10-i°.  There  are  headache,  loss  of  appetite,  and  the  general  symp- 
toms of  acute  infection.  The  limbs  and  back  ache.  Intense  pain  in  the 
nerves,  however,  is  by  no  means  constant.  Tingling  and  formication  are 
felt  ill  the  fingers  and  toes,  and  there  is  increased  sensitiveness  of  the  nerve 
trunks  or  of  the  entire  limb.  Loss  of  muscular  power,  first  marked,  per- 
haps, in  the  legs,  gradually  comes  on  and  extends  with  the  features  of  an 
ascending  paralysis.  In  other  cases  the  paralysis  begins  in  the  arms.  The 
extensors  of  the  wrists  and  the  flexors  of  the  ankles  are  early  affected,  so 
that  there  is  foot  and  wrist  drop.  In  severe  cases  there  is  general  loss  of 
miiseular  power,  producing  a  flabby  paralysis,  which  may  extend  to  the 
muscles  of  the  face  and  to  the  intercostals,  and  respiration  may  be  carried 
on  by  the  diaphragm  alone.     The  muscles  soften  and  waste  rapidly.    There 


*  See  under  facial  paralysis. 


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DISEASES  OP  THE  NERVOUS  SYSTEM. 


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may  be  only  hyperapsthesia  with  soreness  and  stiffness  of  the  limbs  ;  in  some 
(;ases,  increased  sensitiveness  with  ana'sthesia ;  in  other  instances  the  sen- 
sory distnrbances  an>  slight.  The  clinical  picture  is  not  to  be  distin- 
guishod,  in  many  cases,  from  Landry's  jjaralysis;  in  others,  from  Vnv  siili- 
acute  myelitis  of  Duchenne.  James  Koss  concludes  from  an  itnalysis  of 
all  the  reported  cases  of  the  former  disease  that  it  coincides  v  ith  nuiltiple 
neuritis  in  general  etiology,  symptoms,  and  course.  On  the  other  liaiiil, 
Jlun,  in  a  very  thorough  study  of  a  recent  case  of  Landry's  paralysin,  con- 
cludes that  it  is  a  separate  and  distinctive  disease. 

The  course  is  variable.  Li  the  most  intense  forms  the  patient  may  die 
in  a  week  or  ten  days,  with  involvement  of  the  respiratory  muscles  or  from 
paralysis  of  the  heart.  As  a  rule  in  cases  of  moderate  severity,  after  yw- 
sisting  for  five  or  six  weeks,  the  condition  remains  stationary  and  then  slow 
improvement  begins.  The  paralysis  in  some  muscles  may  persist  for  many 
months  and  contractures  may  occur  from  shortening  of  the  muscles,  but 
even  when  this  occurs  the  outlook  is,  as  a  rule,  good,  although  the  pa- 
ralysis may  have  lasted  for  a  year  or  more. 

(2)  Recurring  Multiple  Neuritis. — Under  the  term  polyneuritis  re- 
currens  Mary  Sherwood  has  described  from  Eichhorst's  clinic  two  cases  in 
adults — in  one  case  involving  the  nerves  of  the  right  arm,  in  tlie  otlier 
both  legs.  In  one  patient  there  were  three  attacks,  iu  the  other  two,  the 
distribution  in  the  various  attacks  being  identical.  There  has  recently 
been  at  my  clinic  a  somewhat  similar  case — a  man,  aged  thirty-one,  who 
had,  two  and  a  half  years  ago,  widespread  paralysis,  and  who  now  lias  a 
second  attack. 

(3)  Alcoholic  Neuritis. — This,  perhaps  the  most  important  form  of 
multiple  neuritis,  was  described  in  1822  by  James  Jackson,  Sr.,  of  Bos- 
ton, Avhose  account  of  it  is  very  graphic.  Wilks  recognized  it  as  alcoholic 
paraplegia,  but  the  starting  point  of  the  recent  researches  on  the  disease 
dates  from  the  observation  of  Dumenil,  of  Rouen.  Of  late  yeais  our 
knowledge  of  the  disease  has  extended  rai)idly,  owing  to  the  researches  of 
Huss,  Leyden,  James  Ross,  Buzzard,  and  Henry  Ilun.  It  occurs  most 
frequently  in  women,  particularly  steady,  quiet  tipplers.  Its  appearance 
may  be  the  first  revelation  to  the  physician  or  to  the  family  of  habits  of 
secret  drinking.  The  onset  is  usually  gradual,  and  may  be  preceded  for 
weeks  or  months  by  neuralgic  pains  and  tingling  in  the  feet  and  hands. 
Convulsions  are  not  uncommon.  Fever  is  rare.  The  paralysis  gradually  sets 
in,  at  first  in  the  feet  and  legs,  and  then  in  the  hands  and  forearms.  The 
extensors  are  affected  more  than  the  flexors,  so  that  there  is  wrist-di'']*  ami 
foot-drop.  The  paralysis  may  be  thus  limited  and  not  extend  hi;^her  in 
the  limbs.  In  other  instances  there  is  paraplegia  alone,  while  in  the  most 
extreme  cases  all  the  extremities  are  involved.  In  rare  instances  the  lacial 
muscles  and  the  sphincters  are  also  affected.  A  case  with  this  distiilmtion 
recovered  in  my  wards  last  year.  The  sensory  symptoms  are  very  vai  lable. 
There  are  cases  in  which  there  are  numbness  and  tingling  only,  without 


NEURITIS. 


779 


greiit  pain.  In  other  cases  there  are  severe  burning  or  boring  pains,  the 
iiervo  trunks  are  sensitive,  and  tlie  muscles  are  sore  when  grasped.  The 
luinds  and  feet  are  frequently  swollen  and  congested,  purticularly  when 
holt]  down  for  a  few  moments.  The  cutaneous  reflexes  as  a  rule  are  pre- 
served.    The  deep  reflexes  are  usually  lost. 

Tlie  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after 
piTsisting  for  weeks  or  months  improvement  gradually  begins,  the  mus- 
cles regain  their  power,  and  even  in  the  most  desperate  cases  recovery  may 
follow.  The  extensors  of  the  feet  may  remain  paralyzed  for  some  time, 
iiiul  give  to  the  patient  a  distinctive  walk,  the  so-called  afeppaf/c  gait, 
t'iiaracteristic  of  peripheral  neuritis.  It  is  sometimes  known  as  the  pseudo- 
tiibetio  gait,  although  in  reality  it  could  not  well  be  mistaken  for  the  gait 
of  ataxia.  The  foot  is  thrown  forcibly  forward,  the  toe  lifted  high  in  the 
air  so  as  not  to  trip  upon  it.  Tlio  heel  is  brought  down  first  and  then  the 
entire  foot.  It  is  an  awkward,  clumsy  gait,  and  gives  the  patient  the  ap- 
pearance of  constantly  stepping  over  obstacles.  Among  the  most  striding 
features  of  alcoholic  neuritis  are  the  mental  symi)toms.  Delirium  is  com- 
mon, and  hallucinations  with  extravagant  ideas,  resembling  somewhat 
those  of  general  paralysis.  In  some  cases  the  picture  is  that  of  ordinary 
delirium  tremens,  but  the  most  peculiar  and  almost  characteristic  mental 
disorder  is  that  so  well  described  by  Wilks,  in  which  thn  patient  loses  all 
appreciation  of  time  and  place,  and  describes  with  circumstantial  details 
long  journeys  which  he  has  recently  taken,  or  tells  of  persons  whom  he  has 
just  seen. 

(4)  Multiple  Neuritis  in  the  Infectious  Diseases. — These  have  been  al- 
ready referred  to,  particularly  in  diphtheria,  in  which  it  is  most  common. 
The  peripheral  nature  of  the  lesion  in  these  instances  has  been  shown  by 
post-mortem  examination.  The  outlook  is  usually  favorable  and,  except 
in  diphtheria,  fatal  cases  are  uncommon.  Multiple  neuritis  in  tuberculosis, 
diabetes,  and  syphilis  is  of  the  same  nature,  probably  due  to  toxic  materials 
absorbed  into  the  blood. 

(o)  Arsenical  and  Saturnine  JVeuritis. — The  arsenical  neuritis  is  not 
common  ;  only  a  single  instance  of  it  has  come  under  my  observation.  No 
ease  to  my  knowledge  has  followed  the  use  of  Fowler's  solution  in  my 
ward  or  dispensary  practice,  although  I  am  in  the  habit  of  giving  in 
chorea  and  anaemia  doses  which  might  be  regarded  as  excessive.  The 
most  common  causes  are  accidental  poisoning,  as  in  the  case-i  reported  by 
Mills.  In  a  case  of  E.  G.  Cutler  the  patient  got  the  arsenic  from  green- 
piipor  tags,  which  he  was  in  the  habit  of  putting  in  his  mouth.  The  gen- 
eral symptoms  are  iiot  unlike  those  of  alcoholic  paralysis ;  the  weakness  of 
the  extensors  is  marked  and  the  steppage  gait  characteristic.  The  neuritis 
due  to  load  will  be  discussed  in  the  consideration  of  lead  poisoning.  The 
special  involvement  of  the  motor  nerves  and  the  great  frequency  of  tho 
occurrence  of  wrist-drop  are  the  peculiarities  of  this  form. 

A  similar  form  of  neuritis  is  caused  by  the  bisulphide  of  carbon. 


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DISEASES  OF  THE   NERVOUS  SYSTEM. 


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(6)  Endemic  Ih^irUis  ;  licri-beri. — This  is  a  widely  spread  discuso  in 
parts  of  India,  and  iu  China  and  .Japan.  To  Slinuho  and  Baelz  arc  (hie 
tlio  credit  of  determining  its  true  nature.  It  is  probably  due  to  a  iiiicni- 
organism.  Food  appears  also  to  have  a  large  share  in  its  causation  aiui  it 
has  been  attributed  to  a  fish  diet.  Some  have  thouglit  it  miglit  he  (luc 
to  the  presence  of  parasites  in  the  intestines,  but  there  are  no  grounds  for 
this  belief.  There  are  several  types  of  cases.  In  the  acute  poriiicions 
form  the  nervous  phenomena  are  not  so  marked.  There  are  fever,  anniniii, 
and  general  anasarca.  In  another  group  of  cases  there  arc  luiiiiljiK'Sis, 
loss  of  tendon  reflexes,  areas  of  anaesthesia,  and  muscular  atrojjjiy  and 
anasarca.  In  other  cases  the  paralysis  and  atrophy  are  the  nu).st  jiroiiu- 
Tient  symptoms  and  the  clinical  i)icture  is  that  of  a  rapidly  progrtssinj.' 
multiple  neuritis  with  sensory  and  motor  disturbances.  The  luoitulitv 
varies  from  three  or  four  to  fifty  per  cent.  (Jreat  difference  of  (»|iiiii(iii 
still  prevails  concerning  the  cause  of  the  disease.  Special  interct^t  lias  been 
aroused  in  the  subject  in  this  country,  owing  to  the  fact  that  J.  .1.  I'litiumi 
has  described  a  siniil-ir  disorder  among  the  A'ew  England  fishermen  who  fiv- 
quent  the  Grand  Banks.  It  occurs  in  epidemic  form,  and  has,  as  proinimnt 
symptoms,  general  ccdema,  shortness  of  breath,  and  sensory  di.stuiliunccs 
with  paralysis.  In  other  instances,  the  i)aralysis  is  more  extensive  and 
proves  fatal.  In  1881  and  1889  there  Avere  ejiidemics  among  the  crews  (if 
vessels  fishing  in  this  region.  Birge  describes  eleven  cases  which  occurred 
on  one  vessel  in  a  crew  of  thirteen,  two  of  whom  died.  One  patient  of 
this  crew  I  saw  with  F.  C.  Shattuck,  in  the  ^Massachusetts  General  Hos- 
pital, with  the  well-marked  symptoms  of  multiple  neuritis.  The  disease 
also  exists  in  the  West  Indies,  whence  cases  have  come  to  this  country 
(Seguin). 

Diagnosis. — The  electrical  condition  in  multiple  neuritis  is  tliio 
described  by  Allen  Starr  :  "  The  excitability  is  very  rapidly  and  markedly 
changed;  but  the  conditions  which  have  been  observed  are  quite  various. 
Sometimes  there  is  a  simple  diminution  of  excitability,  and  then  a  very 
strong  faradic  or  galvanic  current  is  needed  to  produce  contractions. 
Frequently  all  faradic  excitability  is  lost  and  then  the  muscles  contract  to 
a  galvanic  current  only.  In  this  condition  it  may  require  a  very  stron;: 
galvanic  current  to  produce  contraction,  an<l  thus  far  it  is  quite  i)atlioi;- 
nomonic  of  neuritis.  For  in  anterior  polio-myelitis,  Avhero  the  muscles  re- 
spond to  galvanism  only,  it  does  not  require  a  strong  current  to  cause  a 
motion  until  some  months  after  the  invasion. 

"  The  action  of  the  different  poles  is  not  uniform.  In  many  cases 
the  contraction  of  the  muscle  when  stimulated  with  the  positive  jiolo 
is  greater  than  Avhen  stimulated  with  the  negative  pole,  and  the  con- 
tractions may  bo  sluggish.  Then  the  reaction  of  degeneration  is  pres- 
ent. But  in  some  cases  the  normal  condition  is  found  and  the  nega- 
tive pole  produces  stronger  contractions  than  the  positive  pole.  A  loss 
of  faradic  irritability  and  a  marked  decrease  in  the  galvanic  irritability  o- 


NEUROMATA. 


781 


the  muscle  and  nerve  are   therefore   important  symptoms  of   multiple 
neuritis."  * 

'riicre  is  rarely  any  difliculty  in  distinguish inpj  tlio  alcohol  cases.  The 
{'oriihination  of  wrist  and  foot  drop  with  congestion  of  the  hands  and  feet, 
and  tlie  peculiar  delirium  already  referred  to,  is  quite  characteristic.  The 
riiiiiilly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching 
to  the  face  and  involving  the  sphincters,  arc  more  commoidy  regarded  as 
of  ?pinal  origin,  hnt  the  general  opinicm  seems  to  point  strojigly  to  the 
fact  that  all  such  cases  are  peripheral.  The  less  acute  cases,  in  which  the 
paralysis  gradually  involves  the  legs  and  arms  with  rapid  wasting,  simu- 
late closely  and  ai'e  usually  confounded  with  the  suhacute  atrophic  spinal 
paralysis  of  Duchennc.  The  diagnosis  from  locomotor  ataxia  is  rarely 
(liflicult.  The  fifppjxtf/e  gait  is  entirely  different  from  that  of  tal)cs.  There 
i,-(  rarely  positive  incoordiiuition.  The  patient  can  usually  stand  well  v.'ith 
the  eyes  closed.  Foot-drop  is  not  common  in  locomotor  ataxia.  The 
liglitning  pains  are  absent  and  there  are  no  pupillary  symptoms.  The  eti- 
ology, too,  is  of  moment.  The  patient  is  recovering  from  a  paralysis  which 
has  been  more  extensive,  or  from  arsenical  poisoning  or  has  (lial)etes. 

Treatment. — llest  in  IhxI  is  essential.  In  the  acute  cases  with  fever, 
the  salicylates  and  antipyi'in  are  recommended.  'I'o  alliiy  the  intense 
pain  nior])lua  or  the  hot  applications  of  lead  Avater  and  laudanum  are 
often  rerpiired.  Great  care  must  be  exercised  in  treating  the  alcoholic 
form,  and  the  attend.mt  must  not  allow  himself  to  be  deceived  by  the 
iilatements  of  the  relatives.  It  is  sometimes  exceedingly  diflicult  to  get  a 
history  of  spirit-drinking.  In  the  alcoholic  form  it  is  well  to  reduce  the 
stimulants  gi'adually.  If  there  is  any  tendency  to  bed-sore  an  air-bed 
should  be  used  or  the  patient  placed  in  a  continuous  bath.  Oentle  fric- 
tion of  the  muscles  may  be  applied  from  the  outset,  and  in  the  later  stages, 
when  the  atrophy  is  marked  and  the  pains  have  lessened,  massage  is  prob- 
ably the  most  reliable  means  at  our  command.  Contractures  may  be 
gradually  overcome  by  passive  movements  and  extension.  Often,  with 
the  most  extreme  deforinity  from  contracture,  recovery  is,  in  tinus  still 
po.;sil)le.  The  interrupted  current  is  useful  when  the  acute  stage  is 
passed. 

Of  intoriud  remedies,  strychnia  is  of  value  and  may  be  given  in  in- 
creasing doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history 
of  sy[)hilis  the  iodide  of  potassium  and  mercury  may  be  given. 


'x: 
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II.  NEUROMATA. 


Hi- 


Tumors  situated  on  nerve  fibres  may  consist  of  nerve  substance  proper, 
the  true  neuromata,  or  of  fibrons  tissue,  the  false  neuromata.      The  true 

*  Lectures  on  Neuritis,  Medical  Record,  New  Y^ork,  1887. 


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782 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


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nouroma  usually  contains  norvo  fibres  only,  or  in  rare  instances  ganf,'iion 
cells.  C'ases  of  ganglionic  or  metlullary  nouroma  are  extremely  ruro; 
some  of  them,  as  Lancereaux  suggests,  are  utuloubtedly  instances  of  mal- 
formation of  the  brain  substance.  In  other  instances,  as  in  the  ci;jo  which 
I  reported,*  the  tumor  is,  in  all  probability,  a  glioma  with  cells  clo«;ly  re- 
sembling those  of  the  central  nervous  system.  The  true  faseicirar  neu- 
roma occurs  in  the  form  of  the  snuiU  subcutaneous  painful  tumor  —tuber- 
cula  dolorosa — which  is  situated  on  the  nerves  of  the  skin  a'jout  the 
joints,  sometimes  on  the  face  or  on  the  breast.  It  is  not  always  made  ii[i 
of  nerve  fibres,  but  nuiy  bo,  as  shown  by  Iloggau,  an  adenomatous  growtli 
of  the  sweat  glands. 

The  true  neuromata,  as  a  rule,  are  not  painful,  and  occasionally  are 
found  associated  with  the  nerve  fibres  in  various  regions.  Those  which 
develop  at  the  ends  and  along  the  course  of  the  nerves  of  the  stump  after 
amputation  consist  of  connective  tissue  and  of  medullated  and  non-iricfhil- 
lated  nerve  fibres.  The  most  remarkable  form  is  the  plex  if  or  in  neuroma^ 
in  which  the  various  nerve  cords  are  occupied  by  many  hundreds  of 
tumors.  The  cases  are  usually  congenital.  The  tumors  occur  in  nil  the 
nerves  of  the  body.  One  of  the  most  remarkable  is  that  described  by 
Piudden,  the  si^ecimcns  of  which  are  in  the  medical  museum  of  Cohuiibia 
College,  New  York.  IMiere  were  over  1,183  distinct  tumors  distributed  on 
the  nerves  oi  the  body,  Pruddeu  f  has  collected  forty-one  cases  from  tiie 
literature,  in  a  majority  of  which  the  peripheral  nerves  were  aifcctcd. 

Neuromata  rarely  cause  symjitoms,  except  the  subcutaneous  ])ainfiil 
tumor  or  those  in  the  amputation  stump.  Here  they  may  be  very  pain- 
ful and  cause  £,reat  distress.-  Motor  symptoms  are  sometimes  present, 
particularly  a  constant  twitching.  Epilepsy  has  sometimes  been  asso- 
ciated, and  relief  has  followed  removal  of  the  growths. 

The  only  available  treatment  is  excision.  The  aubcutaneous  painful 
tumor  does  not  return,  and  excision  completely  relieves  the  symptoms. 
On  the  other  hand,  the  amputation  neuromata  may  recur. 


III.    DISEASES  OF  THE  CRANIAL  NERVES. 

I.  Olfactory  Nerve. 

The  functions  of  this  nerve  may  be  disturbed  at  its  peripheral  ending, 
at  the  bulb,  in  the  course  of  the  nerve,  or  at  the  central  origin  in  the  brain. 
The  disturbances  may  be  manifested  in  subjective  sensations  of  smell, 
complete  loss  of  the  sense,  and  occasionally  in  hypersesthesia. 

{a)  Subjective  Sensations  ;  Parosmia. — Hallucinations  of  this  kind  are 
found  in  the  insane  and  in  epilepsy.     The  aura  may  be  represented  by  an 

•  Journal  of  Anatomy  and  Physiology,  vol.  xv. 

f  American  Journal  of  the  Medical  Sciences,  vol.  Ixicx. 


DISEASES  OF  THE  CRANIA li  NERVES. 


783 


unplousant  odor,  described  U3  resembling  chloride  of  lime,  burning  rugs 
or  feathers.  In  ii  few  cases  with  these  subjective  sensations  tumors  have 
boon  found  in  the  hippocampal  lobules.  In  rare  instances,  after  injury  of 
tliu  head  the  sense  is  jjerverted — odors  of  the  most  ditTerent  character  nuiy 
bo  alike,  or  the  odor  may  be  changed,  as  in  a  patient  noted  by  Morell 
.Ma('i<enzie,  who  for  some  time  could  not  touch  cooked  meat,  as  it  smelt 
to  hor  exactly  like  stinking  fish. 

{/j)  liirrcuficd  snnsilireiu'ss,  or  ht/perosmin,  occurs  chiefly  in  nervous, 
hysterical  women,  in  whom  it  may  sometimes  be  developed  so  greatly  that, 
like  a  dog,  they  can  recognize  the  dilfercnco  between  individuals  by  the 
odor  alone. 

(r)  Attosmin  ;  Loss  of  the  Sense  of  SiticU. — This  may  be  produced  by: 
(1)  Atrt!cti(m8  of  the  termination  of  the  nerve  in  the  mucous  membrane, 
which  is  perhaps  the  most  frequent  cause.  It  is  by  no  means  uncommon 
in  association  with  chronic  nasal  catarrh  rnd  polypi.  In  paralysis  of  the 
lifth  nerve,  the  sense  of  smell  may  bo  lost  on  the  affected  side,  owing  to 
iuterferenco  with  the  secretion. 

It  is  doubtful  whether  the  cases  of  loss  of  smell  following  the  inhala- 
tions of  very  foul  or  strong  odors  should  come  under  this  or  under  the 
central  division. 

(•■i)  The  lesions  of  the  bulb  or  of  the  nerves.  In  falls  or  blows,  in 
curios  of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  nerve 
trunks  may  bo  involved.  After  an  injury  to  tho  head  the  loss  of  smell 
may  he  the  only  symptom.  Mackenzie  notes  a  case  of  a  surgeon  who  was 
thrown  from  his  gig  and  lighted  on  his  head.  Tho  injury  was  slight,  but 
the  anosmia  which  followed  was  persistent.  In  locomotor  ataxia  the  sense 
of  smell  may  be  lost,  due  possil)ly  to  atrophy  of  tho  noiTcs. 

(.'})  Lesions  of  the  olfactory  centre.  There  are  congenital  cases  in 
which  tho  nerve  structures  have  not  been  developed.  Cases  have  been  re- 
ported by  Beevor,  Ilughlings  Jackson,  and  others,  in  which  this  symp- 
tom has  been  associated  with  disease  in  tho  hemisphere.  The  centre  for 
the  sense  of  smell  is  placed  by  Ferrier  in  the  uncinate  gyrus. 

To  test  the  sense  of  smell  tho  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  such  substiinces  as  cloves, 
peppermint,  and  musk.  This  sense  is  readily  tested  as  a  routine  matter  in 
brain  cases  by  having  two  or  three  bottles  containing,  .he  essential  oils. 
In  all  instances  a  rhinoscopical  examination  should  bo  made,  as  the  con- 
dition may  be  due  to  local,  not  central  causes.  The  treatment  is  unsatis- 
factory even  in  tho  cases  due  to  local  lesions  in  the  nostrils. 

II.  Optic  Nerve  and  Tract. 

(1)  Lesions  of  the  Retina. 

These  are  of  importance  to  the  physician,  and  information  of  the 
greatest  value  may  bo  obtained  by  a  systematic  examination  of  tho  eye- 


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784 


DISEASES  OP  THE  NKUVOUS  SYSTEM. 


^ToundH.  Only  a  brief  roftTcnoo  can  lioro  bo  matlo  to  tho  more  iiiipor- 
tunt  of  tb(^  ai)i)eanitK'os. 

{(i)  Retinitis. — 'i'liis  offurH  in  certain  }:fenenil  afTections,  more  jiarlii'ii- 
lurly  iti  liri^'iil's  di.sease,  Hyi)hilis,  K'uka'tuia,  and  ana'nda.  The  (uiniiKiii 
feature  in  all  these  states  is  the  occurrence  of  ha'in()rrha;:;o  ami  the  dc- 
V(!lopment  of  oj)acities.  'J'hero  may  also  be  a  dilTuso  cloudiness  due  td 
elTusion  of  serum.  The  lueniorrha^es  are  in  the  layer  of  nerve  libns. 
They  vary  {greatly  in  size  and  form,  but  often  follow  the  course  of  vcsscN. 
When  recent  the  color  is  bri;,'ht  red,  but  they  {jfradually  change  and  dlil 
haemorrhages  are  almost  bh'ick.  The  white  s])ot8  are  due  either  to  lihiin- 
ous  exudate  or  to  fatty  degeneration  of  the  retinal  elements,  and  oeeusidii- 
ally  to  accumulation  of  leucocytes  or  to  a  b)calized  sclerosis  of  the  rctiiml 
elements.  The  more  important  of  the  forms  of  retinitis  to  be  recdguiztd 
are : 

Albumimine  rcHiiid's,  wliidi  occurs  in  chronic  nephritis,  particularly 
ill  the  interstitial  or  contracted  form.  The  i)t'rcentage  of  cases  allVctcd 
is  from  fifteen  to  twenty-five.  There  ant  instances  in  which  these  retiii;il 
changes  are  associated  with  tlie  granular  kidney  at  a  stage  when  the 
amount  of  albumen  may  be  slight  or  transient;  but  in  all  such  instances 
it  will  be  found  that  there  is  a  marked  arterio-selerosis,  (iowers  rccoi.'- 
nizcs  a  dcfgcncrative  form  (most  common),  in  which,  with  the  retinal 
changes,  there  may  be  s(!arcely  any  alteration  in  the  disk  ;  a  iion'liaj^ii' 
form,  with  many  liaMnorrhages  and  but  slight  signs  of  inila  'on ;  and 

an  inflamnuitory  form,  in  whicli  there  is  much  swelling  of  the  retina  and 
obscuration  of  the  disk.  It  is  noteworthy  that  in  some  instances  tlie  in- 
flammation of  the  optic  nerve  predominates  over  the  other  retinal  changi's 
and  one  may  be  in  doubt  for-a  time  whether  the  (iondition  is  really  asso- 
ciated with  the  renal  changes  or  dependent  upon  intracranial  disease. 

Syphilitic  Jiefiuitis. — In  the  acquired  form  this  is  less  comtnon  than 
choroiditis.  In  inherited  syphilis  ret inilis pigmentosa  h  sometimes  met 
with. 

Retinitis  in  Anmmin. — It  has  long  been  known  that  a  patient  may 
become  blind  after  a  large  haemorrhage,  either  suddenly  or  within  two  or 
three  days,  and  in  one  or  both  eyes.  Occasionally  the  loss  may  be  iiernia- 
iiont  and  complete.  In  some  of  these  instances  a  neuro-rctinitis  has  been 
found,  probably  sufficient  to  account  for  the  symptoms.  In  the  more 
fdironic  anaemias,  particularly  inthe  pernicious  form,  retinitis  is  eonimon, 
as  determined  first  by  Quincke. 

In  malaria  retinitis  or  ncuro-rotinitis  may  bo  present,  as  noted  by 
Stephen  Mackenzie.  It  is  seen  only  in  the  chronic  cases  with  ana'niia, 
and  in  my  experience  is  not  nearly  so  common  proportionately  as  in  per- 
nicious anfomia.  Of  many  instances  which  have  come  under  my  oiiserva- 
tion  of  severe  malarial  anaemia,  particularly  at  the  Philadelphia  Hospital, 
there  were  only  two  with  retinal  hiEmorrhages. 

Letikmnic  Retinitis. — lu  this  affection  the  retinal  veins  arc  largo 


t  more  iiiijior- 


DISEASKS  OK  THK  CIIANIAL  NKllVKS. 


785 


iind  (listondcd  ;  tlicro  is  also  u  peculiar  retinitis,  as  dt'scrihod  hy  liiohrcicdi. 
It  is  not  very  common.  Of  tlic  seventeen  (uises  of  l(!iika;mia  wliich  liavo 
(Oiiir  under  my  observation,  retinitis  existed  in  only  three  of  tiie  ten  in 
wliirli  the  eye-grouiuis  were  examined.  Thoro  are  numerous  lia;mor- 
ihiiL'i-t  and  white  or  yellow  areas,  which  may  bu  lar^(>  and  prominent. 
Ill  one  of  my  eases  the  retina  post  mortem  was  oecuipietl  iiy  many  small, 
imaque,  white  spots,  lookinj^  like  little  tumors,  the  lar^»'r  of  whicii  had  a 
(liiiiDcter  of  nearly  two  millimetres.  In  Case  13  of  my  series  the  leukuiinia 
was  iliaf,'n()se(I  by  Norris  and  De  Schweinitz,  ut  whoso  clinic  the  patient 
liuil  applied  on  account  of  failing  vision,  from  the  condition  of  the  oyo- 
fjroiiiids  alone. 

Urtinitis  is  also  found  occasionally  in  diabetes,  in  pur])ura,  in  chronio 
lead  poisoning,  and  sometinuis  as  an  idiopathic  all'ection. 

{//)  Functional  Disturbances  of  the  Retina.  (1)  Tiuie  Antnurosis. — 
Tills  oc<'urs  in  unemia  and  may  follow  convulsions  or  come  on  independ- 
ently. 'JMius,  a  paticwit  who  iiad  become  suddcidy  blind  the  previous  day, 
was  led  into  one  of  my  wards  at  the  Montreal  (ieiieral  Hospital.  He  had 
had  no  s()ecial  symptoms,  but  examination  showed  extensive  cardio-va8- 
culiir  changes.  The  urine  was  albuminous.  The  oplithalmosc()])ic  exam- 
ination was  negative.  The  condition,  a<  a  rule,  persists  only  for  a  day 
or  two.  This  form  of  amaurosis  occurs  in  j)oisoning  by  lead  and  o(!ca- 
Hionally  by  (piininc.  It  seems  more  probable  that  the  poisons  act  on  the 
centres  and  not  on  the  retina. 

(•.')  I/i/sfcrical  Amaurosis. — ifore  frequently  this  is  loss  of  acutoncs.s 
of  vision — anddyopia — but  the  loss  of  sight  in  one  or  both  eyes  may 
apparently  be  complete.  The  condition  will  be  meutioued  subsecpiently 
\inder  hysteria. 

(;5)  Tobacco  Amhhjopin. — The  loss  of  sight  is  usually  grailual,  equal  in 
both  eyes,  and  affects  particularly  the  centre  of  the  field  of  vision.  The 
eye-grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the 
disks.  On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is 
found  in  all  cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic 
ehanges  may  develop  with  atrophy  of  the  disk. 

(4)  Ni(jht-hlindness — nyctalojiia — the  condition  in  which  objects  aro 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  in- 
visible in  the  shade  or  in  twilight,  and  Iiemeralopia,  in  which  objects 
cannot  bo  clearly  seen  without  distress  in  daylight  or  in  a  strong  artificial 
li^dit,  l)ut  are  readily  seen  in  a  deep  shade  or  in  twiliglrt,  are  functioiuil 
uiionialies  of  the  retina  which  rarely  come  under  the  notice  of  the 
physician. 

(."))  Retinal  hyperesthesia  is  sometimes  seen  in  hysterical  women,  but 
H  not  found  frequently  in  actual  retinitis.  I  have  seen  it  once,  however, 
111  alhiuninuric  retinitis  and  once,  in  a  marked  degree,  in  a  patient  with 
iiortie  insufiiciency,  in  whose  retimje  there  were  no  signs  other  than  the 
throbbing  arteries. 


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786 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


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(2)  Lesions  of  tJi  j  Optic  Nerve. 

(a)  Optic  Neuritis  (Pftpillitis  ;  Choked  Dislc). — In  the  first  sta^ff  thorp 
is  congestion  of  the  disk  and  tlie  edges  are  bhirred  and  striated.  l:i  the 
second  stage,  the  congestion  is  more  marked,  the  swelling  increuf^ios,  the 
stfiation  also  is  more  visible.  The  physiological  cnpping  di8a])])oars  and 
hjLMnorrhages  are  not  uncommon.  The  arteries  present  little  change,  the 
veins  are  dilated,  and  the  disk  may  swell  greatly.  In  slight  grades  of  in- 
flammation the  swelling  gradually  subsides  and  occasionally  the  nerve 
recovers  completely.  In  instances  in  which  the  swelling  and  exudate  arc 
very  great,  tlie  subsidence  is  slow,  and  when  it  finally  disappears  there  is 
complete  atrophy  of  the  nerve.  The  retina  not  infrequently  jjarticipatcs 
in  the  inflammation,  which  is  then  a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis.  It  may  exist 
in  its  early  sttiges  without  any  disturbance  of  vision,  and  even  with  exten- 
sive papillitis  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  anaemia  and  lead  poisoning,  more 
commonly  in  Bright's  disease  as  neuro-retinitis.  It  occurs  occasionally  as 
a  primary  idiopathic  affection.  The  frequent  connection  with  intracranial 
disease,  particularly  tumor,  makes  its  presence  of  great  value  to  practi- 
tioners. The  nature  of  the  growth  is  without  influence.  In  over  ninety 
per  cent  of  such  instances  the  papillitis  is  bilateral.  It  is  also  found  in 
meningitis,  either  the  tuberculous  or  the  simple  form.  In  meningitis  it  is 
easy  to  see  how  the  inflammation  may  extend  down  the  nerve  sheaths,  hi 
the  case  of  tumor  it  was  thought  at.  first  that  a  choked  disk  resulted  from 
increased  pressure  within  the  skull.  It  is  now  more  commonly  regarded, 
however,  as  a  descending  neuritis. 

{h)  Optic  Atrophy. — This  may  be:  (1)  A  primary  affection.  Some  ef 
the  Ciises  have  been  hereditary  and  have  come  on  in  all  the  males  of  a 
family  shortly  after  puberty.  A  large  number  of  the  cases  of  priniarv 
atrophy  are  associated  with  spinal  disease,  particularly  locomotor  ataxia. 
Other  causes  which  have  been  assigned  for  the  primary  atrophy  are  c(d(l, 
sexual  excesses,  diabetes,  the  specific  fevers,  alcohol,  and  lead. 

(3)  ^'econdary  atrophy  results  from  cortical  lesions,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  is  a  sequence  of  jia- 
pillitis. 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary 
and  secondary  atrophy.     In  the  former,  the  disk  has  a  gray  tint,  the  edfrci* 
arc  well  defined,  and  the  arteries  look  almost  normal ;  whereas  in  the  cdi 
socutive  atrophy  the  disk  has  a  staring  opaque-white  aspect,  with  irrogn'ir 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  loss  of  sight,  proportionate  to  the 
damage  in  the  r  erve.  The  change  is  in  three  directions :  "  (1)  T)iniinislied 
acuity  of  vision;  {%)  alteration  in  the  field  of  vision;  and  (3)  altinil  per- 
ception of  color."  (Gowers.)    The  outlook  in  primary  atrophy  is  bad ;  the 


DISEASES  OF  THE  CRANIAL  NERVES. 


787 


majority  of  cases  go  on  to  complete  l^lindness.     In  the  consecutive  form 
tliere  is  greater  chance  of  retention  of  slight  vision. 

(3)  Affections  of  the  Chinsma  and  Tract. 

At  the  chiasma  the  optic  nerves  undergo  partia'  ut  ssation.  Each 
optic  tract,  as  it  joins  the  chiasma,  contains  nerve  fibres  iiich  supply  half 
of  till'  retina  of  elt.hc;  eye.  Thus,  of  the  fibres  of  the  right  tract,  i);irt  pass 
tho  cliiasina  without  decussating  and  supply  the  temporal  half  of  the  right 
ri'tiiia,  the  other  and  larger  portion  of  the  fibres  of  the  tract  dei'ussate  in 
the  chiasma  and  join  the  left  optic  nerve,  sup])lying  the  nasal  half  of  tho 
retina  on  the  other  side.  The  fibres  which  cross  are  in  the  middle  portion 
i»f  tho  chiasma,  while  the  direct  fibres  are  on  each  side.  The  following  are 
tlie  most  important  changes  which  ensue  in  lesions  of  the  tract  and  of  the 
c'liiiisina : 

{a)  Unilateral  Affection  of  Tract  (Fig.  1  B). — If  right  this  produces  loss 
of  fiUK.'tion  in  the  temporal  half  of  the  retina  on  the  right  side,  and  on  the 
imsiil  half  of  the  retina  on  the  left  side,  so  that  there  is  only  lialf  vision, 
and  tlie  patient  is  hlind  to  objects  on  the  left  side.  I'his  is  termed  ho- 
nionynious  hemianopia  or  lateral  hemianoi>ia.  The  fibres  passing  to  the 
right  half  of  each  retina  being  involved,  necessarily  the  left  half  of  each 
visuiil  Held  is  blind.  The  hemianopia  may  be  partial  and  oidy  a  portion 
of  tlie  half  field  may  be  lost.  The  affected  visual  fields  may  have  the  nor- 
iiiiil  extent,  but  in  some  instances  there  is  considerable  reduction.  The 
color  vision  is,  as  a  rule,  lost  in  the  half  field — hemiachromatopia — but  tiie 
half  vision  for  color  may  be  lost  in  central  disease  without  any  change  in 
tho  ticld  for  white.  When  the  left  half  of  one  field  and  the  right  half  of 
tho  other,  or  vice  versa,  are  blind,  the  condition  is  known  as  heteronymous 
hi'iiiiaiiopia. 

(/y)  Disease  of  the  Chiasma. — (1)  A  lesion  involves,  as  a  rule,  chiefly 
the  coiitral  portion,  in  which  the  decussating  fibres  })ass  which  supply  the 
inner  or  nasal  halves  of  the  retinte,  producing  in  consequence  loss  of  vision 
in  the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia 
(I'i.i:.  1  //). 

(v*)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central 
portion,  but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which 
case  there  would  be  total  blindness  in  one  cvo  and  temporal  heniiano])ia  in 
tho  other. 

(■'))  Still  more  extensive  disease  is  not  infrequent  from  pressure  of  tu- 
mors ill  this  region,  the  whole  chiasma  is  involved,  and  total  blindness 
ivsuhs.  The  different  stages  in  the  process  may  often  be  traced  in  a 
^iiigi(!  case  from  temporal  hemianopia,  then  complete  blindiu'ss  in  one 
tye  with  temporal  hemianopia  in  the  other,  and  finally  complete  blind- 
ness. 

(4)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  tho 
'iirect  fibres  passing  to  the  temporal  halves  of  the  retinae  and  inducing 
50 


'te 


788 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


blindness  in  the  nasal  field,  or,  a&  it  is  called,  nasal  hemianopia.    This,  of 
course,  is  extremely  rare. 


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Fio.  1, — TiiK  OPTIC  AND  TfsuAL  TRACTS  (Stnrr).  N,  Lesion  causing  nasal  liriniaiiftiii. 
T,  Lesions  causing  temporal  hemianopia.  H,  Lesion  causing  i'ilaterai  ln'teroiiv- 
inoiis  iiuniianopia.     li,  Lesion  of  tract  causing  homonymous  liemiuiiojiiii. 

.    (4)  Ajfections  of  the  Trad  and  Centres. 

The  optic  tract  crosses  the  cms  to  tlie  hinder  part  of  the  optii-  tli''''-'- 
mus  and  divides  into  two  portions,  one  of  which  fjoos  to  the  t]ial;iinii>'  ami 
external  geniculate  bodies  and  to  the  anterior  quadri<jcniinal  bodii-s.    \  rom 


DISEASES  OP   THE  CRANIAL  NERVEb. 


789 


thosi'  parts  fibres  j^iss  into  the  posterior  part  of  the  internal  capsule  and 
eiitci-  the  occipital  lobe,  forming  the  fibres  of  the  optic  radiation  (Fig.  1), 
which  terminate  in  and  about  the  cuneus,  the  region  of  the  visual  percep- 
tive centre.  The  fibres  of  the  other  division  of  the  tract  pass  to  the  in- 
ternal geniculate  bodies  and  to  the  ])osterior  (luadrigeminal  ])od\'.  It  is 
still  held  by  some  physiologists  that  the  cortical  visual  centre  is  not  co!i- 
tiued  to  the  occipital  lobe  alone,  but  embraces  the  occipito-angular  region. 

A  lesion  of  the  fibres  of  tiie  optic  tract  anywhere  between  the  cortical 
centre  and  the  chiasma  will  produce  lateral  hemianopia.  The  lesion  may 
he  situated  :  (a)  In  the  tract  itself.  {/>)  In  the  region  of  tiie  thalamus  and 
the  coriiora  quadrigemina,  into  whicli  the  larger  part  of  each  tract  enters. 
(')  \  lesion  of  the  fibres  passing  from  the  cor})ora  quadrigemina  to  the  oc- 
eipital  lohe.  This  may  be  either  in  the  hinder  part  of  the  internal  capsule 
(ir  the  white  fibres  of  the  oj)tic  radiation,  (d)  Lesion  of  the  cuneus.  Bi- 
lateral disease  of  the  cuneus  may  result  in  total  Ijlindness.  (')  There  is 
elir.ical  evidence  to  show  that  lesion  of  the  angular  gyrus  may  l)e  associ- 
ateil  with  visual  defect,  not  so  often  hemianopia  as  crossed  amblyopia? 
(liniiu'ss  of  vision  in  the  opposite  eye,  and  great  contraction  in  the 
t'eld  (if  vision.  Tx.sions  in  this  region  are  associiited  with  mind  blind- 
ness, a  condition  in  which  there  is  failure  to  recognize  the  nature  of  ob- 
jects. 

The  effects  of  lesions  in  the  optic  nerve  in  different  situations  from  the 
retinil  expansion  to  the  brain  cortex  are  as  follows  :  (1)  Of  the  optic  iutvc 
— tdtal  blindness  of  the  corresponding  eye;  {'i)  of  the  optic  chiasma, 
either  temporal  hemianopia,  if  the  central  part  alone  is  involved,  or 
nasal  hemianopia,  if  the  lateral  region  '  each  chiasma  is  involved  ;  (;{) 
li'Mon  of  the  optio  tract  between  the   *  ui.isma  and   tlie  geniculate  Itod- 

ies,  produces  lateral  hemianopia;  (4)  lesii ''   ih(>     eutnd  fibres  of  the 

iiervo  hetwoen  the  genicidate  bodies  aiul  the  tii.iiral  cortex  jirnduces 
lateral  hemianopia;  ("))  lesion  of  the  cuneus  causes  liii-'ral  hemianopia, 
and  {(I)  lesion  of  the  angular  gyrus  may  be  associated  witii  heniianojna. 
sometimes  crossed  amblyopia,  and  tlie  condition  known  as  mmd  blind- 
ness. 

Diagnosis. — The  student  or  practitioner  must  have  a  clear  idea  of 
the  physiology  of  the  nerve  centres  before  he  can  ajjpreciate  the  .symptoms 
"f  underhike  the  diagnosis  of  lesions  of  the  optic  nerve.  Having  d'  ,er- 
inined  tjie  presence  of  hemianopia,  the  (|uestion  ari.ses  as  to  tin  itioii 

"f  the  lesion,  whether  in  the  tract  between  the  (diiasma  and  the  geniculate 
Itiidicsor  in  the  central  )>ortion  of  the  fibres  between  the.se  bodies  and  the 
^i^'ual  centres.  This  can  be  determined  in  scmie  cases  by  the  test  kiu)wn 
ii'*  \\eriiicke's //^^///Vy><V  pupiJhfnj  inaction.  The  pupil  reflex  depends  on 
'lie  inteiriity  ,,f  t|,(,  retina  or  receiving  nu'inbrane,  on  the  fihres  of  the  op- 
'11'  nerve  and  tract  whiidi  transmit  the  imj)ulse,  ami  tiie  lU'rve  centre  in  the 
k'enipulate  bodies  which  receives  tiie  impression  and  transmits  it  to  tlie 
third  jieive  along  which  tho  motor  impulses  pass  to  the  iris.     If  h  bright 


I  If 


i 


m  'M.14  <-i 


790 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


It: 


11 


!.   ! 


')?: 


■'  If  If ' 


light  is  thrown  into  the  eye  and  the  pupil  reacts,  the  integrity  of  tliis  re- 
flex arc  is  demonstrated.  It  is  possible  in  cases  of  lateral  hemianojiia  so 
to  throw  the  light  into  the  eye  that  it  falls  upon  the  blind  half  of  tin; 
retina.  If  when  this  is  done  the  pupil  contracts,  the  indication  is  that 
the  reflex  arc  above  referred  to  is  perfect,  by  which  we  mean  tliiit  the 
o|)tic  nerve  fibres  from  the  retinal  expansion  to  the  centre,  the  centru 
itself,  and  the  third  nerve  are  uninvolved.  In  such  a  case  the  coiulu- 
sion  would  be  justified  that  the  cause  of  the  hemianopia  was  (central; 
that  is,  situated  behind  the  geniculate  bodies,  either  in  the  fibres  of  tlit-  dp- 
tic;  radiation  or  in  the  visual  cortical  centres.  If,  on  the  otlier  hand,  when 
the  liglit  is  carefully  thrown  on  the  hemiopic  half  of  the  retina,  the  piipil 
remains  inactive,  the  coiudusion  is  justifiable  that  there  is  interru[iti(iii  in 
tho  path  between  the  retina  aiul  the  geniculate  bodies,  and  that  the  hemi- 
anopia is  not  central,  but  dependent  upon  a  lesion  situated  in  tiie  trait. 
This  test  of  Wernicke's  is  sometimes  difficult  to  obtain.  It  is  Inst  per- 
formed as  follows :  "  The  patient  being  in  a  dark  or  nearly  dark  riMnii 
with  the  lamp  or  gas-light  behind  liis  head  in  the  usual  position,  I  bid  him 
look  over  to  the  other  side  of  the  room,  so  as  to  exclude  acconiinodative 
iris  movements  (which  are  not  necessarily  associated  with  the  leflex). 
Then  I  tlirow  a  faint  liglit  from  a  plane  mirror  or  from  a  lar^e  coiieave 
mirror  held  well  out  of  focus  upon  the  eye  and  note  the  size  of  the  ])upil. 
With  my  other  hand  I  now  throw  a  beam  of  light,  focussed  from  tlielump 
by  an  ophthalmoscopic  mirror,  directly  into  the  optical  centre  of  the  eve; 
then  laterally  in  various  positions,  and  also  from  above  and  below  the 
equator  of  the  eye,  noting  the  reaction  at  all  angles  of  incidence  of  the 
ray  of  light."    (Seguin.) 

The  significance  of  hemianopia  varies.  There  is  a  functional  hemi- 
anopia associated  with  migraine  and  hysteria.  In  a  considcraltle  pro- 
portion of  all  cases  there  are  signs  of  organic  brain-disease.  IltMiiipk'i:i;i 
is  common  and  the  loss  of  power  and  blindness  are  on  the  same  siik. 
Thus,  a  lesion  in  the  left  hemisjthere  involving  the  motor  tract  prodiiees 
right  ]iemi{)li'gia,  and  when  the  fibres  of  the  optic  radiation  are  involved 
in  the  internal  capsule,  there  is  also  left  lateral  hemian()i)ia,  so  that  olijects 
in  the  field  of  vision  to  the  right  are  not  perceived.  Ilemiana^stliosia  is 
not  uncommon,  owing  In  the  close  association  of  the  sensory  and  visual 
tracts  at  the  posterior  part  of  the  internal  capsule.  Certain  h inns  of 
aphasia  also  occur  in  many  <)f  the  cases. 

III.  Motor  Nerves  op  the  Eyeball. 

Third  Nerve. — Arising  fnmi  the  floor  of  the  aqueduct  of  Sylvius,  the 
m>rve  passes  through  the  cms  at  tl  •  side  of  which  it  enu'rges.  rassiiii,' 
along  the  wall  of  the  cavernous  siinis,  it  enters  the  orbit  thnniirli  the 
spheiu)i(la1  fissure  and  supplies,  by  Ms  superior  branch,  the  levattn' palpe- 
briE  superioris  and  the  superior  n'ctus,  and  by  its  inferior  brandi  the  in- 


grity  of  tins  ro- 

hemiaiKtpia  so 
iiid  half  t)t  the 
dioatiou  is  that 

mean  that  Uu; 
litre,  the  coutru 
mse  the  ooiichi- 
VvA  was  ci'iitnil ; 

fibres  of  tlio  (ip- 
)thcr  hand,  when 

retina,  the  impil 
,s  inturruittidii  in 
\(1  that  the  liomi- 
ted  in  the  tnu't. 

1.       It  is  bfSt  {KT- 

learly  dark  rodm 
losition,  I  hid  him 
le  aocoiiunoilativi' 

with  the  rclh'x). 
m  a  hir<;e  coiicavf 
;  size  of  tlio  pupil. 
,sed  from  the  lamp 

centre  of  tlu'  I'vc; 
,ve  and  bi'low  tlu' 

if  incidence  <»f  tho 

functional  hoiui- 
considiTal'h'  pi'"- 
lease.     lloiniph'S-'w 
on  the  same  Mv. 
Itor  tract  |«ni(lmT> 
liation  arc  iiivolvfil 
Ipia,  so  that  ohj^'t.^ 
illemiana^sthosiai.^ 
sensory  and  visual 
Certain  f«'i-ins  of 


LL. 


Let  of  Sylvius, 


the 


J  emerges.     V^^ 
lorbit  throii.trh  l'^*^ 


DISEASES  OP  THE  CRANIAL  NERVES. 


791 


the  levat. 


Kllpi 


ior  branch  ih^''"' 


toriial  and  inferior  recti  muscles  and  the  inferior  oblique.  It  also  sup- 
iilii'S  the  ciliary  muscle  and  the  constrictor  of  the  iris.  Lesions  may 
iitToct  the  centre  or  the  nerve  in  its  course  and  cause  either  paralysis  or 

spasm. 

J'aralysis. — A  nuclear  lesion  is  usually  associated  with  the  disease  of 
the  rentres  for  the  other  eye  muscles,  producing  a  condition  of  gen- 
eral ophthalmoplegia,  ^[ore  commonly  the  nerve  itself  is  involved 
ill  its  course,  either  by  meningitis,  gummata,  or  aneurism,  or  is^'  at- 
tacked by  neuritis,  as  in  diphtheria  and  locomotor  ataxia.  Complete 
paralysis  of  the  third  nerve  is  accompanied  by  the  following  symp- 
toms ; 

Paralysis  of  all  the  muscles,  except  the  superior  oblique  and  external 
rectus,  by  which  the  eye  can  be  moved  outward  and  a  little  downward  and 
inward.  There  is  divergent  strabismus.  There  is  ptosis  or  droojjing  of 
the  upper  eyelid,  owing  to  paralysis  of  the  levator  palpebra?.  The  pupil 
is  of  medium  size.  It  does  not  contract  to  light,  and  the  power  of  accom- 
mmlation  is  lost.  The  most  striking  features  of  this  pandysis  are  the  ex- 
ternal strabismus,  with  diplopia  or  double  vision,  and  the  ptosis.  In  very 
many  cases  the  affection  of  the  third  nerve  is  partial.  Thus  the  levator 
palpehra?  and  the  superior  rectus  may  be  involved  together,  or  the  ciliary 
muscles  and  the  iris  may  be  affected  and  the  external  muscles  may 
escajie. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affect- 
ing chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some 
eases  the  attacks  have  come  on  at  intervals  of  a  month  ;  in  others  a  mncli 
longer  period  has  elapsed.  The  attacks  may  persist  throughout  life. 
They  are  sometimes  associated  with  pain  in  the  head  and  sometimes  with 
migraine.  Mary  Sherwood  has  collected  from  the  literature  twenty-three 
eases. 

]*losis  is  a  common  and  important  symptom  in  nervous  affections. 
We  may  her^  briefly  refer  to  the  conditions  under  which  it  may  occur : 
(a)  A  congenital,  incurable  form,  which  is  frequently  seen  ;  {b)  the  form 
as,sociated  with  definite  lesion  of  the  third  nerve,  either  in  its  course  or 
at  its  nucleus.  This  may  come  on  with  jiaralysis  of  the  superior  rectus 
alone  or  with  paralysis  of  the  internal  and  inferior  recti  as  well,  (r) 
There  are  instances  of  complete  or  ])artial  ptosis  associated  with  cere- 
'•ral  lesions  without  any  other  branch  of  the  third  nerve  being  par- 
alyzed. The  position  of  the  cortical  centre  is  as  yet  unknown.  {(/) 
Hysterical  ptosis,  which  is  doul)le  and  oc<nirs  with  other  hysterical  symp- 
toms, (f)  Sympathetic  or  pseudo-ptosis  is  associated  with  symptoms  of 
vaso-inotor  palsy,  such  as  elevation  of  the  temperature  on  the  affected 
^itle  with  redness  and  oHlenui  of  the  skin.  Contnu'tion  of  the  pupil 
'xists  oti  the  same  side  and  the  eyeball  ajipears  rather  to  have  shrunk  into 
the  orhit.  (/)  In  idiojiathic  muscular  atrophy,  when  the  face  muscles  are 
iiivolved,  there  may  be  marked  bilateral  ptosis.    And,  lastly,  in  weak,  deli- 


it,} 


792 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


i 

r 


J  I T 


cate  women  there  is  often  to  be  seen  a  transient  ptosis,  particularlv  in  the 
morning. 

Among  tlie  most  important  of  the  symptoms  of  the  third-nervo  imnil- 
ysis  are  those  which  relate  to  the  ciliary  muscle  and  iris. 

Cycloplegia^  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  iiowcr 
of  accommodation.  Distant  vision  is  clear,  but  near  objects  caiiiioi  W 
properly  seen.  In  consequence  the  vision  is  indistinct,  but  can  he  re- 
stored by  the  use  of  convex  glasses.  This  may  occur  in  one  or  in  both  eves- 
in  the  latter  case  it  is  usually  associated  with  disease  in  the  nuclei  of  the 
nerve.  Cycloplegia  is  an  early  and  frecjuent  symptom  in  diiihtheritic 
paralysis  and  occurs  also  in  tabes. 

Iridoplef/ia,  or  paralysis  of  the  iris,  occurs  in  three  forms  (riowiM-s). 

(a)  Accommodcttive  iridoj)lc(jia,  in  which  the  jiupil  does  not  diininish 
in  size  during  the  act  of  accommodation.  To  test  for  this  the  ])ati('nt 
should  look  first  at  a  distant  and  then  at  a  near  object  in  the  same  line  of 
vision. 

{b)  Reflex  Iridoplegia. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  the  geniculate  bodies,  then  to  the  nucleus  of  the  third 
nerve,  and  along  the  trunk  of  this  nerve  to  the  ciliary  gaTiglion,  and  so 
through  the  ciliary  nerves  to  the  eyes.  Each  eye  should  be  tested  se]ia- 
rately,  the  other  one  Iwnng  covered.  The  patient  should  look  at  a  diHtiiiit 
object  in  a  dark  part  of  the  room ;  then  a  light  is  brought  suddenly  in 
front  of  the  eye  at  a  distance  of  three  or  four  feet,  so  as  to  avoid  the  ettVct 
of  accommodation.  Loss  of  this  iris  reflex  with  retention  of  the  accom- 
modation contraction  is  known  as  the  Argyll-Kobertson  pupil. 

{c)  Loss  of  the  Skin  Reflex. — If  the  skin  of  the  neck  is  pinched  or 
pricked  the  pupil  dilates  reflexly,  the  afferent  impulses  l)eing  conveyed 
along  the  cervical  sympathetic.  Erb  pointed  out  that  this  skin  relk'X  is 
lost  usually  in  association  with  the  reflex  contraction,  but  the  two  arc  not 
necessarily  conjoined.  In  iridoplegia  the  pupils  are  often  small,  particu- 
larly in  spinal  disease,  as  in  the  characteristic  small  pupils  of  tabes — spinal 
myosis.    Iridoplegia  may  coexist  Avith  a  pupil  of  medium  size. 

Inequality  of  the  pupils — anisocoria — is  not  infrequent  in  progressive 
paresis  and  in  tabes.     It  may  also  occur  in  perfectly  healthy  individuals. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of 
the  muscles  supplied  by  the  third  nerve,  particularly  the  internal  rectus 
a!ul  the  levator  palpebral.  The  clonic  rhythmical  spasm  of  the  eye  iinis- 
cles  is  known  as  nystagmus,  in  which  there  is  usually  a  bilateral,  rhythmi- 
cal, involuntary  movement  of  the  eyeballs.  The  condition  is  uiet  with  in 
many  congenital  and  acquired  brain  lesions,  in  albinism,  and  sonielimos 
in  coal-miners. 


Fourth  Nerve.— This  supplies  the  superior  oblique  muscle.     In  its 
course  around  the  outer  surface  of  the  crus  and  in  its  passage  into  the 


^'^'  Ih 


DISEASES  OF  THE  CRANIAL  NEllVES. 


793 


orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism  or  in  the  exu- 
dutinii  of  basilar  meningitis.  Its  nucleus  in  the  ujjper  part  of  the  fourth 
veiilii<'le  may  be  involved  by  tumors  or  undergo  degeneration  with  the 
otlur  ocular  nuclei.  Tlie  superior  oblifjue  muscle  acts  in  such  a  way  as 
to  tlirect  the  eyeball  downward  and  rotates  it  slightly.  The  paralysis 
eiiuaes  defective  downward  and  inward  movement,  often  too  slight  to  be 
notici'd.  'J'he  head  is  inclined  somewhat  forward  and  toward  the  sound 
side,  iuul  there  is  double  vision  when  the  patient  looks  down,  as  in  do- 
sceiidiug  stairs. 

Sixth  Nerve. — This  nerve  emerges  at  the  junction  of  the  pons  and 
iiUMhillii,  then,  passing  forward,  it  enters  the  orbit  aud  supi)lies  the  external 
rectr.s  muscle.  It  is  affected  by  meningitis  at  the  base  or  by  gummata  or 
other  tumors,  and  sometimes  by  cold.  There  is  internal  strabismus,  and 
tlie  eye  cannot  be  turned  outward.  Diplopia  occurs  on  looking  toward 
the  paralyzed  side. 

"  When  the  nucleus  is  affected  there  is,  in  addition  to  i)aralysis  of  the 
external  rectus,  inability  of  the  internal  rectus  of  the  opposite  eye  to  turn  that 
eye  inwards.  As  a  consequence  of  this  the  axes  of  the  eyes  are  kept  parallel 
and  both  are  conjugately  deviated  to  the  opposite  side,  away  from  tlie  side 
nf  lesion.  The  reason  of  this  is  that  the  nucleus  of  tho  sixth  nerve  sends 
lihres  up  in  the  pons  to  that  part  of  the  nucleus  of  the  ()])posite  third 
nerve  which  supplies  the  internal  rectus.  Wo  thus  have  paralysis  of  the 
internal  rectus  without  the  nucleus  of  tlie  third  nerve  being  involved, 
owing  to  its  receiving  its  nervous  impulses  for  jiarallel  movement  from 
the  sixtli  nucleus  of  the  opposite  side.  As  the  sixth  nucleus  is  in  such 
proximity  to  the  facial  nerve  in  tlie  substance  of  the  pons,  it  is  frequently 
founii  tliat  the  whole  of  the  face  on  the  same  side  is  paralyzed,  and  gives 
tlie  electrical  reaction  of  degeneration,  so  that  with  a  lesion  of  the  left 
sixtli  nucleus  there  is  conjugate  deviation  of  both  eyes  to  the  ri(jht — i.  e., 
paralysis  of  the  left  external  and  the  right  internal  rectus,  and  sometimes 
eoni])lete  paralysis  of  the  left  side  of  the  face."     (Beevor.) 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye.— Gowers 
divides  them  into  five  groups  : 

('/)  Limitation  of  Movement. — Thus,  in  paralysis  of  the  external  rec- 
tus, the  eyeball  is  turned  in  by  the  contraction  of  the  internal  rectus  and 
emnot  be  moved  outward.  When  the  paralysis  is  incomplete  the  move- 
ment is  deficient  in  proportion  to  the  degree  of  the  palsy. 

[Ii]  Strabismus. — The  axes  of  the  eyes  do  not  correspond.  Thus,  par- 
alysis of  the  internal  rectus  causes  a  divergent  squint ;  of  the  external 
lei'tus,  a  convergent  squint.  The  deviation  of  the  axis  of  the  affected  eye 
fi'oni  parallelism  with  the  other  is  called  the  primary  deviation. 

('•)  Secondary  Deviation. — If,  Avhile  the  patient  is  looking  at  an  ob- 
jwt,  the  sound  eye  is  covered,  so  that  he  fixes  the  object  looked  at  with 
the  ullected  eye  only,  the  sound  eye  is  moved  still  further  in  the  same  di- 


•   f 


r 


\ 


'-''  '?! 


?^  ^S  ^'i 


■  ! 


794 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


I  f    I  ;;|; 


rection — e.  g.,  outward — with  pariilysis  of  the  opposite  internal  n^ctiis. 
This  is  known  as  secondary  deviation.  It  depends  upon  tiie  fact  tliat,  if 
two  muscles  are  acting  together,  when  one  is  weak  and  an  eifort  is  iniulc 
to  contract  it,  the  increased  etfort — innervation — acts  powerfully  upon  llu' 
other  muscle,  causing  an  increased  contraction. 

{(t)  I'Jrroneous  Projection. — "  We  judge  of  the  relation  of  oxtcnial 
objects  to  each  other  hy  the  relation  of  their  images  on  the  retina;  hut 
we  judge  of  their  relaticm  to  our  own  body  by  the  position  of  the  ovchiill 
as  indicated  to  us  by  the  innervation  we  give  to  the  ocular  muscles " 
(Gowers).  M'ith  the  eyes  at  rest  in  the  mid-position,  an  object  at  wliich 
we  are  looking  is  directly  opposite  our  facte.  Turning  the  eyes  to  ono 
side,  we  recognize  that  object  in  the  middle  of  the  field  or  to  the  side  of 
this  former  position.  We  estimate  the  degree  by  tlie  amount  of  move- 
ment of  the  eyes,  and  when  the  object  moves  and  we  follow  it  we  judge 
of  its  position  by  the  amount  of  movement  of  the  eyeballs.  AN'hen  one 
ocular  muscle  is  wciik,  the  increased  innervation  gives  the  impression  of 
a  greater  movement  of  the  eye  than  luis  really  taken  place.  The  niiiul,  at 
the  same  time,  receives  the  idea  that  tlie  object  is  further  on  one  side 
than  it  really  is,  and  in  an  attempt  to  touch  it  the  finger  may  go  beyond 
it.  As  the  equilibrium  of  the  body  is  in  a  large  part  maintained  l)y  a 
knowledge  of  the  relation  of  external  objects  to  it  obtained  by  the  action 
of  the  eye  muscles,  this  erroneous  projection  resulting  from  paralysis  dis- 
turbs the  harmony  of  these  visual  imj)ressions  and  may  lead  to  giddiness 
— ocular  vertigo. 

{e)  Double  Vision. — This  is  one  of  the  most  disturbing  features  of 
paralysis  of  the  eye  muscles.  The  visual  axes  do  not  correspond,  so  that 
there  is  a  double  image — diplopia.  That  seen  by  the  sound  eye  is  termed 
the  true  image ;  that  by  the  paralyzed  eye,  the  false.  In  simple  or  honion- 
ymous  diplopia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eve 
by  which  it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  con- 
vergent squint  the  diplopia  is  simple ;  in  divergent  it  is  crossed. 

Ophthalmoplegia. — Under  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Two  forms  are  recognized — ophthalmo- 
plegia externa  and  ophthalmoplegia  interna.  The  conditions  may  oix'iir 
separately  or  together  and  are  described  by  Gowers  under  nuclear  ocular 
palsy. 

Ophthnlmnpleffia  Externa. — The  "condition  is  one  of  more  or  less  com- 
plete palsy  of  tlie  external  muscles  of  the  eyeball,  due  usually  to  a  slow 
degeneration  in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of 
tumors  or  to  basilar  meningitis.  It  is  often  but  not  necessarily  associated 
with  ophthalmoplegia  interna.  Siemerling,  in  the  recent  monogra])h  in 
which  he  has  analyzed  the  material  (eight  cases)  left  by  the  late  I'l'if. 
Westphal,  states  that  sixty-two  cases  are  on  record.  In  only  eleven  df 
these  could  syphilis  be  positively  determined.  The  levator  muscles  of  the 
eyelids  and  the  superior  recti  are  first  involved,  and  gradually  the  other 


DISEASES  OP  THE  CRANIAL  NERVES. 


705 


muscles,  bo  that  the  eyoballs  are  fixed  and  the  eyelids  droop.  There  is 
sometimes  slight  protrusion  of  the  eyeballs.  The  disease  is  essentially 
clironic  and  may  last  for  many  years.  It  is  found  jiartioidarly  in  association 
witii  general  j)aralysis,  locomotor  ataxia,  and  in  jtrogressive  muscular 
atniphy.  Mental  disorders  were  present  in  eleven  of  the  sixty-two  cusi's. 
With  it  may  be  associated  atrophy  of  the  optic  nerve  and  affections  of 
otiier  cranial  nerves.  Occasionally,  as  noted  by  Bristowe,  it  may  be  func- 
tional. 

Op/ifhahnoph'fjin  Interna. — Jonathan  Hutchinson  applied  this  term  to 
11  progressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and 
external  muscles  are  involved  the  affection  is  known  as  total  ophthalmo- 
plegia, and  in  a  majority  of  the  cases  the  two  conditions  are  associated. 
In  some  instances  the  internal  form  may  depend  upon  disease  of  the 
ciliary  ganglion. 

While,  as  a  rule,  ophthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  haemorrhagic  softening  of  the  nuclei  of  the  ocular 
muscles.  There  is  usually  marked  cerebral  disturbance.  It  was  to  this 
form  that  Wernicke  gave  the  name  polio-encephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if 
possible,  the  cause.  The  forms  associated  with  locomotor  ataxia  are 
obstinate,  and  resist  treatment.  Occasionally,  however,  a  palsy,  complete 
or  partial,  may  pass  away  spontaneously.  The  group  of  cases  associated 
witli  chronic  degenerative  changes,  as  in  progressive  paresis  and  bulbar 
j)aralysis,  is  little  affected  by  treatment.  On  the  other  hand,  in  syphilitic 
cases,  mercury  and  iodide  of  potassium  are  indicated  and  are  often  bene- 
ficial. Arsenic  and  strychnia,  the  latter  hypodermically,  may  be  employed. 
In  any  case  in  which  the  onset  is  acute,  with  pain,  hot  fomentations  and 
counter-irritation  or  leeches  applied  to  the  temple  give  relief.  The  direct 
treatment  by  electricity  has  been  extensively  employed,  but  probably  with- 
out any  special  effect.  The  diplopia  may  be  relieved  by  the  use  of  prisms, 
or  it  may  be  necessary  to  cover  the  affected  eye  with  an  opaque  glass. 

IV.  Fifth  Nerve. 


h    II 


>  It 


!,f: 


Paralysis  may  result  from  :  {a)  Disease  of  the  pons,  particularly  haem- 
orrhage or  patches  of  sclerosis,  (b)  Injury  or  disease  at  the  base  of  the 
brain.  Fracture  rarely  involves  the  nerve  ;  on  the  other  hand,  meningitis, 
acute  or  chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (c)  The 
brandies  may  be  affected  as  they  pass  out — the  first  division  by  tumors 
jirossing  on  the  cavernous  sinus  or  by  aneurism ;  the  second  and  third 
•li\  isions  by  growths  M'hich  invade  the  spheno-maxillary  fossa,  [d)  Pri- 
mary neuritis,  which  is  rare. 

Symptoms. — {n)  Sensory  Portion. — Paralysis  of  the  fifth  nerve 
causes  loss  of  sensation  in  the  parts  supplied,  including  the  half  of  the 


m 


DISEASES  OP  TMK   NERVOUS  SYSTEM. 


\  I 


!i 


<4\  ■ 


face,  the  correspond hig  side  of  the  liead,  the  conjimrtiva,  the  mucosa  of 
the  liprt,  toiiffue,  luird  and  soft  palate,  and  of  the  nose  of  the  same  siilc. 
The  ana'sthesia  may  be  pre(!eded  by  tinglinpf  or  pain.  The  miisck's  ol'  iIk. 
face  are  also  insensil)k'  and  the  movements  imiy  be  slower.  Tiie  sense  of 
smell  is  interfered  with.  There  is  loss  of  the  sense  of  taste.  'I'liere  iirc, 
in  addition,  //•<)/>/( u; changes;  the  salivary,  lachrymal,  and  buccuil  secretions 
may  be  lessened,  abrasions  of  the  mucous  meml)ranes  heal  slowly,  and  the 
teeth  may  become  loose.  The  eye  inlhimes,  the  cornea;  becomo  cloiulv 
and  may  ulcerate.  These  latter  symptoms  occur  only  when  the  (Jassciiiiii 
ganglion  is  affected,  as  the  nerve  itself  nuiy  be  involved  for  years  without 
producing  ophthalmia.  Herpes  nuiy  develo])  in  the  region  supplied  l»v 
the  nerve  and  is  usually  associated  with  much  jtain.  It  is  most  coniiiKni 
in  the  upper  branch  of  the  nerve.  The  pain  which  f(»llows  the  herpes  iiiav 
be  peculiarly  enduring,  lasting  for  months  or  years  (( lowers). 

(i)  Motor  Portion. — The  inability  to  use  the  muscles  of  mastica- 
tion on  the  atfected  side  is  the  distinguishing  feature  of  jmralysis  of  this 
portion  of  the  nerve.  It  is  recognized  by  phicing  the  finger  on  the  iiius- 
setcr  and  temporal  muscles,  and,  when  the  ])atient  closes  the  jaw.  tiiu 
feebleness  of  their  contraction  is  noted.  If  paralyzed,  the  external  i)tciv- 
goid  cannot  move  the  jaw  toward  the  unaffected  side  ;  ami  when  de])rcss(Ml, 
the  jaw  deviates  to  the  paralyzed  side.  The  motor  jiaralysis  of  the  fifth 
nerve  is  almost  invariably  a  result  of  involvement  of  the  nerve  after  it  has 
left  the  nucleus.  Cases,  however,  have  been  associated  with  cortical 
lesions,  llirt  concludes,  from  his  case,  that  the  motor  centre  for  tlic 
trigeminus  is  in  the  neighborhood  of  the  lower  third  of  the  ascending 
frontal  convolution. 

Spasm  of  the  Muscles  of  Mastication. — Trismus,  the  masti(!atory  spasm 
of  Romberg,  nuiy  be  tonic  or  clonic,  and  is  either  an  associated  phenome- 
non in  general  convulsions  or,  more  rarely,  an  independent  affection.  In 
the  tonic  form  the  jaws  are  kept  close  together — lock-jaw — or  can  be 
separated  only  for  a  short  space.  The  muscles  of  nuistication  can  be  seen 
in  contraction  and  felt  to  be  hard  and  the  spasm  is  often  painful.  This 
tonic  contraction  is  an  early  symptom  in  tetanus,  and  is  sometimes  seen  in 
tetany.  A  form  of  this  tonic  spasm  occurs  in  hysteria.  Occasionally  tris- 
mus follows  exposure  to  cold,  and  is  said  to  be  due  to  reflex  irritation  from 
the  teeth,  the  mouth,  or  caries  of  the  jaw.  It  may  also  be  a  symptom  of 
organic  disease  due  to  irritation  near  the  motor  nucleus  of  the  fifth  nerve. 

Clonic  sivdsm  of  the  muscles  supplied  by  the  fifth  occurs  in  the  form  of 
rapidly  repeated  contractions,  as  in  "  chattering  teeth."  This  is  rare  apart 
from  general  conditions,  though  cases  arc  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  lia.s 
been  found.  In  another  form  of  clonic  spasm  sometimes  .-^een  in  chorea, 
there  are  forcible  single  contractions.  Gowers  mentions  an  instance  of  its 
occurrence  as  an  isolated  affection. 

(c)  Gustatory. — Loss  of  the  sense  of  taste  in  the  anterior  two  third.s  of 


m 


DISEASES  OF  THE  CKANIAL  NKUVES. 


75)7 


till'  tongue,  us  a  rule,  follows  parulysis  of  the  fifth  nerve.  Tlie  gustatory 
tihros  pasrt  from  the  ehonla  tynijumi  to  the  lingual  l)raii('h  of  the  fifth, 
disease  of  the  tiftii  nerve  is,  however,  not  always  associatcil  with  loss  of 
taste  in  tiu^  anterior  part  of  the  tongue,  in  whieh  ease  either  the  taste 
tilires  escape,  or  the  disease  is  within  the  pons  where  these  tihres  are 
separate  from  those  of  sensation. 

The  (tini/no.si.s  of  disease  of  the  trifacial  nerve  is  rarely  diflicidt.  It 
must  be  remembered  that  the  preliminary  ])ain  and  hypenesthesia  are 
sdinetimes  mistaken  for  neuralgia.  The  loss  of  sensation  and  the  i)alsy  of 
the  muscles  of  nuistieation  are  readily  determined. 

Treatment. — Wiuni  the  pain  is  severe  morphia  may  be  required  and 
local  applications  are  useful.  If  there  is  a  suspicion  of  syphilis,  appropri- 
ate treatment  should  be  given.     Faradization  is  sometimes  beneficial. 


I>^ 


V. 


'?i' 


1 


V.  Facial  Nerve. 


•  i 


Paralysis  {BeWs  PaUii). — The  pnrlio  dura  of  the  sevetith  jiair  nuiy 
l)c  paralyzed  by  (1)  lesions  of  the  cortex — supranuclear  i)alsy ;  (^)  lesions 
(if  the  nucleus  itself;  or  (3)  involvement  of  the  nerve  trunk  in  its  tortuous 
course  within  the  pons  and  through  the  wall  of  the  skull. 

I.  Siiprtiniich'dr  J*(iralysis,  due  to  lesion  of  the  cortex  or  of  the  fa(;ial 
(Hires  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated 
with  hemiplegia.  It  may  be  caused  ])y  tumors,  abscess,  chronii;  infiamma- 
tidu,  or  softening  in  the  regitm  of  the  internal  capsule.  It  is  distinguished 
from  the  perijdieral  form  by  two  well-marked  characters — the  i)ersisteiice 
of  the  nornuil  electrical  excitability  of  both  nerves  and  muscles  and  the 
alisciu'e  of  involvement  of  the  upper  branches  of  the  nerve,  so  that  the  or- 
liicularis  palpebrarum  and  frontalis  muscle  are  spared.  (\.  third  dilferenco 
is  that  in  this  form  the  voluntary  movements  are  more  impaired  than  the 
I'inotional.  There  are  instances  of  cortical  facial  paralysis — nu)noplegia 
facialis — associated  with  lesions  in  the  centre  for  the  face  muscles  in  the 
lower  Rolandic  region.  Isolated  paralysis,  due  to  involvement  of  the  nerve 
tibres  in  their  path  to  the  nucleus,  is  uncommon.  In  the  great  majority 
of  cases  supranuclear  facial  paralysis  is  part  of  a  hemiplegia.  Paralysis 
is  on  the  same  side  as  that  of  the  arm  and  leg  because  tin?  facial  nius- 
clt's  bear  precisely  the  same  relation  to  the  cortex  as  the  spinal  muscles. 
Tlic  luiclei  of  origin  on  either  side  of  the  middle  line  in  the  medulla  are 
united  by  decussating  fibres  with  the  cortical  centre  on  the  opj)osite  side 
(see  Fig.  3). 

II.  The  nuclenr  jjar'ah/si,^  caused  by  lesions  of  the  nerve  centre  in  the 
lui'ilulla  is  not  common  alone;  but  is  seen  occasionally  in  tumors,  chronic 
softening,  and  haemorrhage.  In  rare  instances  of  anterior  polio-myelitis 
till'  facial  nucleus  is  atfected.  In  di})htheria  this  centre  nuiy  also  be 
iin  olved.  The  symptoms  are  practically  similar  to  those  of  an  affection 
of  the  nerve  fibre  itself — infranuclear  paralysis. 


i.-!^lt. 


:  'A 


i 
1' 


mr-^^ 


798 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


5',' 


f''^. 


.ji;,.      > 

^;-''..: 

III.  Involvnment  of  the,  Xerve.  Trunk. — ParulvHirt  may  result  from  : 

{(i)  Idvolvomciit  of  tlic  norve  us  it  jmihscs  tlir()uj,'li  tlie  pouH — that  is. 
Ix'twt'cn  its  miclcua  in  the  lloor  of  the  fourth  vtMitriclo  ami  the  point  nf 
cmcr^fcuco  in  the  i)ostero-hiteral  aspect  of  the  pons.  'I'he  sju'cially  iiit'  i 
estiufj  feature  in  conneetion  with  involvement  of  tliis  ])art  is  the  productinn 
of  what  is  called  alternating  or  croxn  parahjsiH,  the  face  beinjy  involved  on 
the  sanui  side  as  the  lesion,  and  the  arm  and  leg  on  tlie  opposite  side,  hIikc 
the  motor  ])ath  is  involved  above  the  point  of  decaissation  in  the  medulla 
(Fig.  3,2).  'I'his  occurs  only  when  the  lesion  is  in  the  lower  section  of  the 
pons.  A  lesion  in  the  upper  division  involves  the  fibres  not  of  the  out- 
going nerve  on  the  same  side,  but  of  tiie  nerve  of  the  other  side,  whidi 
has  crossed  and  is  ascending  to  the  hemisphere.  In  this  case  there  would 
of  course  l)e,  as  in  hemiplegia,  paralysis  of  the  face  and  limbs  on  the  side 
opposite  to  the  lesion.  The  palsy,  too,  would  resemble  the  cerebral  form, 
involving  only  the  lower  fibres  of  the  fac^ial  nerve. 

{b)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tumors, 
gummata,  meningitis,  or  occasionally  may  be  injured  in  fracture  of  tlic 
base. 

{(')  In  passing  through  tlie  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear,  particularly  by  caries  of  the  bone  in  otitis  niediu. 
This  is  a  common  cause  in  children. 

{(l)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to 
injuries  and  blows  which  not  infrequently  cause  paralysis.  The  lihrcs 
may  be  cut  in  the  removal  of  tumors  in  this  region,  or  the  paralysis  may 
be  caused  by  pressure  of  the  forceps  in  an  instrumental  delivery. 

{<>)  Exposure  to  cold  is  the  most  common  cause  of  facial  paralysis, 
inducing  a  neuritis  of  the  nerve  within  the  Fallopian  canal.  It  is  some- 
times termed  rheumatic  neuritis,  but  there  is  no  evidence  that  it  is  spe- 
cially associated  with  the  rheumatic  poison. 

Facial  diplegia  is  a  rare  condition  occasioiuiUy  found  in  affections  at 
the  base  of  the  brain,  lesions  in  the  pons,  simultaneous  involvement  of  the 
nerves  in  ear  disease,  and  in  diphtheritic  paralysis.  Disease  of  the  nuclei 
or  symmetrical  involvement  of  the  cortex  might  also  produce  it. 

Ssrmptoins. — In  the  periplieral  facial  paralysis  all  the  branches  of 
the  nerve  are  involved.  The  face  on  the  affected  side  is  immobile  and  eiiii 
neither  be  moved  at  will  nor  participate  in  any  emotional  movements. 
The  skin  is  smooth  and  the  wrinkles  are  effaced,  a  point  particuliirly 
noticeable  on  the  forehead  of  elderly  persons.  The  eye  cannot  be  closed, 
the  lower  lid  droops,  and  the  eye  waters.  On  tlie  affected  side  the  ariLrle 
of  the  mouth  is  lowered,  and  in  drinking  the  lips  are  not  kept  in  cl'ise 
apposition  to  the  glass,  so  that  the  liquid  is  apt  to  run  out.  In  smiliiiiT  or 
laughing  the  contrast  is  most  striking,  as  the  affected  side  does  not  iimve, 
which  gives  a  curious  unequal  appearance  to  the  two  sides  of  the  1';iee. 
The  eye  cannot  be  closed  and  the  forehead  cannot  be  wrinkled.  On  a.skiii.<r 
a  patient  to  show  his  upper  teeth,  the  angle  of  the  mouth  is  not  raised.   I" 


i  ■;•    R 


DISEASKS  OF  THP:  CUANIAL  NKllVKS. 


799 


all  tlieso  movemonts  the  fiico  in  drawti  to  tho  skuikI  wide  by  the  iiction  of 
the  iniiscli's.  Spciikintf  may  lu'  slij^litly  iiiti-rfcri'd  witli,  owiii;^  to  tin;  im- 
|Mrf('<'-ti(Hi  ii)  tlie  foniiiitioii  of  tlio  liiliiiil  houikIs.  W  liistliii;,' caiiMot  bo 
[icit'ornu'd.  Tii  chi'wiiig  tho  food,  owiiij^  to  the  piindysis  of  tin-  biiciiiuitor, 
[liirticlca  collect  on  tiie  alTecited  side.  The  paralysiH  of  the  nasal  inusclca 
is  !-mm  on  askinj,'  tiie  patient  to  sritf.  Owinj,'  to  the  fact  that  the  lips  aro 
(jiiiwn  to  the  sound  side,  tl»e  ton<i;iie,  when  protruded,  looks  as  if  it  were 
pushed  to  the  paralyzed  side;  but  on  taking  its  position  from  the  incisor 
tcfth,  it  will  be  fcnind  to  lie  in  the  iruidle  line.  The  reflex  movcuicnts 
arc  lost  in  this  peripheral  form.  It  is  usually  stated  that  the  palate  is 
|)aralyzed  on  the  same  side  and  that  the  uvula  deviates.  Hotii  (lowers 
and  llu^'hiinfjs  .Jackson  di-ny  the  existence  of  this  involvement  in  the 
;,'rc!it  nuijority  of  cases,  and  llorsley  and  lieevor  have  shown  that  these 
parts  are  innervated  by  the  acc^essory  nerve  to  the  vagus. 

When  the  nerve  is  involved  within  the  canal  between  the  <:cmi  and 
the  orififin  of  the  chorda  tympaiii,  tiie  s(Mise  of  taste  may  be  lost  in  tiio 
anterior  part  of  the  tongue  on  the  alTecited  side.  When  the  nerve  is 
(ianuiged  outside  the  skull  the  sense  of  taste  is  unaiTected.  1  Fearing  is 
often  impaired  in  facial  paralysis,  most  commonly  by  preceding  ear  dis- 
ease. The  paralysis  of  the  stapedius  muscle  may  lead  to  increased  sen- 
sitiveness to  musical  notes.  l[er})es  is  sometimes  associated  with  facial 
paralysis.  Pain  is  not  common,  but  there  may  be  neuralgia  about  the 
ear. 

The  electrical  reactions,  which  are  tlioso  of  a  ])eripheral  palsy,  liavo 
considerable  importance  from  a  prognostic  stand])oint.  Krb's  rules  are  aa 
follows:  If  there  is  no  change,  either  faradic  or  galvanic,  the  jirogm-sis 
is  good  and  recovery  takes  place  in  fr(jm  fourteen  to  twenty  days.  If  the 
furadio  and  galvanic  ex(^itability  of  the  nerve  is  only  lessened  and  that  of 
the  muscle  increased  to  the  galvanic  current  and  the  contraction  formula 
altered  (the  contraction  sluggish  An('>('("),  the  outlook  is  relatively 
good  and  recovery  Avill  probably  take  place  in  from  four  to  six  weeks  ;  oc- 
casionally in  from  eight  to  ten.  When  the  reaction  of  degeneration  is 
present — that  is,  if  the  faradic  and  galvanic  excitability  of  the  nerves  and 
the  faradic  excitability  of  the  muscles  are  lost  and  the  galvanic  (^xcita- 
l)ility  of  the  muscle  is  quantitatively  increased  and  qualitatively  changed, 
and  if  the  mechani(^al  excitability  is  altered — the  prognosis  is  relatively 
unfavorable  and  the  recovery  nuiy  not  occur  for  two,  six,  eight,  or  even  fif- 
teen months. 

The  course  of  facial  paralysis  is  usually  favorable.  The  onset  in  tho 
tnrm  following  cold  is  very  rapid,  develo})ing  perha))s  within  twenty-four 
lionrs,  but  rarely  is  the  paralysis  permanent.  On  the  other  hand,  in  tho 
paralysis  from  injury,  as  by  a  blow  on  the  mastoid  process,  tho  paralysis 
may  remain.  When  permanent  the  muscles  are  entirely  ton-less.  In  some 
instances  contracture  develops  as  the  voluntary  power  returns,  and  the  natu- 
ral folds  and  the  wrinkles  on  the  atfocted  side  may  be  deex)ened,  so  that  on 


if    '>5 


■1^   I 


'"fl^ 


-v,;,!    ' 


800 


DISEASES  OF  'iHE  NERVOUS  SYSTEM. 


looking  at  the  face  one  at  first  may  liave  the  im])ros.siou  that  the  affected 
side  is  tlio  sound  one.  Tliis  is  corrected  at  once  on  asking  the  jjaticiit  in 
sniiU',  when  it  is  seen  which  side  of  the  face  lias  the  most  active  ni()\c- 
ment. 

Ti»e  (Uagnosis  of  facial  ])aralysis  is  usually  easy.     The  distinction  lie 
tween  ju'ripheral  and  central  is  based  on  facts  already  mentioned. 

Treatment. — In  the  cases  which  result  from  cold  and  are  probalilv 
due  to  neuritis  within  the  bo;\y  canal,  hot  aj)plications  iirst  sliould  W 
made;  subse(iuently  the  thermo-cautery  may  be  used  lightly  at  intervals 
of  a  day  or  two  over  the  mastoid  ])rocess,  or  small  blisters  applied. 
If  the  ear  is  diseased,  free  discharge  for  the  secretion  should  lu'  uli- 
tained.  The  continuous  current  may  be  employed  to  keep  up  tlu^  nu- 
trition of  the  ma.scle8.  The  })ositive  pide  should  be  })laced  behind  the 
ear,  the  negative  one  along  the  zygomatic  and  other  muscles.  'IMie  a|i- 
plication  can  lie  made  daily  for  a  quarter  of  an  hour  and  the  patient  laii 
readily  be  taught  to  make  it  himself  before  the  looking-glass,  ^fassagc  di 
the  mus(des  of  the  face  is  also  useful. 

A  course  of  iodide  of  potassium  may  be  given  even  when  there  is  no 
indication  of  syphilis. 


ill  .,  ,■. 

■'■  ,'■ 

;i 

■ 

Spasm. — Tlu^  spasm  may  he  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  fai'ial  nerve  and  nniy  be  unilateral  or  bilateral. 

Jt  is  known  also  by  the  name  of  mimi(!  spasm  or  of  convulsive  tie. 
Several  ditTcrent  affections  are  usmdly  considered  under  the  na.ne  of  facial 
or  mimic  spasm,  but  we  shall  here  speak  oidy  of  the  sifn))le  s[msm  of  the 
facial  mus(des,  either  i)riniary  or  following  paralysis,  aiul  shall  not  in- 
clude the  cases  of  habit  spasm  in  children,  or  the  tic  cnniutlsif  of  the 
French. 

(lowers  recr.giiizes  two  classes — one  in  whicdi  tl  tc  is  an  organic  Icsidii, 
and  an  idiopathic  form.  It  is  thought  to  l)e  due  also  to  retlex  causes,  siic]-, 
as  the  irritation  from  carious  teeth  or  the  prescice  of  iiuestinal  worms. 
The  disease  usually  occurs  in  adults,  whereas  the  habit  spasm  and  the  '/' 
rniiriilKi'f  uf  the  Krent'h,  often  confounded  with  it,  are  most  co"imoii  in 
children.  Trnc  mimic  spasm  occasionally  comes  on  in  (diildhood  and  |iei- 
sists.  In  the  case  of  a  school-mate,  the  atTection  was  marked  as  earlv  af> 
the  eleventh  or  twtdrtli  y(>ar  and  still  continues.  When  the  result  of  or 
ganic  disoase  there  has  usually  beifi  a  k  "ion  of  the  centre  in  the  cortex.  a«. 
in  the  case  rcporiecl  by  Herkidey,  or  piv";sure  on  the  nerve  at  the  ha.-e  uf 
the  brain  by  aneurism  or  tumor. 

Syiuptcms. — The  sfiasm  may  involve  only  the  muscles  around  the 
eye — blepharospasm-  -in  which  case  there  is  ccmstant,  n-pid,  quick  actinii 
of  the  orbicularis  palpebrarum,  which,  in  association  with  ])hotoph(iliia, 
may  he  tonic  in  character.  More  commonly  the  spa  m  afTecrs  the  laleial 
facial  muscdes  with  those  of  the  eye  and  there  is  constant  twitching  of  the 
side  of  the  face  with  partial  closure  of  the  eye.     The  frontalis  is  rarely  in- 


1., 


en  there  is  no 


DISEASES  OF  THE  CRANIAL  NERVES. 


801 


volvod.  In  apfgraviited  euscs  tlie  dqirosaora  of  the  ani^K'  of  tlie  nioutli,  tliu 
Icviitor  meuti,  and  the  phitysnui  myoides  are  atTected.  'I'his  spa.srn  is  con- 
fiiu'd  to  one  side  of  the  face  in  a  majority  of  cases,  though  it  may  extend 
ami  heeome  bihiterai.  It  is  increased  by  emotional  causes  and  invohmtary 
movements  of  the  face.  As  a  rule,  it  is  painless,  but  there  may  be  tender 
points  on  the  course  of  the  iiftli  nerve,  ])arti('ularly  the  supraorbital 
branch.  Tonic  spasm  of  the  facial  muscle  may  follow  paralysis,  and  is 
said  to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  dubious.  A  majority  of  the 
cases  persist  for  years  and  are  incurable. 

Treatment. — Sources  of  irritation  should  be  looked  for  and  re- 
moved. AVhen  a  ])ainful  sj)ot  is  present  over  the  fifth  nerve,  blisterin<r 
(ir  the  ap))Iication  of  the  thermo-cautery  may  relieve  it.  Hypodermic; 
injections  of  strychnia  may  be  tried,  but  are  of  dou])tful  benelit.  Weir 
Mitchell  recommends  the  freezing  of  the  cheek  for  a  few  niiimtcs  daily 
or  every  second  day  with  the  sjjray,  and  this,  in  some  instances,  is  beiie- 
liciul.  Often  the  relief  is  transient;  the  cases  return,  and  at  every 
clinic  miiy  be  seen  half  a  dozen  or  more  of  such  patients  who  have  run 
the  ganuit  of  all  measures  without  material  improvement.  OjK'rative 
interference  may  be  "f^sorted  to  in  severe  cases,  although  not  much  can 
lie  exi)ected  of  it. 


"1 

It 


if  '»> 


U' 


VI.  Al'DITOItV   XlvUVR. 


This  nerve,  forming  the  porrnt  nwUis  of  the  seventh  pair,  entci's  the 
intirnal  auditory  meatus,  and  divides  into  tlu'  cochlear  and  vestibular 
liranches.  The  cortical  centre  for  hearing  is  in  the  tcm{)oro-sphenoi(laJ 
lobe.  Primary  disease  of  the  auditory  nerve  in  its  centre  or  intnicranial 
course  is  uncommon.  More  fre<[uently  the  terminal  branches  are  atfected 
wiliiin  the  lai)yrinth. 

{<t)  Affvetion  of  (he  Ciir/iral  f'etihr. — In  tlu-  monkey,  experiments 
iinlicaie  that  the  first  temporal  gyri  represent  the  centre  for  hearing.  In 
man  the  cases  of  disease  indicate  that  it  has  the  same  situation,  as  dc- 
stiiiction  of  this  gyrus  on  the  left  side  results  in  wonl-dcafness,  which 
mav  lie  di'fined  as  an  inability  to  understaiul  the  meaning  of  w(»nls,  (liongh 
iIhv  may  still  be  hea'"l  as  sounds.  The  central  ril)res  of  the  auditory  nerve 
bitween  the  cortical  'Mitre  and  the  nucleus  in  the  fourth  ventricle  maybe 
involved  and  i)roduce  deafness.  This  has  resnlt»'d  from  the  presence  of  a 
tumor  in  the  corpora  quadrigemina,  and  may  be  associated  with  a  lesion  of 
tlio  internal  capsule. 

{/))  Lesions  of  the  }crvp  nf  f/ie  base  of  d\o.  brain  may  result  from  tho 
pressure  of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  h.-vm- 
onhage,  or  traumatism.  A  prinniry  degeneration  of  tlie  nerve  may  occur 
in  locomotor  atjixia.  Nuclear  disease  is  rare,  liy  far  the  most  int<'rest- 
iiig  form  results  from  epidemic  cerebro-spinal  meninj'itid,  iu  which  the 


■t( . 


■.;| 


802 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


I  n 


i 

^ 

»f'  .-■ 

it:. 

T,}ft 

-.,.1  ., 

•11  ■ 

■ 

1      ■■.; 

'    '  '^4 

!_j||^ 

norve   is   frequently  iiivolvetl,  causing   permanent  deafness.      In  yoiuiij 
chiklron  the  condition  results  in  deaf-niutisni. 

(c)  In  a  majority  of  the  cases  associated  with  auditory-nerve  symptnnis 
the  lesion  is  in  the  labyrinth,  either  prinuiry  or  the  result  of  extension  of 
disease  of  the  middle  ear.  'J'hree  <;roups  of  symptoms  nuiy  be  produced— 
hyperajsthesia  and  irritation,  diminished  function  or  nervous  deafness,  ami 
vertigo. 

(1)  Ili/pnuPfi/Iu'sin  and  Irritation. — This  may  be  due  to  altered  fiiiic- 
tion  of  the  centre  as  well  as  of  the  nerve  ending.  True  hyj»era'sthesia— 
hyperacusis — is  a  condition  in  which  sounds,  sometimes  even  those  iiiamii- 
ble  to  other  ]»ersons,  are  heard  with  great  intensity.  It  occurs  in  hy.^lcria 
and  occasioiuilly  in  cerebral  disease.  As  already  mentioned,  in  paralysis 
of  the  stapedius  low  notes  may  Ije  heard  with  intensity.  In  dysa'sthtsia, 
or  dysacusis,  ordinary  sounds  cause  an  unpleasant  sensation,  as  comnidiih 
happens  in  connection  with  headache,  when  ordinary  noises  are  bially 
borne. 

Tinnitus  aurium  is  a  term  em})loyed  to  designate  certain  subjectivo 
sensations  of  ringing,  roaring,  ticking,  and  whirring  noises  in  the  ear.  It  is 
a  very  common  and  oft<3n  a  distressing  symjjtcin).  It  is  associated  with  many 
forms  of  ear  disease  and  nuiy  result  from  pressure  of  wax  oii  the  drum.  It 
is  rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudilcii 
intense  stimulation  of  the  nerve  nuiy  cause  it.  A  form  not  uncommonly 
met  with  in  medical  practice  is  that  in  which  the  patient  hears  a  coiitiniial 
bruit  in  the  ear,  and  the  iu)ise  has  a  systolic  intensification,  iisualiy  on 
one  side.  I  have  twice  been  consulted  by  physicians  for  this  condition 
under  the  belief  that  they  liad  an  intcnuil  aneurism.  It  occurs  in  coiMii- 
tions  of  ana'inia  and  neurasthenia.  Subjective  noises  in  the  ear  may  jnc- 
cede  an  epileptic  seizure  and  are  sometimes  present  in  migraine,  in 
whatever  form  tinnitus  exists,  though  slight  and  often  regarded  as  trivial. 
it  occasions  great  annoyance  and  often  mental  distress,  and  has  even  driven 
l)atienta  to  suicide. 

The  diagnosis  is  readily  made;  but  it  is  often  extremely  diflicult  to  ilo- 
termine  upon  what  condition  the  tinnitus  dei)ends.  The  relief  of  con- 
stitutional states,  sucli  as  ana'inia,  neurasthenia,  or  gout,  may  result 
in  cure.  A  careful  local  examinaticm  of  the  ear  should  always  be  iiunli'. 
One  of  the  most  worrying  forms  is  the  constant  clicking,  sometimes  audi- 
ble many  feet  away  from  the  jKitient,  and  due  probal>ly  to  clonic  spasm 
of  the  muscles  connected  with  the  Eustachian  tube  or  of  the  levator  palati. 
The  condition  may  i)ersist  for  years  uiu'hanged,  and  then  disappear  sud- 
denly. The  pulsating  forms  of  tinnitus,  in  whicdi  the  sound  is  like  that 
of  a  systolic  bruit,  are  almost  invariably  subjective,  and  nothing  is  auiiil>li' 
with  the  stethoscope.  It  is  to  be  remembered  that  in  children  there  i>  ii 
Bystolic  brain  murmur,  best  heard  over  the  ear,  and  in  some  instancis  is 
heard  in  tlie  adult. 
(      (2)  Diminished  Function  or  Xervous  Deafni'sn. — In  testing  for  nervous 


DISEASES  OP  THE  CRANIAL   NERVES. 


803 


i»}I  for  uorvous 


deafness,  if  tho  tuning-fork  cannot  be  hoartl  wlion  placed  noar  the  moatus, 
but  the  vibrations  are  audiblo  by  phioing  the  foot  of  the  tuning-fork  against 
tlic  temporal  bone,  the  conclusion  may  be  drawn  that  the  deafness  is  not 
due  to  involvement  of  tho  nerve.  The  vibrations  are  conveyed  through 
the  temporal  bono  to  the  cochlea  and  vestibule.  The  watch  nuiy  be  used 
for  the  same  purpose,  and  if  the  meatus  is  closed  and  the  watch  is  lieard 
luttor  in  contact  with  the  mastoid  process  than  when  opposite  the  ojKsn 
meatus,  tho  deafness  is  probably  not  nervous.  Practically,  disturbance  of 
tlie  function  of  the  auditory  nerve  is  not  a  very  frequent  symptom  in 
l)rain-dise4vse,  but  in  all  cases  the  funcition  of  the  nerve  should  be  carefully 
t<'st(;d 

(3)  Auditory  Vertigo— Meniere's  Disease.— In  18(*1  Meniere,  a  French 
physician,  described  an  affection  characterized  by  noises  in  the  ear,  ver- 
tigo (which  might  bo  associated  with  loss  of  consciousness),  vomiting,  and, 
in  many  Ciises,  progressive  loss  of  hearing.  The  term  is  now  used  to  in- 
(lude  all  Ciises  of  sudden  vertigo  accompanied  by  noises  in  tlie  car  and 
(h'iifness.  The  frequency  of  vertigo  with  ear  symptoms  is  striking. 
Thus,  of  100  cases  noted  by  Gowers,  in  which  there  was  definite  vertigo, 
in  94  ear  symptoms  were  present,  cither  tinnitus  or  deafness  or  both. 

Symptoms. — The  atttick  usually  sets  in  suddenly  with  a  buzzing 
noise  in  tho  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering. 
He  may  feel  himself  to  be  reeling,  or  the  objects  about  him  may  seem  to 
ho  turning,  or  the  phenomena  may  be  combined.  The  attack  is  often  so 
jilirupt  that  the  patient  falls,  though,  as  a  rule,  he  has  time  to  steady  him- 
Ki'lf  by  grasping  some  neighboring  object.  There  may  be  slight  but 
transient  loss  of  consciousness.  In  a  few  minutes,  or  even  less,  the  ver- 
tigo passes  off  and  the  patient  becomes  pale  atul  nauseated,  a  clammy 
Hweat  breaks  out  on  the  face,  and  vomiting  may  follow. 

The  deif aess,  which  is  always  of  a  iu>rvous  character,  may  1)0  in  only 
•me  ear  and  is  never  complete.  The  tinnitus  is  described  as  either  a  roar- 
ing or  a  throbbing  sound.  Ocular  symptoms  may  be  present;  thus,  jerk- 
ing of  tho  eyeballs  or  nystagmus  may  develop  during  the  attack,  or 
diplopia. 

Labyrinthine  vertigo  is  paroxysmal,  coming  on  at  irregular  intervals. 
Sometimes  weeks  or  mcmths  may  elapse  between  the  attacks ;  in  other 
ciuses  there  may  be  several  att4i(>ks  in  a  day.  As  a  rule,  the  patients  have 
no  alTection  of  the  middle  ear.  The  disease  rarely  occurs  in  young  per- 
sons, is  most  frequent  after  the  fortieth  year,  and  is  more  connnon  in  men 
than  in  w(mien. 

The  pathology  of  tho  disease  has  been  much  discussed.  There  are 
two  tlumries  concerning  its  origin — one,  that  it  is  due  to  affection  of  tho 
lal)yrinth  itself,  which  causes  a  disturbance  of  erpiilibrium,  such  as  is 
proved  by  experiment  to  be  associated  witli  lesion  of  tho  semicircular 
I'.uials ;  tho  other  that  it  is  really  u  trouble  iuvolviug  tlie  centres  presiding 
over  hearing  and  equilibration. 
51 


■ 

■■  it 

:yH 

i'f 

'I 

1 

i 

804 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


1 ' ; 


It  has  also  been  lield  to  bo  a  vaso-motor  neurosis  of  the  vessels  of  11  us 
labyrinth.  The  condition  of  the  labyrijith  in  tlu'so  casi's  is  varialilf. 
Acute  disease  with  hajmorrhapje  litis  boon  dc.-!(!rib(Ml,  or  slow  proj^res-ivci 
degeneration  of  the  nerves,  (liihlinciss  and  vomiting  may,  however,  be 
produced  by  irritation  in  other  parts  of  the  ear;  thus,  there  arc  instances 
in  which  pressure  on  the  drum  or  irritalion  of  the  external  meatus  is  fol- 
lowed by  an  attack  of  giddiness  and  vomiting. 

Diagnosis. — The  combination  of  tinnitus  with  giddiness,  with  or 
without  gastric  disturbance,  is  sulli.icnt  to  establish  a  diagnosis.  'J'hcre 
arc  other  forms  of  vertigo  from  which  it  must  be  distinguished.  Tlio 
form  known  as  gastric  vertigo,  which  is  associated  witli  dyspepsia  and  oc- 
curs most  commonly  in  persons  of  miildle  ago,  is,  as  a  rule,  readily  distin- 
guished by  the  absence  of  tinnitus  or  evidences  of  disturbance  in  the  func- 
tion of  the  auditory  nerve.  This  variety  of  vertigo  is  much  less  comnioti 
than  Trousseau's  descri])tion  woidd  lead  us  to  believe. 

The  cardio-vascular  vertigo,  one  of  the  most  common  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insulliciency,  and  ad  frequently 
in  arterio-sclerosis. 

There  is  a  remarkable  form  of  vertigo  described  by  Oerlier,  which  is 
characterized  by  attacks  of  paretic  weakness  of  the  extremities,  falling  of 
the  eyelids,  remarkable  depression,  but  with  retention  of  consciousness. 
It  attacks  only  men,  and  has  occurred  in  epidemic  form  among  laborers  in 
the  canton  of  Geneva. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  prtit 
mal,  or,  indeed,  of  definite  epilepsy.  It  is  rare  in  pcfii  iiial  to  have  noises 
in  the  ear  or  actual  giddiness,  but  in  the  aura  preceding  an  ('pilei)tic  atUick 
the  patient  may  feel  giddy.  fJiddincss  and  transient  loss  of  consciousness 
may  be  associated  with  organic  disease  of  the  brain,  more  particularly  with 
tumor.  Vomiting  als.)  may  be  present.  A  careful  investigation  of  \.\w 
symptoms  will  usually  lead  to  a  correct  diagnosis. 

The  outlook  in  Meniere's  disease  is  uncertain.  While  many  cases  re- 
cover completely,  in  otliers  deafness  results  and  the  attacks  recur  at 
shorter  intervals.  In  aggravated  cases  the  patient  constantly  sulfers  from 
vertigo  and  may  even  be  confined  to  his  bed. 

Treatment. — Bromide  of  ])otassium,  in  twenty-grain  doses  three 
times  a  day,  is  sometimes  beneficial.  If  there  is  a  history  of  syi)hilis, 
tho  iodide  should  be  administered-  'I'he  salicylates  are  recommended,  and 
Charcot  advises  quinine  to  cinchonism.  Incases  in  which  there  is  increase 
in  the  arterial  tension  nitroglycerine  may  be  given,  at  first  in  very  small 
doses,  but  increasing  gradually.  It  is  not  specially  valuable  in  Meniere's 
disease,  but  in  tho  cases  of  giddiness  in  middle-aged  men  and  women  asso- 
ciated with  arterio-sclerosis  it  sometimes  acts  very  satisfactorily. 


1 


DISEASES  OF  THE  CRANIAL  NERVES. 


805 


VII.    (jLosso-pharvnoeal  \euve. 

This  nervo  contains  botli  motor  anil  sensory  fibres  anil  is  also  a  nervo 
(if  tlie  special  sense  of  taste  to  tlie  tongue.  It  supplies,  by  its  motor 
branches,  the  stylo-pharyngeus  and  the  middle  constrictor  of  the  pharvnx. 
Tlie  sensory  fibres  are  distributed  to  the  upper  part  of  the  ])haryi!X. 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The 
j)haryngeal  symptoms  of  bulbar  paralysis  are  probably  associated  with  in- 
volvement of  the  nuclei  of  this  nerve.  Lesion  of  the  nerve  tnnik  itself  is 
rare,  but  it  may  be  compressed  by  tumors  or  involved  in  meningitis.  Dis- 
turbance of  the  sense  of  taste  may  result  from  loss  of  function  of  this 
nerve,  in  which  case  it  is  chiefly  in  the  posterior  part  of  the  tongue  and 
soft  palate.  (lowers,  however,  states  that  there  is  no  case  on  record  in 
which  loss  of  taste  in  these  regions  has  been  j)roduced  by  disease  of  the  roots 
of  the  glosso-pharyngeal ;  whereas,  on  the  other  hand,  disease  of  the  root 
of  the  fifth  nerve  may  cause  loss  of  taste  on  the  back  as  well  as  the  front 
of  the  tongue,  as  if  the  taste  fibres  of  the  glosso-pharyngeal  came  from  the 
fifth. 

The  general  disturbances  of  the  sense  of  tiiste  may  here  be  briefly  re- 
ferred to.  Loss  of  the  sense  of  taste — (if/eiisia — may  be  caused  by  dis- 
turbance of  the  peripheral  end  organs,  as  in  affections  of  the  mucosa  of 
the  tongue.  This  is  very  common  in  the  dry  tongue  of  fever  or  the  furred 
tongue  of  dyspepsia,  under  which  circumstances,  as  the  saying  is,  every- 
tliing  tastes  alike.  Strong  irritants  too,  such  as  pepper,  tobacco,  or  vinegar, 
may  dull  or  diminish  the  sense  of  taste.  Complete  loss  may  be  due  to  in- 
volvement of  the  nerves  either  in  their  course  or  in  the  centres.  Dis- 
turbance in  the  sense  of  ttiste  is  most  commonly  seen  in  involvement  of 
tlu!  fifth  nerve,  and  it  may  be  that  this  nerve  ahuie  subserves  the  function. 
Perversion  of  the  sense  of  tsiste — purar/eusis — is  rarely  found,  except  as 
!ui  hysterical  manifestation  and  in  the  insane.  Increased  sensitiveness  is 
still  more  rare.  There  are  occasional  subjet^tive  sensations  of  taste,  occur- 
ring as  an  aura  in  epilepsy  or  as  part  of  the  hallucinations  in  the  insane. 

To  test  the  sense  of  taste  the  j)atient's  eyes  shoukl  be  closed  and  small 
(|uantities  of  various  substances  applied.  The  sensation  should  bo  pcr- 
(H'ived  before  the  tongue  is  withdrawn.  The  following  are  the  most  suit- 
aide  tests :  For  bitter,  quinine  ;  for  sweetness,  a  strong  solution  of  sugar  or 
siu'charin  ;  for  acidity,  vinegar ;  and  for  the  saline  test,  common  salt.  One 
of  the  most  important  tests  is  the  feeble  galvanic  current,  which  gives  the 
well-known  metidlic  taste. 


VIII.     PVEl'MOOASTRIC   NeRVE. 

The  vagus  nerve  has  an  important  and  extensive  distribution,  supply- 
ing the  pharynx,  larynx,  lungs,  heart,  onsophagus,  and  Btonnw!h.  The 
lUTve  may  be  involved  at  its  nui^leus  with  the  spinal  accessory  and  th(! 
liypoglossal,  forming  what  is  known  us  bulbar  paralysis.    It  may  bo  com 


806 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


pnjssod  by  tumors  or  unourisni,  or  in  the  exudation  of  meningitis,  8inij)I.> 
or  sypliilitic.  In  ita  course  in  the  neck  the  trunk  may  be  involved  by 
tumors  or  in  wounds.  It  Ims  l)oon  tied  in  ligature  of  the  oarotM,  and  luis 
been  cut  in  the  removal  of  deep-seated  tumors,  'i'he  trunk  may  bo  at- 
tacked by  neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  tlm 
distribution  of  the  sejMirate  nerves. 

(rt)  Pharyngeal  Branches. — In  combiiuition  with  the  glosso-i)haryng(>al 
the  branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  tlio 
umscles  and  mucosa  of  the  i)harynx  are  supplied.  In  pnralynis  due  to 
involvement  of  this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  tlio 
course  of  the  nerve,  as  in  diphtheritic  neuritis,  there  is  difficulty  in  swal- 
lowing and  the  food  is  not  passed  on  into  the  oesophagus.  If  the  ncrvo  on 
one  side  only  is  involved,  the  deglutition  is  not  much  impaired.  In  tlicsi! 
cases  the  particles  of  food  frerjuently  pass  into  the  larynx,  and,  when  the 
soft  palate  is  involved,  into  the  posterior  nares. 

iSpasm  of  the  pharynx  is  always  a  functional  disorder,  usually  occur- 
ring in  hysterical  and  nervous  pco|)le.  Gowers  mentions  a  case  of  a  gcMi- 
tleman  who  could  not  eat  unless  alone,  on  account  of  the  inability  to 
swallow  in  the  presencie  of  others  from  spasm  of  the  pharynx.  This  si)astii 
is  a  well-marked  feature  in  hydrophobia,  and  I  have  seen  it  in  a  case  of 
pseudo-hydrophobia. 

(h)  Larjrngeal  Branches. — The  superiiM-  laryngeal  nerve  supplies  tho 
mucous  membrane  of  the  larynx  above  the  cords  ami  the  crico-thyroid 
muscle.  The  inferior  or  recurrent  laryngeal  curves  around  the  arch  of  tin; 
aorta  on  the  left  side  and  the  subclavian  artery  on  the  right,  passes  aloiis,' 
the  trachea  and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  i)f 
tiie  larynx  except  the  crico-thyroid  and  the  epiglottidean.  Experiments  have 
shown  that  these  motor  nerves  of  tho  pneumogastric  are  all  derived  from 
the  spinal  accessory.  The  remarkable  course  of  tho  recurrent  laryugcal 
nerves  renders  them  liable  to  pressure  by  tumors  within  the  thorax,  i)ar- 
tioularly  by  aneurism.  Tlie  following  are  tho  most  important  forms  of 
paralysis : 

(1)  liilnteral  Paralysis  of  the  Abductors. — In  this  condition,  the  pos- 
terior cricjo-arytenoids  are  involved  and  the  glottis  is  not  opened  duriiij,' 
inspiratio!!.  The  cords  may  be  close  together  in  the  position  of  phonatioii, 
and  during  inspiration  may  bo  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  whistlos 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  occurs 
o(!casionally  as  a  result  of  cold,  or  may  follow  a  laryngeal  catiirrh.  Tlio 
posterior  muscles  have  been  found  degenerated  when  the  others  won; 
healthy.  The  condition  nniy  be  })rodu(!ed  by  pressure  upon  both  vagi,  or 
upon  both  recurrent  nerves.  As  a  central  affection  it  occurs  in  tabes  ami 
Imlbar  p.iralysis,  but  m;iy  ot^nir  also  in  hysteria.  Tho  charactiM-istic 
symptoms  are  inspiratory  stridor  with  unimpaired  phouation.     Possibly, 


DISEASES  OP  THE  CRANIAL  NERVES. 


807 


tioii  with  tlio 


lis  Gowere  suggests,  many  ciises  of  so-called  hysterieal  8})a8m  of  the  glottis 
are  in  reality  abductor  paralysis. 

(2)  Unilateral  Abductor  Paralysis. — This  frequeutly  results  from  tlio 
pressure  of  tumora  or  involvement  of  one  recurrent  nerve.  Aneurism  is 
l)y  far  the  most  common  cause,  though  on  the  right  side  the  nerve  may 
he  involved  in  thickening  of  the  j)leura.  The  symptoms  are  hoarsencjss 
or  roughness  of  the  voice,  such  as  is  so  common  in  aneurism.  Dyspnoea 
is  not  often  present.  The  cord  on  the  affected  side  does  not  move  in  in- 
spiration. Subsequently  the  adductors  may  also  become  involved,  in  whic^h 
(•use  the  phonation  is  still  more  impaired. 

(3)  Adductor  Paralysis. — Tins  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
[liirticularly  of  Avomen,  and  causes  the  hysterical  aphonia,  which  may 
come  on  suddenly.  It  may  result  from  catarrh  of  the  larynx  or  from 
overuse  of  the  voice.  In  laryngoscopic  examination  it  is  seen,  on  attemi)t 
at  phonation,  that  there  is  no  power  to  bring  the  cords  together.  In  this 
connection  the  following  table  from  (Jowers  work  will  be  found  valuable  to 
the  student : 


Symptoms. 


Signs. 


Lksion. 


No  voice ;  no  cough ; 
stridor  only  on  deep  in- 
npiration. 

Voice  low  pitched 
iiiid  hoarse ;  no  cough  ; 
Htridor  absent  or  slight 
on  deep  breathing. 


Voice  little  changed ; 
(U)ugh  normal ;  inspira- 
tion difficult  and  long, 
with  loud  stridor. 

Symptoms  incon- 
cliisive ;  little  affection 
of  voice  or  cough. 

No  voice ;  perfect 
<ough;  no  stridor  or 
(iyHpnooa. 


Both  cords  moder- 
ately abducted  and  mo- 
tionless. 

One  cord  moder- 
ately abducted  and  mo- 
tioidess,  the  other  mov- 
ing freely,  and  even 
beyond  the  middle  line 
in  phonation. 

Hoth  cords  near  to- 
gether, and  during  in- 
spiration not  separated, 
but  even  drawn  nearer 
together. 

One  cord  near  the 
middle  line  not  moving 
during  inspiration,  the 
other  normal. 

Cords  normal  in  po- 
sition and  moving  nor- 
mally in  respiration, 
but  not  brought  to- 
gether on  an  attempt 
at  phonation. 


Total  bilateral  palsy. 


Total  unilateral  palsy 


Totid  abductor  palsy. 


Unilateral 
j)alsy. 


abductoi 


Adductor  palsy. 


^ii'\ 


-  «'  L 
If    ^1 

fit         -ii 


ri        |: 


808 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


I  r    I  ;  ! 


m 


'iri       1: 


6    'i    •' 


Spnxm  of  tho  Muscles  of  the  Larynx. — In  this  the  adductor  musoKs 
are  involved.  It  is  not  an  uncommon  alTcctiou  in  children,  and  has  al- 
ready heon  referred  to  as  laryngismus  stridulus.  Paroxysnud  attacks  of 
laryngeal  spasm  are  rare  in  the  adult,  hut  cases  are  described  in  which  llio 
j)atient,  usually  a  young  girl,  wakes  ut  night  in  an  attack  of  intense  dysp- 
noea, which  may  persist  long  ciu)Ugh  to  produce  cyanosis.  Liveing  states 
that  they  may  replace  attacks  of  migraine.  They  oc(!ur  in  a  charactorislic 
form  in  locomotor  ataxia,  forming  the  so-called  laryngeal  crises.  Then!  is 
a  condition  known  as  spastic  aplionia,  in  which,  when  the  patient  atteniphs 
to  speak,  phonation  is  completely  prevented  by  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

Anwsthesiaxmxyocnur'wi.  bulbar  paralysis  and  in  diphtheritic  neuritis— 
u  serious  condition,  as  portions  of  food  may  enter  the  windpi])c.  It  is 
usually  associated  with  dysphagia  and  is  sometimes  present  m  hysteria. 
llyperaesthesia  of  the  larynx  is  rare. 

{(•)  Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of 
branches  of  tho  vagi  and  of  the  sympathetic  nerves.  Tho  vagus  fibres  sub- 
serve motor,  sensory,  and  })robably  trophic  functions. 

(1)  Motor. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiai; 
action  pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  C/.cr- 
mak  could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing  ii 
small  tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said 
that  the  same  can  be  produced  by  forcible  bilateral  pressure  on  the  cii- 
rotid  canal.  There  are  instances  in  which  persons  appear  to  have  had  vol 
untary  control  over  the  action  of  the  heart.  Tho  most  remarkable  in- 
stance was  that  of  Colonel  Townsend,  who  could  slow  the  action  of  tli(> 
heart  at  will.  Ifetanhition  of  the  heart's  action  has  also  followed  acci- 
dental ligature  of  one  vagus.  Irritation  at  the  nuclei  may  also  be  accom- 
panied by  extreme  slowness.  The  condition  of  brachycardia  may  be  asso- 
ciated with  a  neurosis  of  this  nerve.  On  the  other  hand,  when  thoro  is 
complete  paralysis  of  the  vagi,  the  inhibitory  action  may  be  abolislud 
and  the  acceleratory  influences  have  full  sway.  The  heart's  action  is  then 
greatly  increased.  This  is  seen  in  some  instances  of  diptheritic  neuritis 
and  in  involvement  of  tho  nerve  by  tumors,  or  its  accidental  removal  or 
ligature.  Complete  loss  of  function  of  one  vagus  may,  however,  not  bo 
followed  by  any  symptoms. 

(2)  Sonsory  symptoms  on  the  part  of  the  cardiac  branches  are  very 
varied.  Normally,  tho  heart's  action  proceeds  regularly  without  the  par- 
ticipation of  consciousness,  but  the  unpleasant  feelings  and  sensations  of 
palpitation  and  pain  are  conveyed  to  the  brain  through  this  nerve.  How 
far  the  fibres  of  the  pneumogastric  are  involved  in  angina  it  is  impossil)lo 
to  say.  The  various  disturbances  of  sensation  are  described  under  tho 
cardiac  neuroses. 

{d)  Pulmonary  Branches.— We  know  very  little  of  the  pulmonary 
branches  of  the  vagi.    The  motor  fibres  are  stated  to  control  the  action  of 


DISEASTOS  OP  TIIK  CRANIAL   NKllVKS. 


809 


till!  bronchial  mus(;los,  iitid  it  bus  long  boon  hold  tbatustluna  niiiy  boa  ncu- 
nisis  of  these  fibres.  The  various  alterations  in  tlio  respiratory  rliytlun  are 
jirohably  duo  more  to  changes  in  the  centre  tlian  in  the  nerves  them- 

."elves. 

{(')  Gastric  and  (Esophageal  Brandies.— Tlu!  niuscidar  movements  of 
tlieso  parts  are  presided  over  by  the  vagi  and  vomiting  is  induced  through 
tlii'in,  usually  reilexly,  but  also  by  diivct  irritation,  as  in  nieniugitis.  Spasm 
of  the  a>soj)hagus  generally  occurs  w  ith  other  nervous  plienomeua.  (jias- 
tnilgia  may  sometimes  be  due  to  cramp  of  tlie  stomach,  but  is  more  com- 
nioidy  a  sensory  disturbance  of  this  nerve,  duo  to  direct  irritation  of  the 
peripheral  emls,  or  is  a  neuralgia  of  the  lerminal  fibres.  Hunger  is  said 
to  he  a  sensation  aroused  by  the  pncumogiistric,  ami  .some  forms  of  nervous 
dy.spepsia  probably  depend  upon  di.sturl)etl  function  of  this  nerve.  Tho 
severe  gastric  crises  which  occur  in  locomotor  ataxia  arc  due  to  central 
irritation  of  tho  nuclei.     Some  describe  exophthalmic  goitre  under  lesions 


of  the  vagi. 


IX.  Spina:.  Accessor v  Neuve. 


Paralysis. — The  smaller  or  internal  ])art  of  tliis  nerve  jcjins  the  vagus 
and  is  distributed  through  it  to  the  laryngeal  muscles.  Tho  larger  external 
part  is  distributed  to  the  sterno-mastoid  and  trajjczius  muscles. 

The  nuclei  of  the  nerve,  p:irticularly  of  the  acce;;sory  {)art,  may  bo  in- 
volved in  bulbar  paralysis.  The  nuclei  of  the  external  portion,  situated 
as  they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degenera- 
tion of  tho  motor  nuclei  of  the  cord.  Tiie  nerve  nuiy  be  involved  in 
the  exudation  of  meningitis,  or  be  compressed  by  tumors,  or  in  caries. 
The  st/mptoins  of  paralysis  of  the  accessory  portion  \v]ii(;h  joins  tlie  vagus 
have  already  been  given  in  tlie  jiccount  of  ttio  palsy  of  the  laryngeal 
branches  of  the  pneumogastric?.  Di.sease  or  compression  of  tho  external 
portion  is  followed  by  })aralysis  of  the  .sterno-mastoid  and  of  the  trapezius 
on  tho  same  side.  In  paralysis  of  one  sterno-mastoid,  tho  patient  rotates 
tlio  head  with  difTlculty  to  tlie  oppo? iti'  side,  but  there  is  no  torticollis, 
tliongh  in  some  cases  tho  head  is  hekl  obliquely.  As  tho  trapezius  is 
supplied  in  part  from  tho  cervical  nerves,  it  is  not  completely  paralyzed, 
but  the  portion  which  passes  from  the  occipital  bone  to  the  acromion  is 
fuuctionless.  The  paralysis  of  the  muscle  is  well  seen  when  t!ie  jiatient 
draws  a  deep  breatii  or  slirugs  the  shoulders.  The  middle  portion  of  tho 
trapezius  is  also  weakened,  the  shoulder  droops  a  little,  and  the  angle  of 
the  scapula  is  rotated  inward  l)y  the  action  of  the  rhondioidsand  the  levator 
anguli  scapula?.  Elevaticm  of  the  arm  is  imjjaired,  for  tlie  trapezius  does 
not  fix  tho  scapula  as  a  point  from  which  the  deltoid  can  work. 

In  progressive  muscular  atro])hy  avo  sonu'times  see  bilateral  paralysis 
of  these  muscles.  Thus,  if  the  storno-mastoids  are  affected,  the  head 
tends  to  fall  back ;  when  the  trapezii  are  involved,  it  falls  forward,  a 
characteristic  attitude  of  the  head  in  many  cases  of  progressive  muscular 


■yj' 


;;  .  ;  i  i  '  • 


■,#■ 


.4, 


I    ■''■■] 


t! 


I    f 


810 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


V  \ 


;  .t 


k : 


atrophy.  Gowcrs  suggests  that  lesions  of  tl»o  ftocessory  in  difficult  lalioi 
may  ac'count  for  those  cases  iji  wiiich  during  the  first  year  of  life  the 
(ihild  has  great  ditticulty  in  holding  up  tlif  head.  In  children  this  droop. 
ing  of  tlic  head  is  an  important  syni]»tom  in  cervical  ineuiugitis,  llut 
result  of  caries. 

The  treat inent  of  the  condition  depends  much  upon  the  cause.  In  tin 
nontral  nuclear  atrophy  but  little  ran  be  iloiui.  Iti  paralysis  from  prcssmv 
the  symptoms  nuiy  gradually  be  relieved.  The  paralyzed  muscles  bIkmiM 
1)6  stimulated  by  electricity  and  massage. 

Accessory  Spasm.— ( 7or/tVw///.'<  ;  Wryneck.) — The  forms  of  spasm 
affecting  the  cervical  muscles  are  best  considered  here,  as  the  musdis 
supplied  by  the  accessory  an-  chiefly,  though  not  solely,  responsible  for  tin- 
condition.     The  following  forms  nuiy  be  described  in  this  section : 

(fl)  Comjcuitnl  Torticollix. — This  c^ondition,  also  known  as  fixed  torti- 
collis, dei)ends  upon  the  shortening  and  atrophy  of  the  storno-mastoid  (-11 
one  side.  It  occurs  in  children  aiul  may  not  bo  noticed  for  several  ycuis 
on  account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it 
has  only  recently  come  on.  It  alTects  the  right  side  almost  exclusively. 
A  remarkable  circumstance  in  connection  with  it  is  the  existence  of  facinl 
asymmetry  noted  by  Wilks,  which  aj)pear8  to  be  an  essential  part  of  this 
(iongenital  form.  It  occurred  in  .-i  ises  reported  by  (Jolditig-Hird.  In  h 
case  recently  under  my  observation,  the  wryneck  was  not  noticed  until 
her  tenth  year.  The  nujs(;le  was  divided  and  she  seemed  quite  well ;  hut 
as  she  developed  the  asymmetry  of  the  face  became  very  striking.  In  con- 
genital wryneck  the  sterno-mastoid  is  shorttMied,  hard  and  firm,  and  in  ;i 
condition  of  more  or  less  advaniied  atrophy.  This  must  be  distingui.sliiil 
from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which  may 
occur  at  the  time  of  birth  and  produce  an  induration  or  muscle  callu.><. 
Although  the  sterno-mastoid  is  almost  always  affected,  there  are  rare  casos 
in  whi(di  the  fibrous  atrophy  affects  the  trapezius.  This  form  of  wryneck 
ill  itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  liut 
(Jolding-liird  states  that  the  facial  asymmetry  persists,  or  indeed  may,  !is 
shown  by  photographs  in  my  case,  become  more  evident.  With  reference 
to  the  pathology  of  the  aifection,  (Holding-liird  concludes  that  the  facial 
aeymmetry  and  the  torticollis  are  integral  parts  of  one  affection  wliicli 
has  a  central  origin  and  is  the  counterpart  in  the  head  and  neck  of  infan- 
tile paralysis  with  talipes  in  the  foot. 

{b)  Spasmodic  Wryneck. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alternate  in  tlio  same  case;  or,  as  is  most 
common,  they  are  separate  and  remain  so  from  the  outset.  The  dis- 
oiise  is  most  frequent  in  adults  and,  according  to  Gowers,  most  common  in 
females.  In  this  country  it  is  certainly  more  frequent  in  males.  Of  the 
eight  or  ten  cases  which  came  under  my  observation  in  Montreal  and 
rhiladelphia,  all  were  males.  In  females  it  may  be  an  hysterical  manitVs- 
ix>iioik.    There  may  be  a  marked  neurotic  family  history,  but  it  is  usually 


DISKASES  OF  THE  CUANIAL  NKIIVKS. 


811 


iiiipossiblo  to  fix  ui)oii  any  definite  ctinldgicul  factor.  Some  casoH  huvo 
followed  cold  ;  otlicr.s  u  blow. 

Thu  ttymptQiuti  are  well  defined.  In  the  tonif;  form  the  coiifracttfd 
sttTiio-mastoid  draws  the  oeeiput  toward  tlie  shoulder  of  tlu^  atTected  side; 
the  ehin  is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno- 
niiistoid  may  ho  atfected  alone  or  in  association  witli  the  trapezius.  When 
tlio  latter  is  implicated  the  head  'i  depressed  still  more  toward  the  samu 
Hide.  In  lt)ng-standin;;  cases  these  muscles  are  prominent  and  very  rifj^id. 
There  may  ho  some  (;urvaturo  of  the  H[)ine,  the  convexity  of  which  is  toward 
the  sound  side.  The  cases  in  which  the  spasm  is  clonic  arc  much  moro 
ijistressing  and  serious.  The  spasm  is  rarely  limited  to  a  single  muscle. 
The  sterno-nuistoid  is  almost  always  iuvohcd  and  rotates  the  head  so  as  to 
ii|iproximate  the  nuistoid  process  to  the  inner  end  of  the  clavicle,  turtunj^ 
the  face  to  the  opj)osito  side  aiul  raising  the  chin.  When  with  tins  the 
trapezius  is  afTected,  the  depression  of  the  head  toward  the  same  side  is 
more  marked.  'J'he  head  is  drawn  pomcwhat  l)a('l<ward ;  the  shoulder, 
too,  is  raised  by  its  action.  Acconlin;;  to  ( Jowcrs,  tlic  spleiiius  is  associated 
with  the  sterno-nuistoid  about  half  as  frecjuently  as  the  trapezius.  Its  ac- 
tion is  to  incline  the  head  and  rotate  it  elifjhtly  toward  the  same  side. 
Other  muscles  may  be  involved,  such  as  the  scah'nus  and  platysma  myoidcs ; 
and  in  rare  cast  s  the  head  may  be  rotated  l>y  the  deep  cervical  nniscles, 
the  rectus  and  obliipuis.  There  are  cases  in  which  the  .-pasm  is  l>ilatcral, 
causing  a  backward  movement — the  retro-collic  ai)asm.  This  nuiy  be 
"ither  tonic  or  clonic,  and  in  extronio  cases  the  face  is  horizontal  and  lookw 
upward. 

Tlu!So  clonic  contractions  may  come  (»n  without  warning,  or  be  pre« 
coded  for  a  time  by  irregular  pains  or  stiffness  of  the  neck.  The  jerking 
movements  recur  every  few  monuuits,  and  it  is  impossible  to  keej)  the  heud 
still  for  more  than  a  minute  or  two.  In  time  the  muscles  undergo  hyfKT- 
trophy  and  may  be  distintitly  larger  on  one  side  than  the  <»ther.  In  some 
I'uses  the  pain  is  considerable  ;  in  others  there  is  simply  a  feeling  of  fatigue. 
The  spasms  cease  during  sleep.  Emotion,  excitement,  and  fatigue  increase 
lliom.  'i'he  spasm  may  extend  from  the  muscles  of  the  neck  and  involve 
those  of  the  face  or  of  the  arms. 

The  disease  varies  mucli  in  its  course.  Cases  occasionally  get  well,  })ut 
llie  great  majority  of  them  persist,  and,  even  if  temporarily  relieved,  the 
disease  frequently  recurs.  The  affection  is  usually  regarded  as  a  functional 
neurosis,  but  it  is  possibly  due  to  disturbance  of  the  cortical  centres  pre- 
siding over  tlie  muscles. 

Treatment. — Temporary  relief  is  sometimes  obtained  ;  a  ])erma- 
lUMit  cure  is  exceptional.  Various  drugs  luive  been  used,  but  rarely 
with  benefit.  Occasionally,  large  doses  of  bromide  will  lessen  the  in- 
tensity of  the  spasm.  Morphia,  subcutaneously,  has  been  successful  in 
some  reported  cases,  but  tliere  is  the  great  danger  of  establishing  the 
morphia  habit.     (Jalvanism  may  be  tried.     Counter-irritation  is  probably 


III    l    ! 

It 


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DISEASES  f)P  THE  NERVOUS  SYSTEM. 


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usclosH.  Fixation  of  tlio  head  TiuMJmiiically  can  rarely  hv  borne  by  (lie 
I)aliunt.  Tlicst)  (ilistiiiatc  cases  fall  ultimately  into  tlu^  hands  of  the  wur- 
f^con,  anti  tho  operations  of  stretehin,i(,  division,  and  excision  (d'  the  aeees- 
Hory  nerve  and  division  of  tlu'  muscles  hav((  been  tried.  The  latter  dues 
not  chock  the  sjuism,  and  may  a<,'<(ravate  the  symptoniH.  Tcniponiry 
relief  may  follow,  but,  as  ii  rule,  the  (-ondition  returns.  In  tho  caHos  of 
K|)aHm  of  tiie  decp-soatcd  muscles,  Keen  has  devised  an  operation  for  tlicir 
Bcction. 

(r)  The  iwddiiKj  upasin  of  childrcji  may  here  be  mentioned  as  involv- 
iii}^  chiefly  tho  muscles  innervated  by  the  ucccsHory  nerve,  it  may  he  u 
Himplo  trick,  a  birm  (jf  habit  spasm,  or  a  i)henomcnon  of  epilepsy  (K.  mi- 
tans),  in  which  ease  it  is  associated  with  transient  loss  of  consciousnesa. 
A  similar  noddin;^  si)asm  may  occur  in  older  children.  In  women  it  souu- 
times  occurs  us  an  hysterical  manib'station,  commonly  ua  part  of  tho  so- 
culled  sulaaiu  cunvulsion. 

X.  IIypoolossal  Kkrve. 

This  is  tlio  motor  nerve  of  tho  tongue  and  for  most  of  tho  muscles  iit- 
tuchcd  to  tho  hyoi<l  bono.  Its  cortical  centre  is  probably  tho  lower  ]iurt  cf 
tho  ascendin;jf  frontal  <jyrus. 

Paralysis. — (I)  ('cidrtil  Lesion. — Tho  tongue  is  often  paralyzed  in 
hemiplegia,  and  the  paralysis  may  result  from  ti  lesion  of  the  cortex  itself, 
or  of  the  fibres  as  they  j)ass  to  the  medulla.  It  does  not  occur  alone  and 
will  bo  considered  with  hemiplegia.  'I'here  is  this  dilTerence,  however,  Ix- 
twecn  tho  cortical  and  other  forms,  that  the  n»useles  on  both  sides  of  the 
tongue  may  be  more  or  less  uflected  but  do  not  waste,  nor  are  their  elec- 
trical reactions  disturbed. 

(2)  Nndvitr  and  iufra-nuclmr  lesions  of  tho  hypoglossal  result  from 
slow  progressive  degenerntion,  as  in  bulbar  pii'-ulysis  or  in  locoiMolnr 
ataxia,  and  occasionally  there  is  acute  softening  froui  obstruction  of  the 
vessels.  Trauma  and  lead  jioisoning  have  also  been  assigned  as  causes. 
The  fibres  may  bo  damaged  by  a  tumor,  and  at  tho  base  by  meningitis; 
or  tho  nerve  is  sometimes  Involved  in  its  foramen  by  disease  of  the  skull. 
The  nuclei  of  both  nerves  are  usually  aircetcd  together,  but  may  be  at- 
tackod  separately.  As  u  result,  there  is  loss  of  function  in  tho  nerve  lihrcs 
and  the  tongue  undergoes  atrophy  on  tho  afToctod  side.  It  is  protruded 
toward  tho  i)aralyzod  side  and  may  show  llbrilhiry  twitching. 

The  st/mpfoiiis  of  involvement  of  one  hypoglossal,  either  at  its  centre 
or  in  its  course,  are  those  of  unilateral  paralysis  and  atrophy  of  the  tongue. 
When  protruded,  it  is  pushed  toward  the  affected  side,  and  there  are  fi- 
brillary twitchinga.  The  atrophy  is  usually  nuirked  and  tho  mucous  nieia- 
brano  on  tho  affected  side  is  thrown  into  folds.  Articulation  is  not  nnuh 
impaired  in  the  unilateral  afToction.  When  tlic  disease  is  bilateral,  tlic 
tongue  lies  almost  motionless  in  the  floor  of  the  mouth;  it  is  atrophied, 


DISEASES  OP  THE  SPINAL  NERVES. 


813 


iiiid  ciinnot  he  protriuU'd.  SjuuMrli  und  musticution  arc  cxt'TinoIy  (liHiciiit, 
1111(1  (k'^lutitioii  niuy  hi'  iinpiiirod.  If  the  Hout  of  thn  dirtoitsc  is  iihovo  tlio 
miilvi,  tlu'iv  may  Ik'  littU)  or  no  wastiii;^.  Tlio  coiidiiioti  U  seen  iti  pro- 
^jirssivo  hulliar  paralysis  and  occasionally  in  progressive  inuscidar  atrophy. 

The  ilidijiKisis  is  readily  made  and  tiie  situation  of  the  lesion  ciiu 
usiiully  he  determined,  hinco  wlien  Hupru-nneleiir  there  is  associated  heini- 
plc^da  and  no  wastiti}^  of  the  nuisclos  of  the  tonj^iie.  Nuclear  disease  is 
iiiily  occasionally  unilateral;  most  commonly  hilateral  and  part  of  a  hulhar 
paralysis.  It  should  be  borne  in  mind  that  the  libres  of  the  hypo;,dossal 
may  be  involved  within  the  nieduUu  after  leaving  their  jnudei.  In  such 
a  i-Mv  there  imvy  bo  paralysis  of  the  tongue  on  one  side  and  paralysis  of 
t!ii'  limbs  on  the  opposite  side,  and  the  tongue,  when  protruded,  is  pushed 
toward  the  sound  side. 

Spasm. — This  rare  alTection  may  bo  unilateral  or  bihiteral.  it  is  most 
friMjuently  a  part  of  some  other  convulsive  disorder,  such  as  epilepsy, 
chorea,  or  spasm  of  the  facial  mnsdoa.  In  some  cases  of  stuttering,  spasm 
of  the  tongue  precedes  tin?  explosive  utterance  of  the  words.  It  may  oc- 
cur in  hysteria,  and  is  said  to  follow  reflex  irritation  in  the  lifth  lu-rvo. 
Tlio  most  renuirkable  cases  are  tho.se  of  paroxysmal  clonic  .spasm,  in  which 
the  tongue  is  rapidly  thrust  in  and  out,  as  many  as  forty  or  lifty  times  a 
iiiiinite.  In  the  case  reported  by  (lowers  the  attacks  o<!curred  during 
sleep  and  continued  for  a  year  and  a  half.  'J'hc  spasm  is  usually  bilateral. 
Wcndt  has  reported  u  case  in  which  it  was  unilateral.  The  prognosis  ia 
iLsually  good. 


'ii 


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■|i 


t- ' 


IV.    DISEASES  OF  THE  SPINAL  NERVES. 

Ckuvical  Plexus. 

(1)  Occipitocervical  Neuralgia.— This  involves  the  nerve  territory 
sti])l)lied  by  the  second,  the  occii)italis  major  and  minor,  and  the  aurimi- 
liuis  magnus  nerves.  The  pains  are  chietly  in  the  ba(!k  of  the  head  and 
neck  and  in  the  ear.  The  condition  may  follow  cold  and  is  sometimes 
associated  with  stilTuess  of  the  neck  or  torticollis,  llidcss  coiuuicted  with 
disease  of  the  bones  or  due  to  pressure  of  tumor.s,  the  outlook  is  usually 
;j;oi)d.  There  are  tender  jjoints  midway  between  the  nuistoid  process  and 
the  spine  and  just  above  the  parietal  eminence,  and  between  the  stcrno- 
iTiastoid  and  the  trapezius.  1'he  aifection  may  be  due  to  direct  pressure,  in 
jjorsons  who  carry  very  heavy  loads  on  the  neck. 

(v)  Affections  of  the  Phrenic  Nerve. — Paralysis  may  follow  a  lesion  in 
the  anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or 
niay  be  duo  to  compression  of  the  nervo  by  tumors  or  aneurism.  More 
rarely  paralysis  results  from  neuritis. 

it  may  be  part  of  a  diphtheritic  or  lead  pal^^y  and  is  usually  bilateral. 


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DISEASES  OK  THE  NERVOUS  SYSTEM. 


(II  III 


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Whon  the  diiiphragm  is  paralyzod  respiration  is  carried  on  by  the  inter- 
costiil  and  accessory  mnsi'les.  ^^  hen  the  patient  is  qniet  and  at  rest 
little  may  be  noticed,  bnt  the  abdomen  retracts  in  ins|)irati()n  and  is  forced 
ont  in  expiration.  On  exertion  or  even  on  attempting  to  move  there  iimv 
be  dyspn(Ba.  If  the  paralysis  seta  in  suddc^nly  there  may  be  dypiuea 
and  lividity,  which  is  usually  temporary  (W.  Piusteur).  Intercurrent  nt- 
t-icks  of  bronchitis  seriously  aggravate  the  condition.  J)itMculty  in  c(iii;;li- 
ing,  owing  to  the  impossibility  of  drawing  a  full  breath,  adds  greatly  t(i 
the  danger  of  this  complication,  as  the  mucus  accumulates  in  tlie  tubes. 

When  the  phrenic  ncsrve  is  paralyzed  on  one  side  the  paralysis  may  bi' 
scarcely  noticeable,  but  careful  inspection  showd  that  the  descent  of  tlic 
dia})bragm  is  much  less  on  the  atfected  side. 

The  <fiaf/?iosiK  of  paralysis  is  not  always  easy,  particularly  in  women. 
who  habitually  use  this  muscle  less  than  men,  and  in  whom  the  diu- 
phragmatic  breathing  is  less  conspicuous.  Immobility  of  the  diaphrai,Mii 
is  not  uncommon,  particularly  in  diaphragmatic!  pleurisy,  in  large  ellii- 
sions,  and  in  extensive  emphy.sema.  The  muscle  itself  may  be  degeiiDi- 
atcd  and  its  power  impaired. 

Owing  u,  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  te 
accumulation  of  blood  at  the  l>a,ses  of  the  lungs,  and  there  may  bci  im- 
paired resonance  and  signs  of  a'dema.  As  a  rule,  however,  the  ])aralysi:^ 
is  not  confined  to  this  muscle,  but  is  part  of  a  general  neuritis  or  an  iiii- 
t^rior  polio-myelitis,  and  there  are  other  symptoms  of  value  in  determin- 
ing its  presence,  'i'he  outlook  is  usually  serious.  I'asteur  states  tleit  iM 
fifteen  cases  following  diphtheria,  only  eight  recovered.  The  tr'atiueiit 
is  that  of  the  neuritis  or  polio-myelitis  with  which  it  is  associated. 

lillACHIAI.   PMCXI'S. 


ii 


(1)  Combined  Paralysis. — The  plexus  may  be  involved  in  the  si'jini- 
(;lavicular  region  by  compression  of  the  nerve  trunks  as  they  leave  the 
spine,  or  by  tumors  and  other  morbid  processes  m  the  neck.  Hclow  the 
clavicle  lesions  are  more  common  and  result  from  injuries  following  dislc- 
cation  or  fracture,  sometimes  from  neuritis.  The  most  common  cause 
of  lesion  of  the  l)rachial  plexus  is  luxation  of  the  humerus,  partic  iilailv 
the  subcoracoid  form.  If  the  dislocation  is  (piickly  reduced  the  syiiijo 
toms  are  quite  transient,  and  disappear  in  a  few  days.  In  severe  cases  all 
the  branches  of  the  plexus,  or  oidy  one  or  two,  may  be  involved.  Tlu' 
most  serious  cases  are  those  in  wbit'h  the  dislocati(>n  is  undetected  or  tinre- 
duced  for  some  time,  when  the  prolonged  pressure  on  the  nerves  may  cause 
complete  and  ])crmanent  ])aralysis  of  the  arm.  The  muscles  waste,  the 
reaction  of  degeneration  is  present,  and  tro])hic  changes  in  the  skin  are 
apt  to  occur.  Tlie  medico-legai  bearings  of  thest;  cases  are  important,  aii^ 
may  be  thus  briefly  summarized  :  Hirect  injury,  as  by  a  fall  or  blow  on  the 
shoulder,  resulting  in  great  bruising  of  tlie  nerves  without  dislocaticn,  i;* 


DISEASES  OP  THE  SPINAL   NERVES. 


815 


(xiiudioiiiilly  followed  by  complete  })aralysls  of  the  arm.  A  dislocation  may 
lio  set  immediatoly  and  yet  the  lesicn  of  the  brachial  plexus  may  be  such 
ius  Id  cause  perrnaneut  jjaralysis  of  the  nerves.  The  dislocation  nuiy  l)o 
rcdiiced  and  the  joint  in  subsequent  moven<'^nts  slips  out  n'^n'm.  It  has 
lii'ppened  that  by  the  tinie  the  surgeon  Lees  the  patient  agaiti,  the  damage 
hiiH  become  irrei)arable. 

Injuries  and  blows  on  the  neck  may  cause  partial  paralysis  of  the  arm, 
involving  the  deltoid,  supraspinatus,  infraspinatus,  biceps,  brachialis  an- 
ii(  ii.-;,  and  the  supinator.  The  injury  may  occur  to  the  ciiild  during  de- 
livery. 

A  primary  neuritis  of  the  bra(diial  plexus  is  rare.  More  commonly 
(litt  process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral  branch, 
involving  first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the 
jilcxus,  producing  gradually  ("omplete  'ws  of  power  in  the  arm. 

('I)  Lesions  of  Individual  Nerves  oi  the  Plexus.— (a)  Lout/  Thoracic 
Srrre  [Scrratus  Palsy). — This  occurs  chiefly  in  men.  The  nerve  is  injured 
ill  the  postiM'ior  triangle  of  the  neck,  usually  by  direct  pressure  in  the 
iiirvying  of  loads;  cold  may  cause  neuritis.  It  may  be  involved  also  in 
|inigressivc  nuiscular  atro})hy  and  in  polio-myelitis  anterior.  \\  ben  par- 
aly.'.ed  the  scapula  on  the  alTei'ted  side  looks  winged,  which  results  from 
liic  projection  of  the  angle  and  posterior  bonh;r.  This  is  particularly 
noticeable  when  the  arm  is  moved  forward,  when  the  serratus  no  longer 
holds  the  scapula  against  the  thorax.  It  is  a  well-delined  and  rea<lily 
recognized  form  of  i)aralysis.  The  onset  is  associated  with,  sometimes 
preceded  by,  neuralgic!  pains.  The  cumrse  is  dubious,  ajid  rjiany  numths 
m;iy  elapse  before  there  is  aii)  improvement. 

{!))  ('iiriiinfi  V  Nerve. — This  supplies  the  deltoid  and  the  teres  minor. 
The  nerve  is  apt  to  bo  in'-olved  in  injuries,  in  dislocations,  bruising  Ity  a 
crutch,  or  sometin-es  by  extension  of  inflammation  from  the  joint.  Occ^a- 
sioiially  the  paralysis  arises  from  a  pressure  neuritis  during  an  illness.  As 
:i  couseciucnce  of  loss  of  power  in  the  deltoid,  the  arni  cannot  be  raised. 
The  wastijig  is  usually  nuirked  and  (duinges  the  shape  of  the  shoulih'r. 
Sensation  nuiy  also  be  impaired  in  the  skiti  over  the  muscle.  The  joint 
may  I^e  relaxed  and  there  nuiy  bo  a  distinct  space  between  the  head  of  the 
iiiiinerus  and  the  acromion.  In  other  instamies  the  ligamcMits  are  thick- 
ened, and  .1  condition  not  uidiko  ankylosis  may  be  produceii,  vvhi(di  is 
readily  distinguished  on  moving  the  arm. 

(f)  Mtificulo-spiral  Parali/sis  :  RiuUal  Parali/si.s. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position 
of  the  muaculo-spiral  nerve  It  is  often  bruised  in  the  use  of  the  crutch, 
l»y  injuries  of  the  arm,  blows,  or  fractures.  It  is  frcfpicntly  injured  when 
ii  person  f:  ''-  asleep  vvitli  the  arm  over  the  l)ack  of  a  I'hair,  or  by  pressure 
of  the  body  upon  the  arm  when  a  person  is  sleeping  on  a  beiudi  or  on  the 
trround.  It  may  be  paralyzed  by  sudden  violent  contra(!tion  oi  tju!  fcrituipa. 
It  is  sometimes  involved  in  a  neuritis  from  cold,  but  this  is  unconunoii  in 


F^  If 


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DISEASES  OP  THE  NERVOUS  SYSTEM. 


11  tl 


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1 


comparison  with  other  punscs.  In  the  siibcutjineous  injection  of  ether  the 
nerve  may  be  aocidciitally  struck  and  temporarily  paralyzed.  'J'he  ])arulv- 
sis  of  lead  poisoning  is  the  result  of  involvement  of  certain  branches  df 
tins  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  braehialis  anticus,  iiiu! 
the  sui)inator  longus,  as  well  as  the  extensors  of  the  wrist  and  llnjrcrs. 
Naturally,  in  hfsions  just  above  the  elbow  the  arm  muscles  and  the  supina- 
tor longus  are  sjjaretl.  The  most  characteristic  feature  of  the  ])aralysis  is 
the  wrist-drop  and  the  inability  to  extend  the  first  i)halanges  of  the  liii^'ci> 
and  thumb.  In  the  jjressure  ])alsies  the  supinators  are  usually  involvnl 
and  the  movements  of  supination  cannot  be  accomplished.  The  sensa- 
tions may  be  impaired,  or  there  nuiy  be  marked  tingling,  but  the  h)ss  of 
sensation  is  n    .ly  so  pronounced  as  tliat  of  motion. 

The  affect,  n  is  readily  recognized,  but  it  is  sometimes  dillicult  to  sav 
upon  what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  uni- 
lateral and  involve  the  supinator  longus.  The  paralysis  from  lead  is  lii 
lateral  and  the  supinators  are  unalTected.  Bilateral  wrist-drop  is  a  \(n 
common  symptom  in  many  forms  of  multiple  neuritis,  particularly  liic 
alcoholic :  but  the  mode  of  onset  and  the  involvement  of  the  le;'s  ; 


;:iii| 


arms  are  features  which  make  the  diagno.sis  easy.  The  duration  ami 
course  of  the  musculo-spiral  paralysis  are  very  variable.  The  pressure  pal- 
sies may  disappear  in  a  ft^w  days.  Iiccovery  is  the  rule,  even  when  th' 
ultc  ;tion  lasts  for  many  weeks.  The  electrical  examination  is  of  impor- 
tance in  the  ))rog)U)sis,  and  the  rules  laid  down  under  paralysis  of  the  facial 
nerve  hold  good  here. 

The  treatment  is  that  of  neuritis. 

{</)  Uhior  .^V;vr.— 'I'he  nu)tbr  branches  supply  the  idnar  halves  of  tin 
deep  Ihfxor  of  the  fingers,  the  muscles  of  the  little  finger,  the  inter(i>s(i. 
the  adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb,  and  tlir 
ulnar  fle.xor  of  the  wrist.  The  sensory  branches  supply  the  ulnar  side  (if 
the  hand — two  and  a  half  fijigers  on  the  back,  and  one  and  a  half  fiiiircr^ 
on  the  front.  Paralysis  nuiy  result  from  ])ressure,  usually  at  tiic  elliu»- 
joint,  although  the  nerve  is  here  protected.  Po.ssibly  the  neuritis  in  tin 
ulnar  nerve  in  some  cases  of  acute  illness  may  bo  due  to  this  cause.  ( Jowirs 
mentions  the  case  of  a  lady  who  twice  ha<l  ulnar  neuritis  after  cduflncniciit. 
Owing  to  paralysis  of  the  ulnar  flexor  of  the  wrist,  the  liaml  moves  towaiil 
tlie  radial  side;  adduction  of  the. thumb  is  impossible;  the  first  phalaiiL' • 
cannot  be  flexed,  and  the  others  cannot  bo  extended.  In  long-stand  in- 
cases  the  first  phalanges  are  overextended  and  the  others  strongly  flexed. 
producing  the  claw-hand;  but  this  is  not  so  marked  as  in  the  j)rogn^M\r 
muscidar  atro|)hy.  The  losij  of  sensation  corresponds  to  the  sensory  di.- 
tribution  just  mentioned. 

{>')  Median  Nerve. — This  supplies  the  flexors  of  the  fingers  e.xcept  tin 
ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thinnl , 
the  two  radial  hnnbricales,  the  pronator-!, and  the  radial  flexor  of  the  wrist. 


(lillicult  U>  sa\ 


DISEASES  OP  THE  SPINAL  XEllVES. 


817 


Tlio  sensory  filjres  supply  the  radial  side  of  the  palm  and  the  front  of  th« 
tluinib,  tJK!  (irst  two  iingors  and  half  the  third  iin'^or,  and  the  dorsal  sur- 
faces of  the  same  three  liiijijers. 

Tliis  nerve  is  sekiom  involved  alone.  Paralysis  results  from  injury 
and  occasionally  from  neuritis.  The  signs  are  inahility  to  proiuite  the 
foiearm  beyond  the  mid-position.  The  wrist  can  oidy  be  Hexed  toward 
the  ulnar  side;  the  thumb  cannot  bo  opposed  to  the  tiji^  of  fingers. 
The  se(!ond  phalanges  cannot  Itc  Hexed  on  the  lirst;  t!ie  distal  phalanges  of 
till'  first  and  second  fingers  cannot  be  Hexed  ;  l)ut  in  the  third  and  fourth 
fingers  this  action  can  bo  performed  by  the  ulnar  half  of  the  flexor  pro- 
fundus. The  loss  of  sensation  is  in  the  region  corresponding  to  the  sc>nsory 
(hstribution  already  mentiont'd.  'J'he  wasting  of  the  thunili  niiuscles,  which 
is  usually  marked  in  this  paralysis,  gives  to  it  a  characteristic  aiipearance. 

LlMIIAIt    AND   SaCKAL   PlJCXlSFS. 


U  i 


: 

1  ('•■•'     \ 

at 

Air?i  ii 

I*  *' 


The  hdnhitr  pic.rns  is  somctinu's  involved  in  growtiis  of  the  lymph 
glands,  in  psoas  abscess,  and  in  disease  of  che  bones  of  tiu>  viirtcbra;.  Of 
its  branches  the  obturator  nerve  is  occasionally  injured  during  pjirtiiri- 
iion  Wlu'ii  paralyzed  the  power  is  lost  over  tiic  luldnctors  of  the  thigii 
and  one  leg  cannot  i)e  crossed  over  the  other.  Outward  rot^iti<»n  is  also 
ilisturbed.  'I'ho  (inferior  enirnl  nrrre  is  sometimes  involved  in  wounds 
or  in  dislocation  of  the  hip-joint,  less  commordy  during  parturition,  and 
sometimes  by  disease  of  tlio  Ix/ues  and  in  psoas  abscess.  Tho  8pe(;ial 
symptoms  of  alTection  of  this  nerve  lire  paralysis  of  the  extonsoi-s  of  the 
knee  with  wasting  of  the  nuiscles,  ana'sthesia  of  tiie  antero-lateral  part.-*  of 
thigh  and  of  the  inner  siile  of  the  leg  to  the  big  toe.  This  nerve  is  some- 
times involved  early  in  growths  al)out  the  spine,  and  there  may  Ix^  pain  in 
its  area  of  distribution,  fioss  of  tlie  power  of  alxlucting  the  tliigh  rt^sult-* 
from  paralysis  of  the  t/hi/etil  nerre,  which  is  distributed  to  the  glutens. 
niedius,  ;ind  Tuinimus  muscles. 

The  siionil  jt/e.nis  is  freiiucntly  involved  in  tumrtrs  and  inflammatioiiH 
niiliiii  the  pelvis  and  may  be  injured  during  |MU'turitii>n.  Neuritis  is 
common,  usually  an  extension  from  the  sciatic  nerve. 

(►f  the  branches,  the  sriiifir  iierre,  when   injnrcil  at  or  near  tho 
causes  i)aralysis  of  the  flexors  of  the  legs  and  tiie  musei-'i  l>e|ow  tho 
luit  injury  below  the  middle  of  the  thigh  involves  only  the  latter  m 
There  is  also  anaesthesia  of  the  outer  half  (»f  the  leg,  the  sole,  and  ! 
porticm  of  the  dorsum  of  the  foot.     Wasting  of  the  muscles  i 
fallows,  ami  there  nm'  be  trophic  distnrbam'cs.    In  paralysis  of  om 
the  leg  is  fixed  at  tht- K  .ee  by  the  ucliun  uX  the  ({uadriceps  esteusor  .*  li 
th(!  patiwat  is  able  to  walk. 

I'araiysis  of  the  fimdll  sciatic  norre  is  rarely  seen.  The  glut^Mis  maxiinus 
i~  involveil  and  then*  may  be  dinicnlty  in  rising  from  a  seat.  There  is  u 
-'lip  of  ana'sthesia  along  the  back  of  tiie  middle  third  ol  the  thigh. 


tMr 


■-^■^4  ! 


m 


imm  I 


818 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


i 


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.  ill 


t.!' 


1.  i 

m- 

» 

:.  m 

1       -"■ 

I'-fVi 

'  I-" 

i 

-A' 

1 

1 

i 

External  Popliteal  Xcrve. — I*imilysis  involves  the  pcronapi,  the  lonf,'i'x. 
tensor  of  the  toes,  tibialis  anticus,  imd  the  extensor  brevis  digitonim. 
The  ankle  cannot  bo  flexed,  resiiltinj;  in  a  (condition  known  us  footMlnip, 
and  as  the  toes  (^annot  lie  raised  the  whole  leg  must  be  lifted,  ])rodii(iri;.' 
the  <;liani('.teristic  stcppayc  gait  seen  in  so  many  forms  of  peripheral  iicii- 
ritis.  In  long-standing  cases  the  foot  is  permanently  extended  and  there 
is  wasting  of  the  anterior  tibial  and  peroneal  muscles.  'J'he  loss  of  seiisu- 
tion  is  in  the  outer  half  of  the  front  (»f  the  leg  and  on  the  dorsum  uf 
the  foot. 

Internal  Popliteal  Xerve. — When  paralyzed  plantar  flexion  of  the  fodt 
and  flexion  of  the  toes  are  impossible.  The  foot  cannot  be  adducted,  ikw 
can  the  patient  rise  on  tiptoe.  In  long-standing  cases  talipes  calcaneus 
follows  and  the  toes  assume  a  daw-like  position  from  secondary  contnut- 
ur(i,  <lue  to  overextension  of  the  i)roxinial  atid  llexion  of  the  second  and 
third  phalanges, 

Sciatica. 

This  is,  as  a  rule,  a  neuritis  either  of  tlu>  sciatic  nerve  or  of  its  cords 
of  origin.     It  may  in  some  instances  be  a  functional  neurosis  or  neuralgiii. 

It  occurs  most  commonly  in  adult  males.  A  history  of  rheumatiHin  nr 
of  gout  is  present  in  numy  cases.  Kxposure  to  cold,  particularly  altir 
heavy  muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes. 
Within  the  pelvis  the  nerves  nuiy  be  compressed  by  large  ovarian  or 
uterine  tumors,  by  lymphadenomata,  by  the  fa>tal  head  during  labor,  and 
occasionally  lesions  of  the  hip-joint  induce  a  secondary  sciatica.  The  con- 
dition of  the  nerve  has  been  examined  in  a  few  ca.ses,  aiul  it  has  often 
been  seen  in  the  operation  of  stretching.  It  is,  as  a  rule,  swollen,  vm\- 
dened,  and  in  a  condition  of  interstitial  neuritis.  The  affection  may  be 
most  intense  at  the  sciatic  notch  or  in  the  nerve  about  the  middle  of  the 
thigh. 

Of  the  sj/mptoms,  pain  is  the   most  constant  and  troublesome.     The 
onset  may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  oidy  slight  pain  in  the  back  of  the  thigh,  particularly 
in   certain    ])ositions  or   after   exerti<»n.     So(m    the   i)ain   becomes   mire 
intense,  and  instead  of  being  limited  to  the  upper  portion  of  the  nerve, 
extends  down  the  thigh,  reaching  tlu^  foot  and  radiating  over  the  entire 
distribution  o*"  the  nerve.     The  patient  can  often  point  out  the  nuist  sen 
sitive  spots,  usually  at  the  notch  or  in  the  middle  of  the  thigh;  and  mi 
pressure  these  arc  cx(|uisitely  painful.    The  pain  is  described  as  gnawing  nr 
V)urning,  and  is  usually  constant,  but  in  some  instances  is  paroxysmal,  v 
often  worse  at  night.     On  walking  it  may  be  very  great;  the  knee  is  . 
and  the  j)atieiit  treads  on  llic  toes,  so  as  to  relieve  the  tension  on  the  nerve 
In  protracted  cases  there  is  wasting  of  the  muscles,  but  the  reaction  <if 
degeneration  can  seldom  be  obtained.     In  these  chronic;  cases  cramp  may 
occur   and  fibrillar  contractions.     Herpes  may  develop,  but  this  is  iin- 


•     ,?^^S'^  "^ 


II  of  the  font 


DISEASES  OP  THE  SIMNAL   NERVES. 


819 


usual.     Ill  rare  iiistancoa  the  neuritis  aseends  and   involves   the  spinal 
cord. 

The  duration  and  eonrso  are  extremely  variahle.  As  a  rule  it  is  an 
ol)stinattt  afTeetion,  la«tiii;s^  for  months,  or  oven,  with  slij^ht  remissions,  for 
years,  llidapses  are  not  uncommon,  and  the  diseases  may  Iki  reliined  in 
(me  nervo  only  to  appear  in  the  other.  In  the  severer  forms  the  patient  is 
bedridden,  and  such  cases  prove  among  the  most  distressing  and  trying 
wliich  the  physician  is  called  upon  to  treat. 

In  the  (liiujnosis  it  is  important,  in  tlic  lirst  place,  todi'tcrmine  whether 
the  discjuso  is  primary,  or  secondary  to  some  aifection  of  tlie  pelvis  or  of 
tlic  spinal  cord.  A  careful  rectal  examination  should  he  made,  and,  in 
\v:imen,  i)e]vi('  tumor  should  Ik;  excluded.  Lumhngo  may  he  confounded 
uitli  it.  AtTections  of  tlio  hi[)-j(>int  are  easily  distinguished  hy  the 
iil)sciu;e  of  tenderness  in  the  course  of  th(>  nerve  and  the  sense  of  j)ain 
oil  movement  of  the  hip-joint  or  on  jircssure  in  the  region  of  tlio  tro- 
chanter. 'riuTe  arc  instances  of  sacro-iliac  disease  in  which  the  j>alient 
comphiins  of  pain  in  the  upper  part  of  the  lhii,d),  whic  h  may  sonu'tinies 
radiate;  hut  careful  examiiuition  will  readily  distingiii.-^h  hetwi'en  the 
ill?  'ctions.  Pressure  on  the  nerve  trunks  of  the  cauda  ecjuiiui,  as  a  rule, 
causes  hilateral  pain  and  disturhances  of  sensation,  and,  as  douhle  sciatica 
i-  rare,  tliese  circumstances  always  suggest  lesion  of  the  nerve  roots.  ]}e- 
t Ween  tlu' s(>vere  lightning  ])aiiis  of  tahes  and  sciatica  tlu'  dilTercnces  are 
li-iiidly  well  delined. 

Treatment. — The  pelvic  organs  should  he  carefully  aiul  systenuiti- 
■ally  examini'd.  (!onstitutional  coiulitions,  sudi  as  rheunuitism  and  gout, 
should  receive  appropriate  trcatnuuit.  In  a  few  cases  with  pronounccil 
rheumatic  history,  whi(!h  come  on  acutely  with  fever,  the  salicylates  seem 
t  1  do  good.  In  other  instances  they  are  (juitc  useless.  If  there  is  a  sus- 
picion of  8yi)hilis  the  iodide  of  potassium  should  he  employed,  and  in 
gouty  cases  salines. 

liest  in  hed  with  fixation  of  the  iimh  l)y  means  of  a  long  splint  is  a 
most  valuahle  nu'thod  of  treatT/uuit  in  many  ca.ses,  one  u[)on  whicii  Weir 
Mitchell  has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some 
iiistaiu!es  to  cure,  ohstinate  ;;ud  protracted  cases  which  had  resi.sttid  all 
ether  treatment.  Hydrotherapy  is  sonu^tinu>s  satisfactory,  particularly  tlio 
warm  haths  or  the  mud  hatlis.  Many  cases  are  ri'lievcd  hy  a  prolonged 
rcsideiu'e  at  oiu>  of  the  thermal  springs. 

Antipyriu,  antifehrin,  and  (piinine,  an^  of  douhtful  henefit. 

lioeal  applications  an>  more  henelieial.  The  lut  iron  or  the  therm.- 
'■aiitery  or  l)listers  relieve  the  pain  tcMiiporarily.  Deep  injections  into  thy 
n,  rvo3  give  great  relief  and  nuiy  he  necessary  for  the  jiain.  It  is  hest  t-o 
use  c'M'ainc  at  first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain.  If 
the  pain  is  unhearahle  morphiii  may  he  used,  but  it  is  a  dangerous  remedy 
in  "-liatica  and  shoidd  he  withheld  as  long  as  possihie.  The  disease  is  so 
!  I'otracted,  so  liahle  to  relapse,  and  the  patient's  morale  so  un<lerniiiu>d  by 
52 


"  vviftTpl''*  (S 


I'V:  f 


(J, 


l\ 


J^ 


r 


.  '1 ' 


I 


I 


820 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


I    i 


tho  constant  worry  and  tlio  slcoploss  ni^^hts,  that  the  diiiigor  of  contra(!t- 
ing  llio  morphia  hahit  is  very  givat.  On  no  oonsichn-ation  sliould  tlio 
patient  ho  pcnnitUul  to  uso  thi  hypodorniii;  ncidli!  liiinsi'lf.  It  is  roniu'k- 
ublo  liow  [JiDHiptly,  in  sonu!  casus,  tho  injection  of  distilled  watur  into  Uu; 
norvo  will  relieve  the  pain.  Acupuncture  may  also  l)e  tried ;  the  needier 
should  bo  thrust  deeply  into  tho  most  painful  spot  for  a  distance  of  aiinut 
two  inches,  and  left  for  from  liftoon  to  twenty  ininut.s.  'I'ho  injection  of 
chloroform  into  the  nerve  has  also  been  recommended. 

Electricity  is  an  uncertain  remedy.  Sometimiis  it  j,dvos  prompt  rclicr; 
in  other  cases  it  may  be  used  for  weeks  without  the  slightest  benelit.  li 
is  most  .serviceable  in  tiio  chroiuo  cases  iu  which  there  is  wasting  of  tlu! 
logs,  and  should  bo  combin(Ml  with  massage.  The  galvanic  current  should 
boused;  a  Hat  electrode  shoidd  bo  placed  ov(!r  the  scii'tic  notch,  and  a 
smaller  one  u^:ed  along  the  course  of  the  nerve  and  its  branches.  Jn  \i  ry 
obstinate  cases  norve-strotcliiTig  may  bo  employed.  It  is  sometimes  suc- 
cessful ;  but  in  other  instances  tho  condition  recurs  and  i.s  us  bad  as  over. 


11.   DISEASES   OF  THE  SPINAL  CORD. 

I.    AFFECTIONS  OF  THE    MENINGES. 

Disr:A.si;s  or  tiik  Dura  Matku. 

Pachymeningitis. — The  dura  mater  of  the  cord  is  separated  by  a  loose 
oonnectivo  tissue  from  tho  bony  canal  in  whi(!h  it  lies,  and  an  iidlaniiiia- 
tion  may  invidvc  either  its  outer  or  its  inner  aspect;  hence  tho  division 
into  pachynutningitis  externa  and  interna. 

(a)  J'(ir/ii/nicni)ii/itis  Exturna. — This  is  invariably  a  secondary  indaiii- 
nuition  and  is  occasionally  met  with  iu  an  acute  form  in  caries  or  in  syphi- 
litic alTeetions  of  the  hone.  AI)S(;ess  may  pcmiitrato  tho  spiiud  canal  or 
tho  inllammation  may  even  extend  to  the  peridural  tissue  in  long-staiuliii;,' 
decubitus.     The  symptoms  arc  usually  those  of  a  compression  myelitis. 

The  c/ironic  form  of  external  ])achymeiungitis,  also  a  secondary  alTec- 
tion,  is  much  more  common.  It  is  a  constant  accompaniment  of  tuhcr- 
oulous  disease  of  tho  spine;  and  |)liiyrt  a  very  important  part  in  tho  proiliic- 
tion  of  the  symptoms.  The  alTiU'tion  may  bi!  conliiuid  to  the  part  in 
immediate  connection  with  the  local  disease,  but  in  some  cases  the  sub- 
dural space  over  six  or  eight  vertebne  is  uccupi  il  by  caseous  masses. 
Tho  (!ord  at  the  site  of  the  curvature  in  I'ott's  disease  may  be  coini)ressitl, 
with  perhaps  It  tie  or  no  involvement  of  the  pia  mater.  The  internal  siii- 
fiice  of  the  duni  may  he  p(>rfcctly  smooth,  perhaps  a  little  adherent  to  tlio 
arachnoid,  while  the  pxternal  dura  is  thickeiu'd,  rough,  and  covered  with  ii 
cheesy  Hubstunce  of  n  variable  degree  of  eousistenee.  In  some  instaini'ti 
tho  dura  m  completely  surrounded  by  this  mateiial ;  in  others  it  is  chinlly 


m 


AFPRCTIONS  OF  THE  MENINGES. 


821 


on  the  anterior  snrfiico.  Wo  ciin  unflorstand  the  recovery  in  liases  of  corn- 
jircssion  puriiplegia  if  wo  bear  in  mind  that  in  hirge  part  the  actual  com- 
pression is  proihiced  by  tliia  material  l)et\veen  the  iliseaseil  vertebrtc  and 
the  dura  iriater.  The  symptoms  are  those  of  myelitis  from  comj)ression, 
often  with  signs  of  involvement  of  the  nerve  roots,  such  as  will  he  men- 
tinned  in  th((  next  section. 

{/))  I'aclnpneninyitiH  infcrnn,  described  by  Charcot  and  .lotTroy,  in- 
volves eiuelly  the  c»>rvieal  region  (/'.  rervicalis  hi/parlrophira).  The 
interspace  between  th(!  cord  and  the  dura  is  occupied  by  a  firm,  concen- 
tiicnlly  arranged,  fibrinous  growth,  which  is  seen  to  have  developed  within, 
not  outside  of,  the  dura  nuiter.  It  is  a  condition  anatomically  identi(!al 
with  the  hannorrhagic  pachymeningitis  interim  of  the  brain.  The  cord 
is  usually  compressed  ;  ihe  central  canal  may  be  dilated — hydromyelus — 
and  there  are  secondary  degenerations.  1'hc  nerve  roots  are  involved  in 
the  growth  and  are  damaged  and  compressed.  The  extent  is  variable. 
It  may  be  limited  to  one  segment,  but  more  coninu)nly  involves  a  con- 
Hidcrable  portion  of  the  cervical  enlargement.  The  disease  is  chronic, 
and  in  some  cases  presents  a  characteristic  group  of  symptoms.  There 
iire  intciuso  neuralgic;  pains  in  the  course  of  the  nerves  whose  roots  arc 
involved.  They  are  chiefly  in  the  arms  and  in  the  cervical  region,  and 
viiry  greatly  in  intensity.  'JMiere  nuiy  be  hypera>sthesia  with  numbness  and 
tingling;  atrophic  changes  may  develop,  and  there  may  be  areas  of  ana^s- 
tliffia.  (Jraduidly  motor  disturbances  appear;  the  arms  become  weak  and 
tlie  muscles  atrophied,  particularly  in  certain  groups,  ius  Uie  flexors  of  tiu? 
liand.  The  extensors,  on  tlie  other  hand,  remain  intact,,  so  that  the  con- 
(i\ion  of  claw-hand  is  gradually  produced.  The  grade  of  the  atrophy 
depends  much  upon  the  extent  of  involvement  of  the  (tcrvical  nerve  roots, 
and  in  many  cases  the  atrojiliy  of  tlie  niusck-rf  of  the  shoulders  ami  arms 
hi'conu's  extreme.  The  condition  is  one  of  cervical  juiraplegia,  with  con- 
tractures, flexion  of  the  wrist,  and  typical  hkiih  en  (jriffe.  Usually  l)eforo 
the  arms  are  greatly  atrophied  there  are  the  symptoms  of  what  the  PVcinch 
writers  term  the  second  stage — namely,  involvement  of  the  lower  extremi- 
ties and  the  gradual  production  of  a  spastic  paraplegia,  which  may  develop 
K.'veral  months  after  the  onset  of  the  disease,  and  is  due  to  secondary 
ehangos  in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 
I;i  a  few  in.stances,  in  which  symptoms  pointed  definitely  to  this  condition, 
recovery  has  taken  place.  The  disease  is  to  be  distinguished  from  amyo- 
trophie  lateral  sclerosis,  syringomyelir,  arid  tumors.  From  the  first  it  is 
sejiaratetl  by  the  marked  severity  of  tlie  initial  pains  in  the  neck  and  arms; 
from  the  secomi,  by  the  absem^'  of  the  sensory  changes  charactcristit!  of 
syringomyelia.  From  certain  tumors  it  is  very  ditliciult  to  distinguish, 
as,  iu  fact,  the  fd)riiU)U8  layers  form  a  tumor  around  the  cord. 

The  condition  known  as  Jnvtnatoma  of  the  dura  mater  may  occur  at 
liny  part  of  the  cord,  or,  iu  its  slow,  progressive  form — pachymetungitis 


\\\  'M 


822 


DISEASES  OF  TiIE  NERVOUS  SYSTEM, 


15    :  ,>•. 


?  « 


li;«morrhagh'!i  intorniv — may  l)o  limitod  to  tlio  corvical  rogion  and  jiroduro 
th«  symptoms  just  montiom'(i.  It  is  soniotimoa  oxtcnsivo,  and  may  coexist 
with  a  similar  condition  of  tho  cerebral  dura.  Cysts  may  occur  lillcd  wiilj 
liajinorrhagic  contents. 

DlSlC.V.SKS   OK   THK    PlA    MaTKU. 

in)  Acute  Spinal  Meningitis;  Leptomeningitis. 

Etiology. — Spinal  meningitis  occurs:  (I)  In  tuberculosis.  Tliis  is 
perhaps  the  most  common  form  in  general  practice  and  has  already  lucii 
considered,  ("i)  In  specific  cerebro-si)inal  meningitis,  whicdi  occurs  en- 
demically  or  epidemically,  and  has  also  been  considered  under  its  apitro- 
j)riate  section.  (.'{)  As  a  secondary  involvement  in  certain  infectious  din- 
eases,  ])neumonia,  small-pox,  scarlet  fever,  and  typhoid  fever.  This  t'criu 
is  very  rare  Even  in  piuiunionia,  in  vvliich  the  cerebral  meninges  aro 
freqiu'utly  involved,  the  spinal  nuMiinges  are  seldom  alTecteil,  except  per- 
haps ii\  the  tirst  two  or  three  inches  of  the  cervii^al  region.  (4)  From  in- 
jury or  the  extension  of  inflammation,  as  after  operation  on  sjiina  Iiiliiln. 
(."))  There  are  csises  in  which  the  meningitis  appears  to  have  followed  ex- 
posure to  cold  ami  wet. 

Morbid  Anatomy. — The  affection  may  bo  diffused  over  tiie  tiitnv 
cord  or  localized  to  tlu;  cervical  region.  In  the  early  stag(f  the  vessels  of 
the  pia  mater  are  injected.  The  fluid  in  the  pia-arachnoid  space  is 
slightly  turbid.  In  some  intense  grades,  on  opening  the  dura  tlw^  contour 
of  the  cord  cannot  be  seen,  as  it  is  completely  enveloped  in  a  sero-libriii- 
ous  or  jnirulent  exudate,  which  here  and  there  cau.ses  bulging  of  tlio 
aracdmoid.  Owing  to  tlie  position  of  the  body,  the  exudate  is  luosl 
abundant  in  the  i)osterior  part,  or  sinks  to  tho  lumbar  region.  In 
acute  cases  the  j)ia  itself  does  not  look  thickened,  hut  in  more  (diroiiic 
forms  the  membrane  nuiy  bo  grayish  and  turbid.  In  a  majority  of  in- 
stances, if  the  inflammation  is  intense,  the  exudate  is  seen  in  the  anterior 
and  posterior  median  fissures  ami  tho  cortical  portion  of  the  coid  is 
SAVoUen  and  infiltrated,  so  the  condition  can  be  ])roperly  called  iiuMiiiigo- 
myelitis.  The  affection  may  be  limited  to  the  spinal  nu'uinges,  but  in  ii 
imijority  of  instances  it  is  a  cerel)ro-spinal  lesion. 

Symptoms. — These  have  already  been  referred  to  in  considering  llm 
two  commonest  varieties,  the  tuberculous  and  the  epidemic.  The  disease 
often  sets  in  with  a  "hill  and  fevor.  Pain  in  the  back,  stilTncss  in  the 
neck,  pain  on  pressaru  along  the  vertebra*,  tremor  or  spasm  of  the  mus- 
cles, and  disturbances  of  sensation  are  usually  present.  (Jirdlo  sen.sitinns 
are  not  common.  The  reflexes  may  be  iiu'rea.se;l.  Later,  paralytic  syiii]i- 
toma  may  develop,  but  they  are  uncommon,  except  in  pure  spinal  nu  ti- 
ingitis. 

Tho  durr/tiosis  is  often  difiicult.  In  a  large  proportion  of  the  i"i<es 
supposed  to  be  spinal  meningitis  the  membranes  are  not  inflamed.     1  luivu 


tP 


AFFECTIONS  OF  THE   MENINGES. 


823 


iilmidy  rcforrcd  to  tin-  iilculity  of  tlie  spiiiul  syiiiptoins  in  (rrtuiu  of  llic 
infoi'tioua  discasi's  witli  those  of  ucuto  K'jitoniciiiu^itis.  in  Uic  cuko  of  u 
|!iitu'nt  with  hiijli  fever,  niurived  KtilVnesH  of  the  back  mid  nei'k  inus(  leK,  or 
('I  isthotonus  witli  rij,Mdity  und  tremor  of  the  inusoles,  it  in  not  nnimtiiral 
til  make  a  ]»»sitive  (liajj;nosis  of  spinal  nienin^jtitiH,  hvit  every  symptom  of 
(he  condition  may  be  present  witiioiit  any  inllammatory  exiKhiti'.  'J'he 
triitii  of  Stokes's  dictum,  aU'eady  rpKited  (p.  '-i')),  lias  been  brou;,dit  honn' 
to  mo  on  many  occasions.  On  tlie  other  liand,  tiiere  are  instanccH  of 
uc'.l-marked  leptomeninjritis,  more  ]»articularly  tlie  ccrebro-spinal  form, 
ill  vhieh  spinal  sym))toms  are  trillinjjf  or  absent.  To  distinguish  between 
the  dilferent  forms  of  sjdnal  nu'iiinj^itis  is  sometimes  extremely  ditlicult. 
A  correct  diajjfiiosis  is  oftenest  made  in  tuberculous  eases,  since  here  the 
{irodromata  are  well  defined  and  the  sym])toms  indicative  of  involvement 
of  the  (teiebral  meninfjes  well  marked.  There  are  casea  in  which  the 
spinal  nu'niiiji;es  bear  the  brunt  of  the  ailVction.  1  have  alread;.  referred 
to  one  case  in  which  the  nienin<j;itis  was  thouj,dil  to  be  due  to  trauma- 
tism. 'I'lie  coexistence  of  disease  at  the  apex  of  the  lungs  or  (»f  htcul 
tubcrcuUais  lesions  elsewhere  is  of  great  value. 

The  diagnosis  of  the  epidemiir  form  has  already  been  considered. 

{0}  Chronic  Leptomeningitis.— As  a  primary  lesion  this  is  extremely 
rare.  It  sometimes  follows  the  prolonged  use  of  alcohol.  It  occurs  in 
connection  with  syphilis,  trauma,  and  as  a  eomiilication  of  various  si'le- 
roses  of  the  sjfinal  cord,  either  systemic  or  insular. 

Audtdinicdlli/  the  condition  is  characterized  by  a  thickening  and  tnr- 
liiility  of  the  pia,  often  with  ailhesions  to  the  arachnoid  and  tlio  dura. 
Tiie  membrancij  may  be  stained  with  blood-jiigmeiit.  These  alterationH 
may  occur  in  localized  spots  or  over  ext<'nsive  areas.  The  nerve  roots  may 
he  involved  and  thickened.  The  sjiinal  cord  itself  is  rarely  alTeeted, 
though  strands  of  connective  tissue  may  extend  into  the  cortical  zone, 
producing  slight  sclerosis.  The  opaque,  white,  cartilaginous  plates  whicdi 
ociur  so  often  on  the  posterior  surface  of  the  spinal  arachnoid  and  are 
sometimes  adherent  to  the  jiia  cause  no  symptoms  and  an*  lutt  to  be  mis- 
taken for  this  chronic  meningitis. 

The  xi/iii/i/diti.s  of  this  form  are  indetlnite.  Simple  tliickciiing  of  the 
meninges  may  produce  no  signs  during  life  unless  the  s[»iiial  nerves  roots 
arc  invohed.  In  any  cast-  tlu;  iliagnosjs  is  somewhat  doul)tful.  '{'here 
are  instamces  in  which  pain  in  the  back,  slilTiiess  of  the  dorsal  muscles, 
and  pains  radiating  in  the  nerves  of  the  trunk  or  in  the  extremities  have 
lii'cii  marked.  Jlypera'sthesia  and  skin  eruptions  may  be  jircsent.  When 
ilii'  cord  is  involved  paralytic;  symptoms  may  develoji.  The  rcllexes  are 
iiurcased.     The  course  is  always  cdironie,  lasting  for  many  years. 

The  treatment  is  i)urely  symptonuitie.  Uecovery  probably  never 
occura. 


I 


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824 


DISEASES  OP  THE  NEllVOUS  SYSTEM. 


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.  -  ''  ' 


ILi;mourua(1K  fnto  thk  Spixai-  MiiMHitANEs;   II.r.MATouuiiArnis. 

In  nuMiiiigcal  iipdplcxy,  iis  it  is  chIKmI,  the  blood  iniiy  be  betwoon  Iho 
(iuni  miitor  and  tlio  spiiml  caiiul — t'xtmiiu'ningoal  lurniorrluif^o — or  wilhin 
the  dura  inatcr — iiitraiucniiip'al  ha'iiiorrlia^c. 

{(i)  K.rlnv)iciiiii()('al  llu'morrlidiie  occurs  usually  as  a  result  of  traiiiim. 
Tlu!  exudation  may  be  extensive  witlutut  conn»ressioii  of  the  cord.  'I'lic 
blood  eonios  from  tho  lar;?e  plexuses  of  veins  wliicb  surround  tlu!  diiiii. 
'I'lie  rupture  of  an  aneurism  into  tbo  spinal  (uuuil  nuiy  producjo  extensive 
unil  rapidly  fatal  lui^morrliajje. 

{li)  I)ilrnnn'ni)i(/('(il  //irniorr/itii/c  is  rather  more  c'ommon,  but  is  rarely 
extensive  from  (Wises  acting  directly  on  the  sj)inal  menin;^es  themselves. 
Scattered  luvmorrhages  are  not  unfre<]uent  in  the  acute  infectious  l'ev(>rs, 
and  I  have  twi{H\  in  malijjnant  snuill-pox,  seen  much  elTusion.  Hleedinj; 
o('curs  also  in  death  from  convulsive  disorders,  such  as  cpilep.sy,  tetaiius, 
and  strychnia  poisoning.  The  most  exti'iisive  luemorrhages  oturur  in  cases 
in  which  tho  blood  comes  from  rupture  of  an  aneurism  at  the  base  of  the 
bruin,  either  of  the  basilar  or  vertebral.  Jn  several  eases  of  this  kind  1  have 
found  a  large  aniount  of  blood  in  tlu?  spinal  meninges.  In  ventricular 
apoplexy  the  blood  may  ])ass  from  the  fourth  ventricle  into  th(!  spinal 
meninges.  There  isaspecinuMi  in  tho  medical  museum  of  Mctilill  ('olicjjje 
of  the  most  extensive  intraventricular  ha'inorrhage,  in  which  the  IiIikmI 
passed  into  the  fourth  ventricle,  and  descended  beiu-ath  the  spinal  aradi- 
aoiil  for  a  considerable  distance.  On  the  other  hand,  ha'inorrhage  into 
the  spinal  nuMiinges  may  possibly  asceiul  into  tho  brain. 

The  si/mptums  in  nu)derato  grades  may  be  slight  und  indelinitc.  In 
the  non-traumutio  ea.ses  the  hivtnorrhage  nuiy  either  come  on  suddenly  or 
after  a  day  or  two  of  uiu'a.sy  .sensations  along  the  spine.  As  a  rule,  llio 
onset  is  abruj)t,  with  sharj)  j)ain  in  the  back  and  symptoms  of  irrilutinn  in 
the  course  of  the  nerves.  There  may  be  muscular  spasms,  or  paralysis  may 
come  on  suddoidy,  either  in  tho  legs  alone  or  both  in  the  legs  and  arms. 
In  some  instances  the  paralysis  develops  more  slowly  and  is  not  complete. 
There  is  no  loss  of  consciousnes.s,  and  there  are  no  signs  of  ciu'ebral  dis- 
turbance. The  clinical  picture  naturally  varies  with  the  site  of  the  hicnior- 
rhage.  If  in  tho  lumbar  region,  the  legs  alone  are  involved,  the  retlexes  may 
be  abolished,  and  the  action  of  the  bladder  and  rectum  are  impairiMl.  In 
the  dorsal  region  there  is  more  or  less  complete  paraplegia,  the  rcllex(>s  are 
usually  retained,  and  there  arc  signs  of  disturbance  in  the  thoracic  nerves, 
such  as  girdle  sensations,  pains,  and  sometimes  eruption  of  herpes.  In  tho 
cervical  region  the  arms  as  well  as  the  legs  may  bo  involved  ;  there  may 
be  difficulty  in  breathing,  stiffness  of  tho  muscles  of  the  neck,  and  oeea- 
sioually  pupillary  symptoms. 

Tho  prognosis  depends  much  ujion  tho  cause  of  the  hiiMnorrhage. 
Uecovery  may  take  place  in  tho  traumatic  cases,  and  in  those  associatid 
with  the  infectious  diseases. 


m 


AKFF.CTIONS  OK  TIIK   liLOOD-VKSSKLS. 


825 


.IIACIIIS. 


m.  AFFECTIONS  OF  THE  BLOOD-VESSELS. 

{(i)  Congestion.  —  Apint.  from  iutiml  myelitis,  we  nuily  set-  ptist  mor- 
tctii  I'vitlciici's  ol'  cdii;;!'.-!!.!!)!!  of  tlic  spinal  conl,  and  when  we  (!(»  it  is  uhu- 
ally  limited  eitlier  ti»  the  rjny  iiialtcr  or  to  u  delinitc  portion  of  tlut  orpin, 
'I'licre  is  necessarily,  froin  tln!  posture  of  (he  I)ody  post  mortem,  ii  j^routcr 
(Ic^'ree  of  vasenlarity  in  tlie  postiu'lor  poi'tion  of  the  cord.  'I'Ik  white  mat- 
ter is  rarely  found  con;^'ested,  even  when  iidlanied  ;  in  fact,  it  is  remarka- 
l)|e  how  iinii'orndy  pale  this  portion  of  the  cord  is.  The  e-my  niatter  often 
lias  a  reddish-pink  tint,  but  rarely  a  deep  reddish  line,  except  when  mye- 
litis is  present.  If  we  know  littK'  anatomically  of  conditions  of  conj^cK- 
tion  of  the  cord,  we  know  le.ss  clinicaily,  for  there  are  no  features  in  imy 
way  characteristic  of  it. 

(/')  Anajmia.— S(»,  too,  with  this  stale.  There  may  he  extreme  ^'rade.s 
of  anu'mia  of  the  cord  without  .sym|itonis.  In  chlorosis  and  pei'idcicHiH 
atia'tniu  there  are  randy  syinjitoms  pointinjj;  to  the  cord,  and  there  is  no 
reason  to  suppose  that  such  sensidions  as  heaviness  in  the  lindis  and  tiii- 
jflinj:  are  especially  associated  with  ana'mia. 

There  are,  however,  some  very  intorcstin'j  facts  with  n  fen  lu  e  to  the 
pnifound  ami'mia  of  the  cord  which  fidhtws  lij^fature  (d"  the  aona.  In  ex- 
periments made  in  Wehdi's  lahorjil^ry  hy  llerter,  it  was  found  that  wiihiii 
a  few  moments  after  the  application  of  the  lij;atnre  t;)  the  aorta  paniplej^iii 
came  on.  I'andysis  of  the  sphincters  devcdoped,  hut  less  nipidly.  Within 
fourteen  davH  contrac  tures  of  (he  lindis  .set  in  with  atrophy  and  fihrillar 
Iwitchinjjs.  lIistolo}j;ically  it  was  shown  that  within  thirty-six  hours  there 
vvere  markeil  clian,<res  in  tlu!  p;ni:iion  ctdls  of  the  anterior  horns  in  the 
hunliar  sej^ments,  aiul  later  there  were  sij,'iis  of  a  dcliniti"  myelitis.  This 
condition  is  of  interest  in  connection  with  the  fact  of  the  ni|  id  develop- 
ment of  a  ]iaraple<iia  after  profuse  ha'niorrhaf,'e,  nsually  from  the  stonuudi 
or  uterus.  It  may  come  on  at  once  or  at  the  end  of  u  weik  or  ten  days, 
and  is  prohalily  due  to  an  anatomical  (diange  in  the  nerve  eh  nients  similar 
to  that  produced  in  Herter's  e.vpcrimcnts. 

In  this  connection  maybe  mentioned  the  interestinpf  oh.servations  of 
liiehtheim  upon  the  dei^eiieration  of  the  jxisterior  columns  of  the  cord 
in  pernicious  iinn'mia,  of  which  he  has  reported  three  cases.  Ife  re- 
jianls  it  as  a  form  of  toxic  myolili.s  <liie  to  the  altered  eoiulition  of  tho 
blood. 

{(•)  Embolism  and  Thrombosis.— Mlockin^r  of  the  spinal  arteries  hy  em- 
lioli  rarely  occurs.  It  nuiy  he  produced  ex[ierimeiitally,  and  Money  fouiul 
that  it  was  ashociuted  witli  choreiform  movements.  Thronihosis  of  tho 
smaller  vessels  in  c  .nneotion  with  eiularteritis  jilays  an  important  part  in 
many  of  the  ivniv  aul  chronic  chanpfes  in  the  conl. 

('/)  Endarteritis. — It  is  remarkahle  how  frequently  in  jiersons  over  fifty 
the  arteries  of  the  sjiinal  cord  are  found  sclerotic.  The  followint:^  forms 
may  be  met  wiUi:  (1)  A  nodular  peri-arteritis  or  endarteritis  associated 


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826 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


with  syphilis  and  sometimes  with  gummata  of  the  mcn'ngea ;  (2)  an  ui  tor- 
itis  obliterans,  with  great  thickening  of  tire  intima  and  narrowing  of  tho 
lumen  of  the  vessels,  involving  chiefly  the  medium  and  larger-sized  arteries. 
Miliary  aneurisms  or  aneurisjns  of  the  larger  vessels}  are  rarely  found  in 
the  spinal  cord.  In  the  classical  work  of  I^yden  but  a  single  instance  of 
the  latter  is  mentioned. 

(c)  HsBmorrhage  into  the  Spinal  Cord  {lltemelomyelia).— The  cxkhnm', 
of  a  primary  haemorrhage  into  the  cord  haa  been  denied  on  the  ground 
that  in  all  instances  it  is  preceded  by  a  condition  of  softening.  A  majority 
of  authors,  however,  admit  the  existence  of  a  primarj'  form.  About  forty- 
two  cases  are  on  record,  which  are  collected  in  the  thesis  of  Ilayem*  and 
in  the  article  of  Berkeley.f  It  is  more  common  in  males  than  in  females, 
and  at  the  middle  period  of  life.  The  cases  hate  followed  eitlier  cold  and 
exposure  or  overexertion,  and,  most  frequently  of  all,  traumatism.  It  oc- 
curs also  in  tetanus  and  convulsions.  lIa?morrlmge  may  be  associated  witli 
tumors,  Avith  syringo-myelia,  or  with  myelitis;  it  is  often  difficult  to  de- 
termine whether  the  case  is  one  of  primary  hemorrhage  with  myelitis,  or 
myelitis  with  a  secondary  hajmorrhage. 

The  anatomical  condition  is  very  varied.  The  cord  may  be  enlarged 
at  the  site  of  the  hiemorrhage,  and  occasionally  the  white  substance  may 
be  lacerated  and  blood  may  escape  beneath  the  meninges.  The  extravasa- 
tion is  chiefly  in  the  gray  matter,  end  may  be  limited  or  focal,  or  very 
diffuse,  extending  a  considerable  distance  in  the  cord.  In  a  case  which 
occurred  at  the  Montreal  General  Hospital  under  Wilkins  the  haemorrliage 
occupied  a  position  oj)posite  the  region  of  the  fifth  and  sixth  cervical 
nerves  and  on  transverse  section  the  cord  was  occupied  by  a  dark-rc^  clot 
measuring  twelve  by  five  millimetres,  around  which  the  white  substance 
formed  a  thin,  ragged  wall.  The  clot  could  be  traowl  upward  as  far  as  the 
second  cervical,  and  downward  as  far  as  the  fourth  dorsal. 

The  sudden  onset  of  the  symptoms  is  the  most  characteristic  feature 
in  hajmatomyolia.  The  loss  of  power  necessarily  tariea  with  the  locality 
affected.  If  in  the  cervical  region,  both  armsand  legs  may  be  involved ; 
but  if  in  the  dorsal  or  In ni  liar,  there  is  only  paraplegia.  There  is  usually 
loss  of  sensation,  and  at  flrrit  loss  of  reflexes.  Myelitis  frequently  develoi)s 
and  becomes  extensive,  with  fever  and  trophic  chunges.  The  ccndition 
may  rapidly  })rove  fatal ;  in  other  instances  there  Is^adual  recovery,  often 
with  partial  paralysis.  .  _  *   '  ' 

The  diagnosis  may  ho  made  in  some  instances,  particularly  those  in 
which  the  onset  is  sudden  after  injury,  but  there  ia  great  difficulty  in  dif- 
ferentiating luiemorrhagic  myelitis  from  certain  casc.^  of  ha;morrhago  into 
the  spinal  meninges.  The  question  of  diagnosiij  ha«  been  carefully  consid- 
ered by  Iloeh  J  in  a  recent  report  of  two  cafces  from  my  clinic. 

*  Paris,  1872. 
f  Brain,  1889. 
%  Johns  HopkinH  Hospital  Iteporta,  toL  ii,  fascicalua  6, 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


827 


(/)  Caisson  Disease;  Diver's  Paralysis.— This  rcmarkablo  affection, 
found  in  divers  and  in  workers  in  caissons,  is  characterized  by  a  paraplegia, 
more  rarely  a  general  palsy,  which  supervenes  on  returning  from  the  com- 
pressed atmosphere  to  the  surface. 

The  disease  has  been  carefally  studied  by  the  French  writers,  by  Ley- 
den  and  Schultze  in  Germany,  and  in  this  country  particularly  by  A.  II. 
Smith.  The  pressure  must  be  more  than  that  of  three  atmospheres.  The 
ayniptoms  are  especially  apt  to  come  on  if  the  change  from  the  high  to 
the  ordinary  atmospheric  pressure  is  quickly  made.  They  may  supervene 
immediately  on  leaving  the  caisson,  or  they  may  be  delayed  for  several  hours. 
In  the  mildest  form  there  are  simply  pains  about  the  knees  and  in  the 
leg.-!,  often  of  great  severity,  and  occurring  in  paroxysms.  Abdominal 
pain  and  vomiting  are  not  uncommon.  The  legs  may  be  tender  to  the 
touch,  and  the  patient  may  walk  with  a  stiff  gait.  Dizziness  and  headache 
may  accompany  these  neuralgic  symptoms,  or  may  occur  alone.  More 
commonly  in  the  severe  form  there  is  paralysis  both  of  motion  and  sen- 
sation, usually  a  parai^legia,  but  it  may  be  general,  involving  the  trunk 
and  arms.  Monoplegia  and  hemij^legia  are  rare.  In  the  most  extreme 
instances  the  attacks  resemble  apoplexy,  and  the  patient  rapidly  becomes 
comatose  and  death  occurs  in  a  few  hours.  In  the  cases  of  paraplegia  the 
outlook  is  usually  good,  and  the  paralysis  may  pass  off  in  a  day,  or  may 
continue  for  several  weeks  or  even  for  months.  Identical  features  are 
met  with  in  the  deep-sea  divers. 

The  explanation  of  this  condition  is  by  no  means  satisfactory.  Two 
enroful  autopsies  have  been  made.  In  Leyden's  case  death  occurred  on 
the  fifteenth  day,  and  in  the  dorsal  portion  of  the  cord  there  were  numer- 
ous foci  of  haemorrhages  and  signs  of  an  acute  myelitis.  In  Schultze's 
case  death  occurred  in  two  and  a  half  months,  and  a  disseminated  myelitis 
was  found  in  the  dorsal  region.  In  both  cases  there  Avere  fissures,  and 
appearances  as  if  tissue  had  been  lacerated.  It  has  been  suggested  that 
the  symptoms  are  due  to  the  liberation  in  the  spinal  cord  of  bubbles  of 
nitrogen  which  have  been  absorbed  by  the  blood  under  the  high  pressure, 
and  the  condition  found  at  the  autopsies  just  leferrcd  to  is  held  to  favor 
this  view. 

A  large  majority  of  the  cases  recover.  The  severe  neuralgic  pains 
often  require  morphia.  Inhalations  of  ox\'gen  and  the  use  of  compressed 
air  have  been  advised.  When  paraplegia  develops  th"  treatment  is  similar 
to  that  of  other  forms.  In  all  cu:sson  work  care  should  be  exercised  that 
the  time  in  passing  through  the  lock  from  the  high  to  the  ordinary  press- 
ure be  sufficiently  prolonged.  According  to  A.  II.  Smith,  at  least  five 
minutes  should  be  allowed  for  each  additional  atmosphere  of  pressure. 


1 


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828 


DISEASES  OP  TOE  NERVOUS  SYSTEM. 


MI.    ACUTE  AFFECTIONS  OF  THE  SPINAL  CORD. 


'-t) 


\i  W  ' 


(1)  Acute  Diffuse  Myelitis. 

Etiology. — Acute  myelitis  results  from  mauy  causes,  and  may  aflect 
the  cord  iu  u  limited  or  extended  portion — the  gray  matter  chiefly,  or  the 
gray  and  white  matter  together.  It  is  met  with  :  (a)  As  an  independent 
affection  following  exposure  to  cold,  or  exertion,  and  leading  to  rapid 
loss  of  power  with  the  symptoms  of  an  acute  ascending  paralysis,  (b)  As 
a  secpiel  of  the  infectious  diseases,  such  as  small-pox,  tophus,  and  measles. 
(6')  As  a  result  of  traumatism,  either  fracture  of  the  spine  or  very  severe 
muscular  effort.  Concussion  witi.vout  fracture  may  produce  it,  but  this  is 
rare.  Acute  myelitis,  for  instance,  scarcely  ever  follows  railway  accidents. 
(d)  In  disease  of  the  bones  of  the  spine,  either  caries  or  cancer.  Tliis  is  a 
more  comnion  cause  of  localized  acute  transverse  myelitis  than  of  the  dilTuse 
affection,  (c)  In  disease  of  the  cord  itself,  such  as  tumors  and  syphilis; 
in  the  latter,  either  in  association  Avith  gummata,  in  which  case  it  is 
usually  a  late  manifestation,  or  it  may  follow  within  a  year  or  eighteen 
nionths  of  the  primary  affection.* 

Morbid  Anatomy. — In  localized  acute  myelitis  affecting  wliite  and 
gray  matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is 
swollen,  the  pia  injected,  the  consistence  greatly  reduced,  and  on  incising 
the  membrane  an  almost  diiffuent  fluid  may  escape.  In  less  intense 
grades,  on  section  at  the  affected  area,  all  trace  of  distinction  between  the 
gray  and  white  matter  is  lost,  or  extremely  indistinct.  The  tissue  may  be  in- 
jected, or,  as  is  often  the  case,  ha?morrhagic.  It  is  particularly  in  these 
forms,  due  to  extension  of  disease  from  Avithout  or  to  acute  compression, 
that  we  find  definite  involvement  of  the  white  matter.  In  other  instances 
the  gray  matter  is  chiefly  affected.  There  may  be  localized  areas  through- 
out the  cord  iu  which  the  gray  matter  is  reduced  in  consistence  "nd 
hcemorrhagic,  the  so-called  red  softening.  There  may  be  definite  cavity 
formations  in  these  foci.  In  some  cases  of  disseminated  or  focal  myelitis 
the  meninges  also  are  involved  and  there  is  a  myelo-meningitis.  And, 
lastly,  there  are  instances  in  which,  throughout  a  long  section  of  the  cord, 
sometimes  through  tlie  lumbar  and  the  greater  part  of  the  dorsal,  or  in  the 
dorsal  and  cervical  regions,  there  is  a  diffuse  myelitis  of  the  gray  sub- 
stance. 

Histologically  the  nerve  fdires  are  much  swollen  and  irregularly  c  is- 
torted,  the  axis  cylinders  are  beaded,  the  myeliu  droplets  arc  abundant, 
and  the  laminated  bodies  known  as  corpora  amylacea  may  be  seen.  I'ho 
granular  fatty  cells  are  also  numerous  and  there  may  be  leucocytes  and 
red  blood-corpuscles.  C/hanges  in  the  blood-vessels  are  striking;  the 
smaller  veins  are  distended  and  may  show  varicosities.    The  perivascular 

•  Brcteau,  Dcs  Maladies  Syphilitiques  Precoces,  Paris  Thesis,  1889. 


■:^mwf' 


ACUTE  AFFECTIONS  OP  THE  SPINAL  CORD. 


829 


fii-^:/! 


irrcffularlv  c  is- 
arc  abundant, 
be  seen.    The 


lymph  spaces  contain  numerous  leucocytes,  and  the  smaller  arteries  them- 
selves are  frequently  the  scat  of  hyaline  thrombi.  The  ganglion  colls 
lire  swollen  and  irregular  in  outline,  the  protoj)lasm  is  extremely  granu- 
lar and  vacuolated,  and  the  nuclei,  though  usually  invisible,  may  show 
signs  of  division,  and  the  processes  of  the  cells  are  not  seen. 

In  cases  whicli  persist  for  some  time  we  have  an  opportunity  of  seeing 
the  later  stages  of  acute  myelitis.  The  acute,  inllammatory,  hypera^mic  or 
red  soften"ng  is  succeeded  by  stages  in  which  the  aiTe(;ted  area  becomes 
more  yellow  from  gradual  alteration  of  the  blood-pigment,  and  finally 
white  in  color  from  the  advancing  fatty  degeneration.  In  cases  of  com- 
pression myelitis,  a  sclerosis  may  gradually  be  produced  with  the  anatom- 
ical picture  of  a  clux     j  diffuse  myelitis. 

Symptoms.— (ff)  Acute  Central  Myelitis.— It  is  this  form  which 
conies  on  spontaneously  after  cold,  or  in  connection  with  syphilis  or  one 
of  the  infectious  diseases,  or  is  seen  in  a  typical  manner  in  ti»e  extension 
from  injuries  or  from  tumor.  The  onset,  thougli  scarcely  so  abrupt  as  in 
liteniorrhago,  may  be  sudden ;  a  person  may  be  attacked  on  the  street  and 
have  difficulty  in  getting  home.  In  some  instances,  the  onset  is  preceded 
by  i)ains  in  the  legs  or  back,  or  u  girdle  sensation  is  present.  It  may 
be  marked  by  cliills,  occasionally  by  convulsions;  fever  is  usually  present 
from  the  beginning — at  first  slight,  but  subsequently  it  may  become 
high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Lan- 
dry's ascending  paralysis.  Tlie  paraplegia  may  be  complete,  ami,  if  the 
myelitis  extends  to  the  cervical  region,  there  may  be  impairment  of  mo- 
tion, and  ultimately  comjdete  loss  of  power  of  the  upper  extremities  as 
well.  The  sensation  is  lost,  but  there  may  at  first  be  hypera\sthesia.  The 
reflexes  in  the  initial  stage  are  increased,  but  in  acute  central  myelitis,  un- 
less limited  in  extent  to  the  dor.sal  and  cervical  regions,  the  refiexes  arc 
usually  abolished.  The  rectum  and  bladder  are  paralyzed.  Trophic  dis- 
turbances are  marked  ;  the  muscles  waste  rapidly ;  the  skin  is  often  con- 
gested, and  there  may  be  localized  sweating.  The  temperature  of  the 
affected  limbs  may  be  lowered.  Acute  bed-sores  may  develop  over  the 
sacrum  or  on  the  heels,  and  sometimes  a  multiple  arthritis  is  ])resent.  In 
these  acute  cases  the  general  symptoms  become  greatly  aggravated,  the 
pulse  is  rapid,  the  tongue  becomes  dry;  there  is  delirium,  the  fever  in- 
creases, and  may  reach  107°  or  108°. 

The  course  of  the  disease  is  variable.  In  very  acute  (-ases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases  par- 
ticularly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  difficult.  In 
common  with  the  acute  ascending  paralysis  of  Landry,  and  with  certain 
cases  of  multiple  neuritis,  it  presents  a  rapid  and  progressive  motor  paraly- 
sis. From  the  former  it  is  distinguished  by  the  more  marked  involvement 
of  sensation,  the  trophic  disturbances,  the  paralysis  of  bladder  and  rectum, 


1  ^1:1 


880 


DISEASES  OP  THE  NBRVOUS  SYSTEM. 


■    '   i 


■','} 


the  rapid  wasting,  the  electrical  changes,  and  the  fever.  From  acuto  casca 
<>i  multiple  neuritis  it  may  be  more  difficult  to  distinguish,  as  the  sciisorv 
features  in  tiiese  cases  may  be  marked,  though  there  is  rjirely,  if  ever,  in 
multiple  neuritis  complete  anassthesia;  the  wasting,  moreover,  is  more 
rapid  in  myelitis.  The  bladder  and  rectum  are  rarely  involved — thoujrli 
in  exceptional  cases  they  may  be — and,  most  important  of  all,  the  trojihic 
changes,  the  development  of  bulhc,  bed-sores,  etc.,  are  not  seen  in  inulti|,lc 
neuritis. 

{[/)  Acute  Transverse  Myelitis. — The  symptoms  naturally  differ  with 
the  situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  dorsal  region.,  the  most  eoiiunori 
situation,  produces  a  very  characteristic  i)icture.  The  symptoms  of  onset 
are  variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the 
legs.  The  paralysis  may  sot  in  quickly  and  become  com];)lete  within  a 
few  days ;,  but  more  commonly  it  is  preceded  for  a  day  or  two  by  sensa- 
tions of  pain,  heaviness,  and  dragging  in  the  legs.  The  paralysis  of  the 
lower  limbs  is  usually  complete,  and  if  at  the  level,  say,  of  tlie  sixth  dorsal 
vertebra,  the  abdominal  muscles  are  involved.  Sensation  may  be  partially 
or  completely  lost.  At  the  onset  there  may  be  nnmbncss,  tingling,  or  even 
hyperiiEsthesia  in  the  legs.  At  the  level  of  the  lesion  there  is  often  a  zone 
of  hyperesthesia,  which  is  discovered  by  passing  a  test-tube  containing  liot 
water  along  the  spine,  when  the  sensation  of  warmth  changes  to  one  of 
actual  pain.  A  girdle  sensation  may  occur  early,  and  when  the  lesion  is  in 
this  fjituation  it  is  usually  felt  between  the  ensiform  and  umbilical  regions. 
The  reflex  functions  are  variable.  There  may  at  first  be  abolition  of  the  re-  • 
flexes ;  subsequently,  the  reflexes,  passing  through  the  segments  lower  tliiin 
the  one  affected,  may  be  exaggerated  and  the  limbs  may  pass  into  a  con- 
dition of  spastic  rigidity.  It  does  not  always  happen,  however,  that  the  re- 
flexes arc  increased  in  a  total  transverse  lesion  of  the  cord.  They  may  he 
entii'ely  lost,  as  pointed  out  some  years  ago  by  Bastian,  and  insisted  ujion  hy 
him  in  a  recent  memoir.*  F.  T.  Miles  has  also  called  attentioi\  to  this  fact 
and  reported  five  cases  in  which  the  reflexes  were  lost  in  total  transverse 
lesion  of  the  cord.  That  this  is  not  due  to  the  preliminary  shock  is  shown 
by  the  fact  that  the  abolition  of  the  reflexes  may  continue  for  four  or  more 
months.  The  trophic  changes  are  not  marked.  The  muscles  become  ex- 
tremely flabby, but  not  wasted  in  an  extreme  degree;  subsequently  rigidity 
develops.  If  the  gray  matter  of  tlie  lumbar  cord  is  involved,  the  flaccidity 
persists  and  the  wasting  may  be  considerable.  The  reaction  of  degenera- 
tion is  not  present.  The  temperature  of  the  paralyzed  limbs  is  variable. 
It  may  at  first  rise,  then  fall  and  become  subnormal.  Lesions  of  the  skin 
are  not  uncommon,  and  bed-sores  are  apt  to  form.  There  is  at  first  re- 
tention of  nrino  and  subsequent  incontinence.  If  the  lumbar  centres  arc 
involved,  there  are  from  the  outset  vesical  symptoms.     The  urine  is  alka- 

•Medico-Chirurgical  Transactions,  vol.  Ixxiii. 


ACUTE  AFFECTIONS  OF  THE  SPINAL  CORD. 


881 


lino  in  roaobion  ami  may  rapidly  bocomo  amnioniacal.  Tlio  bowuLs  are 
coiistiimtofl  and  tbero  id  ii.sually  incontinence  of  the  faeces.  Some  writers 
attribute  the  cystitis  associated  with  transverse  myelitis  t(j  disturbed  tro- 
phic inlluence. 

The  course  of  coinplot;;  transverse  myelitis  depends  a  good  deal  upon 
it.-*  cause.  Death  may  result  from  extension.  Segments  of  the  cord  may 
be  coniplotcly  and  permanently  destroyed,  in  which  case  there  is  persistent 
paraplegia.  The  pyramidal  iilires  below  the  lesion  undergo  the  secondary 
(lc;{cneration,  and  there  is  an  ascending  degeneration  of  the  posterior  me- 
dian columns.  If  the  lower  segments  of  the  cord,  are  involved  the  logs 
may  remain  flaccid.  In  some  instances  a  transverse  myelitis  of  the  dorsal 
iv'^'um  involves  the  anterior  horns  above  and  below  the  lesion,  producing 
lliiccidity  of  the  muscles,  with  wasting,  fibrillar  contractions,  and  tlio  reac- 
tion of  degeneration.  More  commonly,  however,  in  the  cases  which  last 
many  months  there  is  more  or  less  I'igidity  of  the  muscles  with  spasm  or 
porsistent  contraction  of  the  flexors  of  the  knee. 

(;J)  Transverse  Myelitis  of  the  Cervical  Region. — If  at  the  level  of  the 
sixi'  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upi)cr  extremities, 
mor(^  lY  less  complete,  sometimes  sparing  the  muscles  of  the  slioulder. 
(iradua.ly  there  is  loss  of  sensation.  The  paralysis  is  usually  complete  be- 
low the  point  of  lesion,  but  there  are  rare  instances  in  which  tlie  arms  only 
are  atTccted,  the  so-called  cervical  paraplegia.  In  addition  to  the  symp- 
toms already  mentioned  there  are  several  which  are  more  characteristic  of 
transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of  vomit- 
ing, hiccoxigh,  and  slow  pulse,  which  may  sink  to  twenty  or  thirty,  ])upillary 
changes — myosis — sometimes  attacks  of  dysphagia,  dyspnoea,  or  syncope. 


«■'  tii 


i:^ 


;; 


II.  Myelitis  op  riiE  Axtkuiou  Horns 

{^Polio-viyclitis  Anterior  /  Alroj)hic  Spinal  Paralysis). 

Definition. — An  aiTection  occurring  most  commonly  within  the  first 
three  years  of  life,  characterized  by  fever,  loss  of  power  in  certain  mus- 
cles, and  rapid  atrophy. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  has  been  ut- 
tvil)utcd  to  cold,  to  the  irritation  from  dentition,  or  to  overexertion. 
Since  the  days  of  Mephibosheth,  parents  have  been  inclined  to  attribute 
tliis  form  of  paralysis  to  the  carelessness  of  nurses  in  letting  the  children 
fall,  Init  very  rarely  is  the  disease  induced  by  traumatism,  and  in  perhaps  a 
majority  of  the  cases  the  child  is  attacked  while  in  full  health.  As  Sinkler 
lias  pointed  out,  the  cases  are  more  common  in  the  warm  months.  Boys 
iiro  more  liable  to  bo  affected  than  girls.  Several  instancies  of  the  occur- 
rence of  numerous  cases  together  in  epidemic  form  have  been  described. 
Mcdin  reports  from  Stockholm  an  epidemic  in  which  from  the  9th  of 
August  to  the  23d  of  September  29  cases  came  under  observation.  In  two 
instances  two  children  in  the  same  family  were  attacked  within  a  few  days. 


f  1    J  ;  "  I 
5       1)1 

11 


■  I 


I  i- 

lii 


882 


DISEASES  OP  THE  NERVOS  SYSTEM. 


h  i ' 


Although  most  frequent  in  chihiren,  it  develops  occasionally  in  young 
adults,  or  oven  in  niiddle-agod  persons. 

Morbid  Anatomy. — The  disease  is  oftenest  seen  in  either  the  wr- 
vioal  or  lurnhar  enlargements.  In  very  early  cases,  such  as  those  df- 
sciribed  by  David  Drinnmond  and  Charlewood  I'urner,  the  lesion  has  been 
that  of  an  acute  hajmorrhagic  myelitis  with  degeneration  and  rapid  dc. 
struction  of  the  large  ganglion  cells.  The  condition  nuiy  be  strictly  con- 
fined to  the  anterior  cornua;  in  some  instances  there  is  slight  niciiin^'eal 
involvement.  In  cases  in  which  the  examiiuition  is  not  made  for  soino 
months  or  years  the  changes  are  very  characteristic.  The  anterior  oorini 
in  the  affected  region  is  greatly  atrophied  aiul  the  largo  motor  colls  arc 
either  entirely  absent  or  only  a  few  renuiin.  The  ailected  half  of  the  cord 
may  bo  considerably  smaller  than  the  other.  The  antero-lateral  coliunn 
may  show  slight  sclerotic  changes,  chiefly  in  the  pyramidal  tract.  The 
corresponding  anterior  nerve  roots  are  atrophied,  and  the  muscles  arc 
wasted  and  gradually  undergo  a  fatty  and  sclerotic  change. 

Symptoms. — In  a  majority  of  the  cases,  after  slight  indisposition 
and  feverishness,  the  child  is  noticed  to  have  lost  the  use  of  one  limb. 
Convulsions  at  the  outset  are  rare,  not  constant  as  in  the  acute  ccrchral 
palsies  of  children.  Fever  is  usually  present,  the  temperature  rising  to 
101°,  sometimes  to  103°.  Pain  is  rarely  complained  of;  there  may  oc- 
casionally be  slight  aching  in  the  joints.  The  paralysis  is  abrupt  in 
its  onset  ami,  as  a  rule,  is  not  progressive,  but  reaches  its  maxiiiunn 
in  a  very  short  time,  oven  within  twenty-four  hours.  It  is  ruroly  gen- 
eralized. The  suddenness  of  onset  is  remarkable  and  suggests  a  pri- 
mary affection  of  the  blood-vessels,  a  view  which  the  hajmorrhagic  char- 
acter of  the  early  lesion  supports.  The  distribution  of  the  paralysis  is 
very  variable.  One  or  both  arms  may  be  a+fected,  one  arm  and  one  leg, 
or  both  legs ;  or  it  may  be  crossed  paralysis,  the  right  leg  with  the  left 
arm.  In  the  upper  extremities  the  paralysis  is  raroly  complete  and  groups 
of  muscles  may  be  affected.  As  Remak  has  pointed  out,  there  is  an 
upper-arm  and  a  lower-arm  type  of  palsy.  The  deltoid,  the  bicei)s,  bra- 
chialis  anticus,  and  supinator  longus  may  be  affected  in  the  former,  and 
in  the  latter  the  extensors  or  flexors  of  the  lingers  and  wrists.  This  dis- 
tribution is  due  to  the  fact  that  the  groups  of  nerve-cells  are  attacked 
which  preside  over  certain  muscles  acting  functionally  together. 

In  the  legs  the  tibialis  anticus  and  extensor  groups  of  muscles  are  more 
affected  than  the  hamstrings  and  glutei.  The  muscles  of  the  face  are 
never,  the  sphincters  rarely,  involved.  While  the  rule  is  for  the  paralysis; 
to  be  abrupt  and  sudden,  there  are  cases  in  which  it  comes  on  slowly  and 
takes  from  three  to  five  days  for  its  development.  At  first  the  alTected 
limb  looks  natural,  and  as  children  between  two  and  three  are  usually  fat, 
very  little  change  may  be  noticed  for  some  time ;  but  tlie  atrophy  pro- 
ceeds rapidly,  and  the  limb  becomes  flaccid  and  feels  soft  aiul  ilahliy. 
Usually  jis  early  as  the  end  of  the  first  week  the  reaction  of  degeneration 


ACUTE   AFFECTIONS  OF  THE  SPINAL  COKD. 


S33 


is  present.  The  nerves  aro  found  to  liavo  lost  ilieir  irrilability.  'I'lio 
muscles  do  not  react  to  the  induced  current,  Init  to  the  constant  current 
tlicy  rcsjiond  by  a  .sluggish  contraction,  usually  to  a  weaker  current  than 
is  normal,  and  nujro  to  the  positive  pole  than  to  the  ncgnl  ive.  'I'Ik!  paraly- 
gis  remains  stationary  for  a  tinu),  an  '  theu  tiiero  is  gi-aihial  ini]ir()venient. 
Complete  recovery  is  rare,  and,  when  the  anatomical  condition  is  consid- 
ered, is  scarcely  to  be  exjjected.  The  large  motor  cells  of  the  cornua, 
wlien  thoroughly  disintegrated,  ciiniiot  be  restored.  In  too  many  cases 
the  iinprov^'uient  is  only  slight  iiml  permanent  pandy.-is  remains  in  cvr- 
tain  grou2)s.  Sensation  is  unaireeted;  the  skin  rellexes  are  absent,  and 
the  deep  reflexes  are  usually  lost. 

When  the  paralysis  persists  the  wasting  is  extreme,  tlie  growth  of  the 
bones  of  the  aifected  limb  is  arrested,  or  at  any  rate  retarded,  ami  the 
joints  may  be  very  relaxed ;  as,  for  instaiuie,  when  the  deltoid  is  afTectcd 
the  head  of  the  humerus  is  no  longer  kept  in  contact  Avith  the  glenoid 
cavity.  In  the  later  stages  very  serious  deformities  are  produced  by  the 
contracture  of  the  muscles. 

Diagnosis. — The  condition  is  only  too  evident  in  the  majority  of 
cases.  There  is  a  flaccid,  flabby  paralysis  of  one  or  more  limbs  which  has 
set  in  abruptly.  The  rapid  wasting,  the  lax  state  of  the  muscles,  the 
electrical  reactions,  and  the  absence  of  reflexes  distinguish  it  from  the 
cerebral  palsies.  The  pseudo-i^aresis  of  rickets  is  a  eoiulition  to  be  care- 
fully distinguished.  In  this  the  loss  of  power  is  in  the  legs,  rapid  atrophy 
is  not  present,  certain  movements  are  possible  but  painful.  The  general 
hyperaisthesia  of  the  skin,  the  characteristic  changes  in  the  bones,  and  the 
diffuse  sweats  arc  present.  Disease  of  the  hip  or  knee  may  produce  u 
pseudo-])aralysis  which  can  with  care  be  readily  distinguished. 

Prognosis.— The  outlook  in  any  case  for  coni{)leto  recovery  is  bad. 
The  natural  course  of  the  disease  must  be  borne  in  mind ;  the  sudden 
onset,  the  rapid  but  not  progressive  loss  of  power,  a  stationary  period,  then 
marked  improvement  in  certain  muscle  groups,  and  Anally  in  many  cases 
contractures  and  deformities.  There  is  no  other  disease  in  whi(.'h  the 
physician  is  so  often  subject  to  unjust  criticism,  and  the  friends  should  be 
tokl  at  the  outset  that  in  the  severe  and  extensive  ])ara1ysis  complete 
recovery  should  not  bo  expected.  The  best  to  be  hoped  for  is  a  gradual 
restoration  of  power  in  certain  muscle  groups.  In  estimating  the  probable 
grade  of  permanent  paralysis,  the  electrical  examination  is  of  great  value. 

Treatment  of  Acute  Myelitis.— In  the  rapidly  developing  form 
•luo  either  to  a  dilTuse  inflammation  in  the  gray  matter  or  to  transverse 
myelitis,  the  important  measures  are :  Scrupulous  cleanliness,  care  and 
watchfulness  in  guarding  against  bed-sores,  the  avoidance  of  cystitis,  either 
by  systematic  catheterization  or,  if  there  is  incontinence,  by  a  carefully 
adjusted  bed  urinal,  or  the  use  of  antiseptic  cotton -wool  repeatedly 
changed.  In  an  acute  onset  in  a  healthy  subject  the  spine  may  be  cupped. 
Counter-irritation  is  of  doubtful  advantage.     Chapman's  ice-bag  is  some- 


w 


m  I 


!■.: 


m 


i„:lL 


m'  V 


I  M 


M'5 


H 


1:     1 


831 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


times  useful.  No  drugs  Imvc  tlio  nlifflitcst  itiflucnco  upon  an  ncuto  niydititi, 
uud  cvou  in  subjects  with  well-marked  sypliilis  neitlier  niercMiry  nor  iddid,. 
of  potassium  is  curative.  Tonic  remedies,  such  as  quinine,  arsenic,  arid 
strychnia,  may  be  used  in  the  later  stages.  Wiien  the  niuscdes  have  wasud, 
nuissago  is  bonoficial  in  maintaining  their  nutrition.  Electricity  sliould 
m)t  be  used  in  the  early  stages  of  juyelitis.  It  is  of  no  value  in  the  trans- 
verse m>(ditis  in  the  dorsal  region  with  retention  of  the  nutrition  in  the 
nmscles  of  the  leg. 

The  treatment  of  acute  infantile  i)aralysis  has  a  bright  and  a  dark  side. 
In  a  case  of  any  extent  completo  recovery  cannot  bo  expected  ;  on  the 
other  hand,  it  is  remarkable  how  much  improvement  may  finally  take 
l)Iace  in  a  limb  which  is  at  first  comidetely  llaccid  and  helpless.  'J'lie  fol- 
lowing treatmciut  may  be  pursued  :  If  seen  in  the  febrile  stage,  a  brisk 
laxative  and  a  fover  mixture  may  bo  given.  The  child  should  be  in  bed 
and  the  alfected  limb  or  limbs  wrapped  in  cotton.  As  in  the  great  majority 
of  cases  the  damage  is  already  done  when  the  physician  is  called  and  the 
disease  makes  no  further  progress,  the  application  of  blisters  and  oIIkt 
forms  of  counter-irritation  to  the  back  is  irratioiud  and  only  cruel  to  the 
child. 

The  general  nutrition  should  be  carefully  maintained  by  feeding  the 
child  well,  ami  taking  it  out  of  doors  every  day.  As  so(m  as  the  chiUl  can  bear 
friction  the  afi'ec^ted  part  should  be  carefully  rubbed;  at  first  once  a  day, 
bsequently  morning  and  evening.  Any  intelligent  mother  can  be  taught 
■tematically  to  rub,  knead,  and  pinch  the  muscles,  using  either  the  bare 
nand  or,  better  still,  sweet  oil  or  cod-liver  oil.  This  is  worth  all  the  other 
nieasures  advised  in  the  disease,  and  should  be  systematically  practised  for 
months,  or  even,  if  necessary,  a  year  or  more.  Electricity  has  a  nnich 
more  limited  use,  and  cannot  be  compared  with  massage  in  maintaininj; 
the  nutrition  of  the  muscles.  The  faradic  current  should  be  aj)plied  to 
those  muscles  which  respond.  The  essence  of  the  treatment  is  in  iiiaiii- 
tiiining  the  nutrition  of  the  muscles,  so  that  in  the  gradual  imiirovciiieiit 
which  takes  place  in  parts,  at  least,  of  the  affected  segments  of  the  cord 
the  motor  impulses  may  have  to  deal  with  well-nourished,  not  atrophied 
muscle  fibres. 

Of  medicines,  in  the  early  stage  ergot  and  belladonna  have  been 
warmly  recommended,  but  it  is  unlikely  that  they  have  the  slightest 
influence.  Later  in  the  disease  stfychnia  may  be  used  with  advantage  in 
one  or  two  minim  doses  of  the  liquor  strychniua?,  which,  if  it  has  no  other 
effect,  is  a  useful  tonic. 

The  most  distressing  cases  are  those  which  come  under  the  notiiie  of 
the  physician  six,  eight,  or  twelve  months  after  the  onset  of  the  paralysis, 
when  one  leg  or  one  arm  or  both  legs  are  flaccid  and  have  little  or  no 
motion.  Can  nothing  be  done?  A  careful  electrical  test  should  be  made 
to  ascertain  which  muscles  respond.  This  may  not  be  apparent  at  lust, 
and  several  applications  may  be   necessary   before  any  contractility  is 


ACUTE  AFFKCTIOXS  OF  THE  SPINAL  CORD. 


835 


jiii'.iccd.  With  ii  few  lessons  an  iiitclli^oiit  iiiotluT  ciui  he  tiiu^'lil  tn  iiso 
the  electricity  as  well  as  to  apply  the  inassa<,'c.  if  in  a  case  in  wliich  the 
IKiialysis  has  lasted  for  six  or  ei^'iit  months  no  ohservahle  iiuprovenient 
taki's  ])laee  in  the  next  six  months  with  thorou;(h  and  systematic  treat- 
iiiriit,  little  or  no  ho^ie  can  be  entertained  ol'  furtlu'r  ciiancc. 

In  till'  later  sta<j;u  care  shonid  be  taken  to  prevent  the  (h'i'onnities 
n>ultini^  from  the  contractions.  (Jreat  benefit  results  from  a  carernlly 
apiilied  ai»])aratus. 

III.   Act  TK  AM)  SL'HAC'L'TK   Polio-m  yklitis   in    Al)li;rs. 

An  acnto  imlio-myolitis  in  adults,  the  exact  counterpart  of  the  disease 
ill  children,  i.s  recognized.  A  majority,  liowevcr,  of  the  cases  described 
tiiiih'r  this  heading  have  been  nuilti[)le  neuritis;  but  the  suddenness  of 
onset,  the  raj'id  wasting,  and  the  marked  reaction  of  degeneration  are 
tlioiight  by  some  to  be  distinguishing  features.  ,Multii)le  neuritis  may, 
lidwever,  set  in  with  rapidity;  tliere  may  be  great  wasting  and  the  reaction 
(if  degeneration  is  sometimes  jiresent.  The  time  element  alone  may  deter- 
mine the  true  nature.  IJecovery  in  a  case  of  extensive  multiple  })aralysi8 
fmiii  ])olio-myelitis  will  certainly  be  with  loss  of  power  in  certain  groups 
of  muscles;  whereas,  in  multiple  neuritis  the  recovery,  while  slow,  may 
be  jierfeot. 

The  subacute  form,  the  parrfli/nie  yenernle  spinale  anterionre  sii/jnif/uii 
of  Duchenne,  is  ir.  all  probability  a  periidieral  ])alsy.  The  paralysis  usually 
lii'jrins  in  the  legs  with  atrophy  of  the  muscles,  then  the  arms  are  involved, 
Imt  not  the  face.     Sensation  is,  as  a  rule,  not  involved. 

IV.  Ac'iTK  AscEXDiNG  (Landry'.s)  Paualysis. 

Definition. — An  advancing  paralysis,  beginning  in  the  legs,  rapidly 
extending  to  the  trunk  and  arms,  and  finally,  in  many  cases,  involving  the 
muscles  of  respiration.  It  ])resents  a  remarkable  similarity  in  its  symp- 
toms to  certain  cases  of  polyneuritis,  with  vvjiich  it  is  now  grouped  by 
many  writers. 

Etiology  and  Pathology. — 'i'ho  disease  occurs  most  commonly  in 
males  between  the  twentieth  and  thirtieth  years.  It  has  sometimes  fol- 
lowed the  specific  fevers.  An  elaborate  study  of  93  cases  collected  from 
tile  literature  has  been  nuule  by  James  Ross,  who  concludes  that  in  etiol- 
osry,  symptoms,  course,  and  termination  it  conforms  to  a  peri})heral  neu- 
ritis. Neuwerk  and  Barth  luive  reached  a  similar  conclusion.  In  their 
lase  an  interstitial  neuritis  was  found  in  the  nerve  roots,  but  the  peripheral 
nerves  were  normal.  On  the  other  hand,  (!ases  have  been  reported  of 
rapidly  ascending  paralysis  in  which  the  periphral  nervc;J  and  nerve  roots 
Were  unaffected.  In  a  case  of  eleven  days'  duration  recently  studied  by 
Hmi,  the  lesions  were  certainly  too  slight  to  account  for  the  advancing 
ami  wide-spread  paralysis,  and,  with  our  present  knowledge,  Ilun  is  cor- 
53 


h\] 


'  ^  ^ 


^^ 


1  ' 

I  ■ 

I.. 


I    I 


si  " 


i'' 


i  * ' 


836 


DISKASKS  OP  THE  NEliVOUS  SV.STKM. 


rc'ft  in  stjitinsr  tluit  "iiciito  ascending  paralysis — (U-lincd  so  as  to  exclude 
all  cases  in  wliieli  the  sensory  sytniit(»nis  are  [)r()minent,  or  in  wliicli  wdl- 
niarked  liulbar  symptoins  are  not  preHont — iinist  therefore  he  rej^anliMl  ^ 
a  clinical  entity  for  which  no  corrcspondinj,'  lesion  has  as  yet  been  disiov- 
ercd."  It  is  not  iinprohalilc  that  some  toxic  a<,'ont  is  respcjiisible  for  tlic 
syniptoins. 

Symptoms.  Weak  I I'ss  of  the  left's,  gradually  j)rogre8sin<r,  dftin 
with  tolerable  ra[)idity,  's  ihe  (irst  symptom.  In  some  eases  within  a  few 
hours  the  paralysis  of  the  legs  becomes  complete.  The  muscles  of  tliu 
trunk  are  next  all'ected,  and  within  a  few  days,  or  even  less  in  more  aciitc 
cases,  the  arms  are  nho  involved.  The  neck  muscdes  are  next  attaikcil, 
and  finally  the  mu.u-les  (ji  respiration,  deglutition,  and  articulation.  The 
reflexes  are  lost,  but  the  muscles  neither  waste  nor  show  electrical  cli!iii;.'(s, 
The  sensory  symptoms  are  variable  ;  in  some  cases  tingling,  Tium])iu'ss,  and 
hyj)era'sthesia  have  been  present.  In  the  more  chara<'teristic  cases  sensa- 
tion is  intact  and  the  sphincters  are  uninvolved.  Enlargement  of  tin 
spleen  has  been  iu)ticed  in  several  eases.  The  course  of  the  disease  is 
variable.  It  may  prove  fatal  in  less  than  two  days.  Other  cases  persist 
for  a  week  or  for  two  wee'  .  In  some  instances  recovery  has  occurred,  lait 
in  a  large  proportion  of  tin-  cases  the  disease  is  fatal. 

The  didi/iiiisis  is  dill. cult,  ])articularly  from  certain  forms  of  iniilti[ilc 
neuritis,  and  if  we  include  in  Landry's  ])aralysis  the  cases  in  which  sensa- 
tion is  involved,  distinction  between  the  tw(.  alTections  is  im]iossible.  W'v 
apparently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor 
paralysis  without  involvement  of  the  sphincters,  Avithout  wasting  or  elec- 
trical chan'^es  in  the  muscles,  without  trophic  lesions,  and  without  fever- 
features  suflicient  to  distinguish  it  from  either  the  acute  central  inviditis 
or  the  polio-myelitis  anterior.  It  is  doubtful,  however,  whetiier  tliise 
characters  always  sutHce  to  enable  us  to  differentiate  the  cases  of  multijilt' 
neuritis. 


IV.    CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


»!«itf  *■-, 


I.  Spastic  Pauaplegia. 

Definition. — Loss  of  power  with  spasm  of  the  muscles  of  the  lower 
extremities. 

While  clinically  spastic  paraplegia,  or,  as  it  is  sometimes  called.  /"/"■•-■ 
dorsalis  spasmodique,  is  a  Avell-defined,  readily  recognizable  affection,  cii"- 
logically  iuid  anatomically  it  presents  marked  differences,  and  vurio:,s 
groups  must  be  separated,  all  of  which  present,  hoAvever,  the  combinaii 'ii 
of  spasm  Avith  loss  of  })ower.  As  the  pyramidal  tracts  are  involvci'  the 
term  lateral  sclerosis  is  sometimes  used  as  the  equiAalent  of  spastic  jiara- 
plegia.     I  shall  consider  the  folloAving  forms  : 


nillONIC   AFFKC'TIONS  OF  THK  SPINAL  COUI). 


837 


iicl\  wi'U- 
ijarili'tl  as 
•  u  (liscov- 
ilf  fur  the 

11!^,  iifini 
ll\in  a  tVw 
;U"S  "f  tlu' 

UOIT  lU'UtC 

,  ultarki'il, 
tion.  The 
ill  t'liiiiii:*'^. 
tilmi'ss,  ami 

■asi'S  scnsa- 

icut  '■!'  'ti*' 
0  ilisoiist'  is 

c'cwnvtljitit 

of  iiiultiiiV 
svliicli  scnsii- 
i>ssil)U'.     ^V(• 
nciuj,'  motor 
itinfi  IT  oleo- 
loul  t'l'vcr— 
tnil  myelitis 
\wihvr  tlR'st' 
(,[  multiiilt' 


CORD. 


|of    tlu'  ll'WL't 

jCiilU'il.  /"'"■'"• 
ITcH-tion.fiiii- 
laiul    viiviov.s 

Ifombii':'''"'" 

Involve-'   ili^' 

spariti<'  I'avu- 


(l)  Secondaxy  Spastic  Paralysis.    A rit-r  any  tianvcrsc  K-sinn  (,r  tlic 

(•(H'd,  wlu'tlicr  tlio  result  of  slow  t'oniprcssioii  (as  in  carii's),  cliroiiic  myi'- 
liiis  tlio  prissHure  of  tumor, clironic  incniiifjo-iiiyi'litis, (n-  multiple  seleinsis, 
(leu^eneratidii  takes  place  in  the  pyramidal  tracts  Itclnw  llie  point  uf  ilis- 
ca.M'.  The  lens  soon  hecomi' stilY  and  ri^itl,  and  t lie  rcllexes  increase.  It 
happens  occasionally,  as  Mastian  lias  shown,  that  in  compression  piua- 
|iliLria  the  limbs  imiy  bu  lluecid  without  increase  in  the  reflexes — /ii(ni/)lt'i/ir 
jhisijno  of  the  French.  'J'lie  condition  of  the  fiaticnt  in  these  secondary 
I'driiis  varii's  very  much.  In  chronic  myelitis  or  in  multiple  xderosis  he 
may  he  able  to  walk  about,  but  with  a  characteristic  spastic  <;ail.  In  the 
njinpression  myelitis,  in  fracture,  or  in  caries,  there  may  be  comitletc  loss 
(if  power  with  rifjjidity. 

(•i)  Primary  Spastic  Paraplegia.— 'i'his  is  believed  to  depend  upon  a 
jiriniary  sclerosis  of  the  lateral  or  pyramidal  tru  •' -.  Clinically  it  is  i-om- 
iiKiu  to  meet  with  eases  in  adults,  particularly  in  ^\;  bilitic  sulijects,  who 
have  j)aiiis  in  the  back,  porlmps  a  girdle  sensatic.n,  jitul  a  jjradually  devel- 
iiimijf,  ])r()j,M'essive  spastic  jiaraplej^aa.  It  nwiy  be  impossible  from  the 
hi-lory  or  the  physical  examiiuition  to  delei.niiu^  whether  tlu-  condition 
is  secondary  to  a  transverse  myelitis  or  a  meiiinjfo-myclitis,  or  whether  the 
ksio.i  i-  li  primary  degeneration  of  the  ])yrami(lal  tracts.  The  (piestion  is 
slill  ilehated  whether  a  prinuiry  lesion  of  the  lateral  tracts  ever  takes  place, 
or  whether,  in  such  instances,  there  is  not  always  som(!  lesion  of  the  motor 
(rlls  in  the  anterior  horns.  Cases  may  p'^'rsist  for  years  without  any 
atrophy.  In  other  instances  there  are  signs  of  involvement  of  the  posterior 
columns  as  well,  forming  the  condition  of  ataxic  jiaraplegia,  which  will 
bi'  considered  separately.  So  far  as  I  know,  the  only  case  which  is  claimed 
tiMJemonstrate  the  existence  of  a  prinuiry  lateral  sclerosis  is  that  of  Dresch- 
IVhl's,  whicli  occurred  in  1881. 

The  symptoms  of  spastic  paraplegia  are  very  distitictive.  The  i)atient 
riiiuplainsof  feeling  tired,  of  stillness  in  the  legs,  and  perhaps  of  i)ains  of  a 
(lull  aching  character  in  the  back  or  in  the  calves.  'JMiere  may  be  no  detl- 
iiite  loss  of  power,  oven  when  the  spastic  condition  is  well  established.  In 
other  instances  there  is  detinite  ■weakness.  The  stitTness  is  felt  most  in 
the  morning.  In  a  well-developed  case  the  gait  is  most  characteristic. 
riie  legs  are  moved  stiffly  and  with  hesitation,  the  toes  drag  and  catch 
:ii,Miiist  the  gronnd,  and,  in  extreme  cases,  when  the  hall  of  the  foot  rests 
upon  the  ground  a  distinct  clonus  develops.  The  legs  are  ke])t  close 
together,  the  knees  toncu,  and  in  certain  cases  the  adductor  spasm  may 
laiise  cross-legged  progression.  On  examination,  the  legs  nuiy  at  first 
iilipear  tolerably  supple,  perhaps  flexed  and  extemled  readily.  In  other 
eases  the  rigidity  is  marked,  jiarticularly  when  the  limbs  are  extended. 
The  spasm  of  the  adductors  of  the  thigh  may  be  so  extreme  that  the 
lf,i,'s  are  separated  with  the  greatest  difficulty.  In  cases  of  this  extreme 
lijiidity  the  patient  usually  loses  the  powder  of  walking.  The  nutrition  is 
tcU  maintained,  the  muscles  may  be  hypertrophied.  The  reflexes  are  greatly 


li    ? 


I 


\  '^ 


.4'.! 


I- 1 


838 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


increased.  The  slightest  touch  upon  the  patellar  tendon  prodnces  an  active 
knee-ierk.  The  rectus  clonus  and  the  ankle  clonus  are  easily  obtaiiuil. 
In  s(»ine  instances  the  slightest  touch  may  throw  the  logs  into  vidlcut 
clonic  si)asni,  the  condition  to  which  Brown-Sequard  gave  the  name  ni 
spinal  ei)ile])sy.  The  superficial  reflexes  are  also  increased.  The  uriiis 
may  be  uiuilTocted  for  years,  but  as  a  late  manifestation  rigidity  mav 
develop. 

The  dinffHOsis  is  readily  made,  but  it  is  often  very  difficult  to  detcrmino 
accurately  the  nature  of  the  underlying  pathological  condition.  A  histi'i y 
of  syphilis  is  present  in  many  of  the  cases.  The  course  of  the  disease  is 
progressively  downward.  Years  may  elapse  before  the  patient  is  licd- 
ridden.  Involvement  of  tlie  spliinctcrs,  as  a  rule,  is  late;  occasionally, 
however,  it  is  early.  Tlie  sensory  symptoms  rarely  progress  and  the 
patients  may  retain  the  general  nutrition  and  enjoy  excellent  heallli. 
Ocular  symptoms  are  rare. 

(3)  The  Spastic  Paraplegia  of  Infants  {Paraplegia  CerehraJis  Spasfim 
— Heine). — This  is  usually  a  birth  palsy,  often  the  result  of  difficult  labor. 
In  twenty-three  of  the  twenty-four  of  Little's  cases,  there  was  cither  ditli- 
cult  labor  or  premature  delivery.  Several  children  may  be  affected  in  a 
family.  Gee  report>(  two  cases  in  one  family,  Schultze  three,  and  Avith 
Latimer  I  saw  a  brotlier  and  a  sister  with  the  disease.  In  this  connection 
it  is  interesting  to  note  that  Bernhardt  has  recently  described  a  fauiily 
form  of  spastic  paraplegia,  in  which  four  brotliers  were  affected,  the  dis- 
ease developing  in  each  about  the  thirtieth  year.  The  stiffness  of  tliu 
legs  may  not  be  noticed  for  some  months  after  birth,  but  usually  on  dress- 
ing the  child  the  mother  notices  the  rigidity.  When  attempts  are  made 
to  walk  the  stiffness  and  awkwardness  then  become  apparent.  On  stand- 
ing, the  attitude  is  very  characteristic.  There  is  talipes  equinus,  varyiiitr 
from  the  slightest  raising  of  the  heel  to  a  condition  in  which  the  (liild 
stands  on  tiptoe.  In  older  children,  as  they  walk,  the  toe-cap  of  the  shoe 
is  usually  much  worn.  The  strong  adductor  action  may  produce  typical 
cross-legged  progression,  in  which  each  foot  is  dragged  over  and  planted 
in  front,  or  even  on  the  other  side  of  its  fellow.  In  attempting  to  flex 
the  legs  there  is  a  marked  resistajice,  which  gradually  yields — the  lead- 
pipe  contraction,  as  Weir  Mitchell  calls  it.  The  reflexes  are  increasfd. 
though  in  some  children  it  is  not  an  easy  matter  to  obtain  them.  Tlie 
ankle  clonus,  as  a  rule,  is  not  obtainable.  Sensation  is  unimjiaired,  ami 
the  bladder  and  rectum  are  not  involved. 

The  symptoms  of  this  affection  in  children  are  almost  identical  with 
the  spastic  paraplegia  of  adults.  The  arms  may  be  involved— spastie 
diplegia.  The  disease  is  probably  of  cortical  origin.  There  are  frequently 
symptoms  indicating  cerebral  defects,  such  as  idiocy,  imbecility,  and 
nystagmus.  Some  of  the  cases  dejiend,  no  doubt,  upon  bilateral  meniniroal 
haemorrhage  occurring  during  delivery.  Others  are  probably  due  to  arnst 
of  development  of  the  pyramidal  tracts.     This  condition  in  children  iniist 


CURONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


839 


iKit  be  confounded  with  tetany  or  with  the  pseudo-paralytic  rigidity  so 
often  associated  with  rickets. 

(•1)  Ataxic  Paraplegia. — This  name  is  applied  by  CJowcrs  to  a  disease 
cliaractterizcd  clinicully  by  a  combination  of  ataxia  and  spastic  paraplegia, 
iui'l  anatomically  by  involvement  of  the  posterior  and  lateral  columns. 

The  disease  is  most  common  in  middle-aged  males.  Exposure  to  cold 
and  traumatism  have  been  occasional  antecedents.  In  striking  contrast 
to  (irdinury  tabes  a  history  of  syphilis  is  rarely  to  be  obtained. 

The  anatomical  features  are  a  sclerosis  of  the  posterior  columns,  which 
is  not  more  marked  in  the  lumbar  region  and  not  specially  localized  in 
the  root  zone  of  the  postero-external  columns.  I'lie  involvement  of  the 
lateral  columns  is  diffuse,  not  always  limited  to  the  pyramidal  tracts,  and 
there  may  be  an  annular  sclerosis. 

The  symptoms  are  well  defined.  The  patient  complains  of  a  tired 
feeling  in  the  legs,  not  often  of  actual  pain.  The  sensory  symptoms  of 
true  tabes  are  absent.  An  unsteadiness  in  the  gait  gradually  develops 
with  progressive  weakness.  The  reflexes  are  increased  from  the  outset, 
and  there  may  be  well-developed  ankle  clonus,  lligidity  of  the  legs 
shnvly  comes  on,  but  is  rarely  so  nuirkcd  as  in  tlie  uncomplicated  cases 
of  lateral  sclerosis.  From  the  start,  incoordination  is  a  well-characterized 
feature,  id  the  difficulty  of  "valking  in  the  dark  or  swaying  when  tlie 
eyes  are  closed  may,  as  in  true  tabes,  be  the  first  symptom  to  attract  atten- 
tion. In  walking  the  patient  uses  a  stick,  keeps  the  eyes  fixed  on  the 
ground,  the  legs  far  apart,  but  the  stami)ing  gait,  Avith  elevation  and  sud- 
den descent  of  the  feet,  is  not  often  seen.  The  incoordination  may  extend 
to  the  arms.  Sensory  symptoms  are  rare,  but  (Jowers  calls  attention  to  a 
(lull,  aching  pahi  in  the  sacral  region.  The  sphincters  usually  become 
involved.  Eye  symptoms  are  rare.  Late  in  the  disease  mental  symptoms 
may  develop,  similar  to  those  of  general  paresis. 

In  well-marked  cases  the  diar/nosis  is  easy.  The  combination  of 
marked  incoordination  with  retention  of  the  rellexes  and  more  or  less 
spasm  are  characteristic  features.  The  absence  of  ocular  and  sensory 
symptoms  is  an  important  })oint. 

(5)  Hysterical  Spastic  Paraplegia.— T?  :  is  no  sjiinal-cord  disease 
wliieh  may  be  so  accurately  mimicked  by  iiysterical  ])atients  as  spastic 
paraplegia.  There  is  wasting  in  the  hysterical  paraplegia,  tlie  sensory 
symptoms  are  not  marked,  the  loss  of  power  is  not  complete,  and  thf^re  is 
not  that  extensor  spasm  so  characteristic  of  organic  disease.  The  hyster- 
ical contracture  will  be  considered  later. 

The  reflexes  are,  as  a  rule,  increased.  The  knee-jerk  is  present,  and 
there  may  be  well-developed  ankle  clonus.  Cowers  calls  attention  to  the 
fact  i,hat  it  is  usually  a  spurious  clonus,  "  due  to  a  half-voluntary  contrac- 
tion in  the  calf  muscles."  A  true  clonus  does  occur,  however,  and  there 
may  be  the  greatest  difficulty  in  determining  whether  or  not  the  case  is 
oue  of  hysterical  paraplegia. 


^   K-.-l 


llLi 


840 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


(6)  Primary  Combined  Sclerosis  (Putnam).— In  addition  to  the  ataxic 
piinipk'giii  just  mentioiiod,  liere  may  be  coii.sidered  certain  cases  which  are 
characterized  anatomically  by  a  relatively  clironic  .sclerosi?  of  the  posterior 
columns,  of  the  lateral  columns,  cliiefly  the  pyran-idal  tract,  and  also  of 
the  cerebellar  tract.  With  these  are  usually  a.-ir>of.-iated  more  acute  cluiii<r(.>s 
in  adjoining  areas,  either  diffuse  or  systemic,  sfjme  grade  of  degeneration 
in  the  gray  matter,  and  involvement  of  the  ner^'c  roots.  This  form  has 
been  studied  by  J.  J.  Putnam  and  Dana.  The  case.s  are  usually  in  woimn 
— seven  out  of  nineteen  collected  by  Dana ;  the  ages,  from  forty-five  to 
sixty-four.  The  disease  runs  a  rather  ni[>id  course.  Neuropathic  inherit- 
ance is  present  in  some  instances.  Putnam  thinks  that  possibly  both  lead 
and  arsenic  play  a  part  in  the  etiolo;/y. 

The  s}/»ipfoms  are  both  sensory  and  motor.  The  onset  is  usually  with 
numbness  in  the  extremities,  progressive  loss  of  strength,  and  emaciation. 
Paraplegia  gradually  develops,  before  which  there  have  been,  as  a  rule, 
spastic  symptoms  with  exaggerated  knee-jerk.  The  arms  are  affecto(i  iiss 
than  the  legs.  Mental  symptoms  similar  to  dementia  paralytica  ma}-  de- 
velop toward  the  close. 

The  diaynosis  of  this  mixed  sclerosi.s  rests  upon  the  combination  of 
sensory  and  motor  symptoms  with  the  presence  of  exaggerated  reilexts. 
As  stated,  the  sensory  features  consisi.  chi^-fly  of  para?sthesia,  and  there 
may  be  difficulty  in  distinguishing  the  condition  from  multiple  neuritis. 
The  frequency  of  the  disease  in  more  or  less  enfeebled  or  anaemic  women 
past  middle  life  is  also  an  important  feature. 

Treatment  of  Spastic  Farapl^ria. — In  the  majority  of  cases  spas- 
tic paraplegia  is  incurable.  The  cases  which  result  frojn  transitory  com- 
pression, as  in  caries,  may  get  well ;  but  in  the  other  forms  the  disease  is 
uniformly  progressive,  and  remedies  have  little  or  no  control.  When 
syphilis  is  suspected  a  thorough  course  of  mercnrv'and  iodide  of  potassium 
should  be  given.  Scrupulous  attention  should  be  paid  to  the  bladder 
symptoms,  and  the  same  measures  may  Ikj  used  as  will  be  advised  in  loco- 
motor ataxia.  In  the  infantile  form  of  paraplegia  much  may  be  done  hy 
the  orthopaedic  surgeon  to  overcome  rigidity  and  contracture.  In  several 
instances  I  have  known  persistent  friction  with  forcible  flexion  and  exti^n- 
sion  and  the  application  of  proper  apparatus  enable  a  patient  to  get  about 
comfortably. 

II.  Locomotor  Ataxia 

( Tabes  Dorsalis  ;  Posterior  Spinal  Sclerosis). 

Deflnition. — An  affection  of  the  nervou.s  system  characterized  <  liu- 
ically  by  incoordination,  with  sensory  and  trophic  disturbances  and  in- 
volvement of  the  special  senses,  particularly  the  eyes.  Anatomically  there 
are  found  sclerosis  of  the  posterior  columns  of  the  cord,  foci  of  degenera- 
tion in  the  basal  ganglia,  and  sometimes  chronic  degenerative  changes  in 
the  cortex  cerebri. 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


841 


Etiology. — It  is  a  wid  >spread  disease,  more  frequent  in  cities  tluin  in 
tlio  country.  The  relative  projiortion  may  be  judged  from  the  fact  tliat 
of  1,H1(;  cases  in  n  y  neun^logicul  dispensary  in  two  years  there  were  25 
casL'S  of  locomotor  ataxia.  Males  are  attacked  more  frequently  than  fe- 
males, the  proportion  being  at  least  ten  to  one.  Mitchell  has  called  at- 
triition  to  the  fact  that  it  is  a  rare  disease  in  the  negro.  Of  25  cases  at 
my  clinic,  3  were  in  negroes.  It  is  a  disease  of  adult  life,  a  majority  of 
the  cases  occurring  between  the  thirtieth  and  fortieth  years.  Occasionally 
(■uses  are  seen  in  young  men.  The  form  of  ataxia  which  occurs  in  chil- 
(hen  is  a  different  disease.  Of  special  causes  syphilis  is  the  most  inijxir- 
tuut.  According  to  the  figures  of  Erb,  Fournier,  and  Gowers,  in  from  fifty 
to  seventy-iive  per  cent  of  all  cases  there  is  a  histo'y  of  this  disease.  Erb's 
rirent  figures  are  most  striking;  of  300  cases  of  tabes  in  ])rivate  practice 
8'J  ])er  cent  had  had  .syphilis. 

Exce.s.sive  fatigue,  overexertion,  exposure  to  cold  and  wet,  and  sexual 
excesses  are  all  assigned  as  causes.  There  are  instances  in  which  the  dis- 
ease has  c-lost'ly  followed  severe  exposure.  James  iStewart  has  noted  that 
tlie  Ottawa  lumbermen,  Avho  live  a  very  hard  life  in  the  camj)s  during  the 
Aviiiter  months,  are  frequently  the  subjects  of  locomotor  ataxia.  Trauma 
has  been  ncjted  in  a  few  cases.  Alcoholic  excess  does  not  seem  to  ])redis- 
pose  to  the  disca.se.  Among  ])atients  in  the  better  classes  (if  life  I  (^o  not 
ri'inember  one  in  which  there  had  been  a  previous  history  (jf  i^i'o onged 
(himkenness. 

Morbid  Anatomy'. — When  a  patient  has  died  in  the  advanced  stage 
of  tlie  disea.se  the  following  are  the  moi3f  important  changes: 

i/i)  The  perii)heral  nerves  may  show  signs  of  degeneration.  Xeuritis 
may  indeed  be  present  even  when  there  have  been  no  special  symjitoms 
iiidieating  it.  In  other  instances  there  is  not  only  neuritis,  but  muscular 
atrophy. 

{!>)  Tl'.e  posterior  roots  of  the  spinal  cord  are  small,  gray,  and  atro- 
l»liic. 

{(■)  The  meninges  of  the  posterior  and  lateral  columns  are  thickened, 
more  firmly  adheri  nt  than  normally,  and  the  blood-vessels  usually  show 
signs  of  arterio-selerosis. 

{d)  The  changes  in  the  spinal  cord  are  as  follows:  (1)  In  advanced 
cases  the  posterior  columns  are  uniforndy  sclerotic  and  the  dorsal  and 
l'uid)ar  regions  are  most  extensively  involved.  In  long-standing  cases 
tlicre  is  generally  an  increase  of  connective  tissue  throughout  the  <'ord  and 
there  may  be  degeneratitm  (2)  of  the  ascending  antero-lateral  tract;  (3) 
of  the  direct  cerebellar  tract;  (4)  of  the  pyramidal  tract. 

{(')  In  early  ca.ses  the  course  of  the  anatomical  changes  may  be  traced. 
The  fcteps  in  the  process  are  as  follows :  The  posterior  root-zone  of  Char- 
cot is  first  involved,  often  with  the  fibres  of  the  posterior  root,  so  that  it 
liiis  1)een  tliouglit  to  begin  perhaps  as  a  neuritis  of  these  roots  within  the 
Vertebral  canal.     The  narrow  strip  which  lies  between  the  pyramidal  tract 


i'ti     ' 
pi  ''^^     " 


1  ^ 


842 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


m- 


I  'I 


aiul  the  postorior  cornu,  known  as  Lissaucr's  tract,  is  early  involved,  to- 
gether with  the  nerve-cells  of  the  adjacent  Clarke's  vesicular  column,  iii 
what  is  known  as  the  pre-ataxic  stage  these  may  be  the  only  altor.uions. 
Subsequently  the  sclerosis  extends  widely  in  the  postero-external,  and 
subsequently  in  the  postero -median  columns. 

(/)  The  cerebral  changes — of  less  consequence  than  the  spinal — inav 
consist  of  (1)  sclerosis  in  the  restiform  bodies,  in  the  iuferior  peduiiclw 
of  the  cerebellum,  and  of  certain  of  the  cranial  nerves,  i)articularly  tlio 
third,  the  optic,  and.  the  auditory ;  (2)  cortical  changes,  consisting  in  soiiio 
cases  of  a  diffuse  meningo-encephalitis. 

Symptoms. — These  are  best  considered  under  the  three  stages  of  inv- 
ataxic,  ataxic,  and  paralytic. 

Pre-ataxic  Stage. — The  following  arc  the  most  characteristic  features 
ol  this  period : 

.P((i)is,  usually  of  a  sharp  stabbing  character;  hence  the  term,  li,i,'lit- 
ning  pains.  They  last  for  only  a  second  or  two  and  are  most  common  in 
the  legs.  They  may  be  associated  with  a  hot,  burning  feeling.  Occa^;ion- 
ally  herpes  may  develop  at  the  site  of  the  pain.  They  may  occur  at  irregu- 
lar intervals,  and  arc  more  prone  to  follow  excesses  or  to  come  on  when  the 
health  is  impaired. 

Ocular  Symptoms. — {a)  Ptosis,  Avhich  may  be  single  or  double  and  is 
by  no  means  uncommon  either  alone  or  (/>)  in  association  with  external 
strabismus.  The  first  complaint  may  be  of  double  vision.  Occasionally 
there  may  be  paralysis  of  all  the  external  muscles  of  the  eye,  producin;: 
ophthalmoplegia  externa,  (r)  Argyll-llobertson  pujiil,  in  which,  as  already 
mentioned,  there  is  loss  of  the  iris  reflex  to  light,  but  contraction  du I'iii;: 
accommodation.  The  pupils  are  usually  small — spinal  myosis.  {d)  <  (p- 
tic  atrophy.  'J'his  is  often  an  early,  or  even  the  first  symptom.  The  loss 
of  vision  jjrogresses,  and  in  a  large  majority  of  cases  leads  to  total  blind- 
ness. 

Loss  of  the  Kme-jerTc. — This  is  one  of  the  earliest  symptoms,  and  may 
occur  years  before  there  is  ataxia.  Taken  alone  it  is  of  no  moment,  as 
there  are  individuals  in  whom  the  knee-jerk  is  absent ;  but  in  connection 
with  the  lightning  pains  aiui  the  ocular  symptoms,  it  is  of  special  impor- 
tance. These  are  the  most  common  symptoms  of  the  pre-ataxie  stage,  and 
may  persist  for  years  Avithout  the  development  of  incoordination.  The 
patient  may  look  well  and  feel  well,  and  be  troubled  only  by  occasional 
attacks  of  lightning  pains;  or  there  is  persistent  ptosis,  external  straliis- 
mus  develops,  or,  what  is  more  serious,  a  progressive  atrophy  of  the  o[)tic 
nerve.     There  is  often  a  gradual  loss  of  sexual  power. 

The  disease  may  never  progress  beyond  this  stage,  and  when  ojitic 
atrophy  develops  early  and  leads  to  blindness,  the  ataxia  rarely,  if  ever, 
supervenes.  There  is  a  sort  of  antagonism  between  the  ocular  sym])tonis 
and  the  progress  of  the  ataxia.  Charcot  lays  considerable  stress  upon  this, 
and  Dejerine  assured  me  that  of  the  enormous  tabetic  material  at  tho 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


843 


Bicutre  in  not  ii  single  instiince  in  ■wiiicli  optic  atrophy  had  come  on  early 
iimi  progressed  to  blindness  was  the  patient  ataxic,  although  there  were 
cases  wliich  had  had  the  lightning  pains  and  lesions  of  the  optic  nerves  for 
iwcnty-five  years. 

Ataxic  Stage.  —  Motor  Symptoms. — Tlie  ataxia  develops  gradually. 
One  of  the  first  indications  to  the  patient  is  inability  to  get  about  readily 
in  the  dark  or  to  maintain  his  equilibrium  when  washing  his  face  with 
tlu'  eyes  shut.  When  tlie  j)atient  stands  with  the  feet  together  and  the 
eyes  closed,  he  sways  and  has  difliculty  in  maintaining  his  2)osition.  This 
is  known  as  Romberg  symptom.  On  turning  (piiekly  he  is  apt  to  fall, 
(inidually  the  characteristic  ataxic  gait  develops.  The  patient,  as  a  rule, 
walks  with  a  stick,  the  eyes  are  directed  to  the  ground,  the  Ijody  is  thrown 
forward,  and  the  legs  are  wide  apart.  In  Avalking,  the  leg  is  thrown  out 
violently,  the  foot  is  raised  too  high  arid  is  brought  down  in  a  stamping 
manner  with  the  heel  first,  or  the  whole  sole  conies  in  contact  with  the 
ground.  Ultimately  the  patient  may  be  unable  to  walk  without  the  assist- 
ance of  two  canes.  This  gait  is  very  characteristic,  and  unlike  that  seen 
in  any  other  disease.  The  incoordination  is  not  only  in  walking,  but  in 
the  performance  of  other  mo\ements.  If  the  patient  is  asked,  when  in 
tlu'  recumbent  posture,  to  touch  the  knee  with  one  foot,  the  irregularity  in 
tho  movement  is  very  evident.  Incoordination  of  the  arms  is  less  com- 
mon, but  usualh'  develops  in  some  grade.  It  may  in  rare  instances  exist 
liL't'ore  the  incoordiiuition  of  the  legs.  In  the  largo  number  of  ataxics 
wliich  frequented  the  Infirnuiry  for  Xervous  Diseases  at  Philadelphia, 
there  was  only  one,  so  far  as  I  remember — at  Weir  Mitcheirs  clinic — in 
wliich  the  arms  were  first  affected.  It  may  be  tested  by  ■  king  the  })atient 
to  close  his  eyes  and  to  touch  the  tip  of  the  nose  or  the  tip  of  the  ear  with 
the  finger,  or  with  tho  arms  thrust  out  to  bring  the  tips  of  the  fingers 
together.  Tiie  incoordination  may  early  be  noticed  by  a  difficulty  Avhich 
the  patient  experiences  in  buttoning  his  collar  or  in  performing  one  of 
the  ordinary  routine  acts  of  dressing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked 
incoordination  there  is  no  loss  of  muscular  power.  The  grip  of  the  hands 
miiy  be  strong  and  firm,  the  power  of  the  legs,  tested  liy  trying  to  fiex 
tlu'in,  may  be  unimpaired,  and  their  nutrition,  except  toward  the  close, 
may  be  unaffected. 

Sensory  Symptoms. — The  lightning  pains  may  persist.  They  vary 
greatly  in  different  cases.  Some  patients  are  rendered  miserable  by  the 
fro(iuent  occurrence  of  the  attacks;  others  escape  altogether.  In  addition, 
tommon  symptoms  are  tingling,  pins  and  needles,  particularly  in  the  feet, 
iind  areas  of  hypertesthesia  or  of  ana?sthesia.  The  patient  nuiy  complain 
<if  u  change  in  the  sensation  in  the  soles  of  the  feet,  as  if  cotton  was  inter- 
posed between  the  floor  and  tho  skin.  Sensory  disturbances  occur  less 
fro(]uently  in  the  hands.  Retardation  of  tactile  sensation  is  common,  and 
ii  pill-prick  on  the  foot,  instead  of  boing  instantaneously  felt,  is  not  per- 


844 


DISP]ASES  OF  THE  NERVOUS  SYSTEM. 


I!  '.'. 


coived  for  a  sccontl  or  two  or  may  be  delayeu  for  as  niuoh  as  ten  seconds. 
The  pai?!  felt  may  persist.  ,\  curious  plienomenoii  is  the  loss  of  the  iidwcr 
of  localizing  the  pain.  For  instance,  if  the  pjitient  is  pricked  on  one  limli 
he  may  say  that  he  feels  it  on  the  other  (allocheiria),  or  a  pin-prick  on  tlio 
foot  may  be  felt  in  both  feet.  The  muscular  sense  becomes  mucii  im- 
j)aired  and  the  patient  no  longer  recognizes  the  i)osition  in  which  his  limlis 
are  placed.     This  may  be  2)resent  in  the  pre-ataxic  stage. 

Jlcflv.i'cs. — As  mentioni'd,  the  loss  of  the  knee-jerk  is  one  of  the  earHust 
symptoms  of  the  disease.  Occasionally  a  case  is  found  in  which  it  i,>  re- 
tained. The  skin  reflexes  may  at  lirst  be  increased,  but  later  are  usually 
involved  with  the  deci)  rellexes. 

Special  Sen.ses. — Tlu;  eye  symj)toms  noted  above  may  be  present,  hut, 
as  mentioned,  ataxia  is  rare  with  atrophy  of  the  optic  nerve. 

Deafness  may  develop,  due  to  lesion  of  the  auditory  nerve.  There  may 
also  be  attacks  of  vertigo.     Olfnctory  symptoms  are  rare. 

Visceral  Si/in/ifoins. — Among  the  most  remarkable  sensory  disturl)aiifO; 
are  the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  vnrious  visccni; 
tlius  laryngeal,  gastric,  nei)liralgic,  rectal,  urethral,  and  clitoral  (irises  have 
been  described.  The  most  common  are  the  gastric  aiul  laryngeal.  In  the 
former  there  are  int 'iise  pains  in  the  stomach,  vomiting,  and  a  secretion 
of  hyperacid  gastric  juice.  The  attack  may  last  for  several  days  or  even 
longer.  There  may  l)e  severe  pain  without  any  vomiting,  'i'iie  attacks 
are  of  variable  intensity  and  usually  require  morphia.  Paroxysms  of  rectal 
pain  and  tenesmus  are  described.  They  have  not  been  common  in  my 
experience.  Laryngeal  crises  also  are  rare.  There  may  be  true  spasm 
with  dyspneea  and  ]U)isy  inspiration.  In  one  instance  at  least  the  patient 
has  died  in  the  attack. 

The  s})hincters  are  frequently  involved.  Early  in  the  disease  thef 
may  be  a  retardation  or  hesitancy  in  making  water.  Later  there  is  reten- 
tion, ami  cystitis  may  occur.  Unless  great  care  is  taken  the  intlamniatidii 
may  extend  to  the  kidneys.  Constipation  is  extremely  comm<m.  Late  in 
the  disease  the  sphincter  ani  is  weakenetl.  The  sexual  power  is  usually 
lost  in  the  ataxic  stage. 

Trophic  Cliaixjes. — Skin  rashes  may  develop  in  the  course  of  the  light- 
ning pains,  such  as  her])es,  anlema,  or  local  sweating.  Alteration  in  the 
nails  may  occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually 
beneath  the  great  toe.     Onychiu  may  prove  very  troublesome. 

The  arthroiiathies  or  joint  lesions  affect  chiefly  the  knees.  They  arc 
unquestionably  associated  with  the  disease  itself,  and  not  necessarily  a 
result  of  trauma.  The  condition,  known  as  ('harcot's  joint,  is  anatdinie- 
ally  similar  to  that  of  chronic  arthritis  deformans.  The  effusion  may  be 
rapid  and  there  may  be  great  disintegration  and  destruction  of  the  carti- 
lages and  bones,  leading  to  dislocation  and  deformity.  Pus  was  present 
in  a  well-marked  Charcot's  joint  in  a  patient  of  C.  K.  Mills  at  the  Phila- 
delpliia  Hospital.    Spontaneous  fractures  may  occur.    Among  other  trophic 


■mil; 


1)0  present,  Imt, 


3rve.    There  nuiv 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


845 


flistnrbances  may  be  mentioJied  atrn])liy  of  the  muscles,  wliieli  is  usuallv  a 
hitr  inaiiifestatioii,  hut  may  ho  localized  and  associated  with  neuritis.  In 
any  very  lartje  collect  iim  of  cases  many  instances  of  atrophy  ai'e  found,  duo 
either  to  involvement  of  the  anterior  horns  or  to  iJerijjheral  neuritis. 

(rrebral  Sijmptoms. — Hemiplegia  nniy  develop  at  any  stage  of  the 
disease,  more  commoidy  when  it  is  well  advanced.  It  may  he  due  to 
tiii'inorrhagic  softening  in  consequence  of  disease  of  the  vessels  or  to  pro- 
jiressive  cortical  changes,  iremianiesthesia  is  sometimes  present.  Very 
nirely  the  hemiplegia  is  due  to  coarse  syidiilitic  disease. 

Dementia  paralytica  frequently  exists  with  tabes,  and  it  nuiy  be  ex- 
tri'iiiely  difficult  to  determine  which  has  l)een  the  primary  alTection.  In 
ii  majority  of  the  cases  the  locomotor  ataxia  has  ])i'ece(led  the  symptoms 
(if  general  paresis.  In  other  instances  melancholia,  dementia,  or  paranoia 
(lovelo[). 

{(•)  Paralytic  Stage. — After  persisting  for  an  indefinite  number  of 
years  the  patient  gradually  loses  the  ])ower  of  walking  and  becomes  bed- 
ridden or  paralyzed.  In  this  condition  he  is  very  likely  to  be  curried  off 
by  some  intercurrent  alTection,  such  as  pyelo-nephritis,  jjueumonia,  or 
tulierculosis. 

The  Course  of  the  Disease. — A  patient  may  remain  in  the  pre-ataxic 
stage  for  an  iniletinite  period,  and  the  loss  of  knee-jerk  and  the  gray 
atrophy  of  the  optic  nerves  may  be  the  sole  indications  of  the  true  nature 
of  tlie  disease.  In  such  cases  incoordination  rarely  develops.  In  a  tiki- 
jority  of  cases  the  progress  is  slow,  and  after  six  or  eight  years,  sometimes 
less,  the  ataxia  is  well  developed.  The  symj)toms  may  vary  a  good  deal ; 
thus  the  pains,  which  may  have  been  excessive  at  first,  often  lessen.  The 
disease  may  remain  stationary  for  years ;  then  exacerbations  occur  and  it 
makes  rapid  progress.  Occasionally  the  disease  seems  to  be  arrested. 
There  are  instances  of  what  may  be  called  acute  ataxia,  in  which,  Avithin 
a  year  or  even  less,  the  incoordination  is  marked,  and  the  paralytic  stage 
may  develop  within  a  few  months.  The  disease  itself  rarely  causes  death, 
and  after  becoming  bedridden  the  patient  may  live  for  fifteen  or  twenty 
years. 

Diagnosis. — In  the  pre-ataxic  stage  the  combination  of  lightning 
pains  and  the  absence  of  knee-jerk  is  distinctive.  The  association  of  [)ro- 
gressive  atrophy  of  the  optic  nerves  with  loss  of  knee-jerk  is  also  charac- 
teristic. The  early  ocular  palsies  are  of  the  greatest  importance.  A  squint, 
]»t<»sis,  or  the  Argyll-Robertson  pupil  may  be  the  first  symptom,  and  may 
exist  with  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone, 
liowever,  does  occasionally  occur  in  healthy  individuals. 

The  diseases  most  likely  to  be  confounded  with  locomotor  ataxia  are : 
(1)  Peripheral  Xeuritis. — The  pseudo-tabetic  gait  of  arsenical,  alcoholic, 
or  diabetic  paralysis  is  quite  unlike  that  of  locomotor  ataxia.  In  these 
forms  there  is  a  paralysis  of  the  feet  and  the  leg  is  lifted  high  in  order 
that  the  toes  may  clear  the  floor.     The  use  of  the  word  tabes  in  this  con- 


i 

i 


I? 


1. 

f 

1 

t 

^ 

f 

. 

t 

1 

flf    1 

& 

I 

840 


D1SKA3ES  OF  THE  NEIIVOUS  SYSTEM. 


iU 


noction  sljould  no  lonj^'or  bo  coutiiiucil.  If  in  any  doubt,  tbe  al)S('iicp  of 
the  liylitniiij;  pains  and  eye  symptoms  and  tlio  history  will  suHirc  in  the 
majority  of  cases  to  mako  the  dia<jnosis  clear.  In  diiththeritie  paialysis 
the  early  loss  of  knee-jerk  and  the  associated  eye  symptoms  may  siil:<.'(>i 
tabes,  but  the  history,  tlie  existence  of  paralysis  of  the  throat,  and  the 
absence  of  pains  render  a  diaji^nosis  easy, 

("i)  Ataxic  Parajih'f/ia. — Marked  incoordination  with  K])astic  ])ariilvsis 
is  characteristic  of  the  condition  which  (J owers  has  termed  ataxic  jmni- 
ple^ia.  In  a  niajcu'ity  of  the  cases  this  aifection  is  distinguished  also  by 
the  absence  of  i)ains  and  of  eye  symptoms. 

(3)  Cerch'Uar  JJiscase. — The  cerebellar  incoordination  has  only  a  sujut- 
i'cial  resemblance  to  that  of  locomotor  ataxia;  the  knee-jerk  is  present, 
there  are  no  lightning  pains,  no  sensory  disturbances;  Avhile,  on  tiic  other 
hand,  there  arc  headache,  o\)t'ui  neuritis,  and  vomiting. 

(4)  Some  acu/e  affcrfions  involving  the  posterior  columns  of  the  cord 
may  be  followed  by  incoordination  and  resemble  tabes  very  closely.  In  a 
cas3  recently  under  my  care,  the  gait  was  characteristic  aiid  Ilomberg's 
symj)tom  was  present.  The  knee-jerk,  however,  was  retained  and  there 
were  no  ocular  symptoms.  The  condition  had  developed  within  throe  or 
four  months,  and  there  was  a  well-marked  history  of  syphilis.  Under 
large  doses  of  iodide  of  potassium  the  ataxia  and  other  symptoms  com- 
pletely disappeared. 

(5)  General  Paresis. — In  some  cases  this  offers  a  serious  difficulty.  In 
the  first  i)lace,  in  general  paresis,  tabetic,  symptoms  often  develo});  on  tlij 
other  hand,  there  are  cases  of  locomotor  ataxia  in  which,  towai'd  the  eml, 
there  are  symptoms  of  general  paresis.  Cases  of  unusually  acute  ataxia 
with  mental  symptoms  belong,  as  a  rule,  to  the  former  disease.  The  (jues- 
tiou  will  be  considered  under  general  paresis. 

(())  Visceral  crises  and  neuralgic  symptoms  may  lead  to  error,  and  in 
middle-iigod  men  Avith  severe,  recurring  attacks  of  gastralgia  it  is  always 
well  to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  I'xani- 
ination  of  the  eyes  and  of  the  knee-jerk. 

Prognosis. — Complete  recovery  cannot  be  expected,  but  arrest  of  tlie 
progress  is  not  uncommon  and  a  marked  amelioration  of  the  symptoms  is 
frequent.  Optic-nerve  atrophy,  one  of  the  most  serious  events  in  the  dis- 
ease, has  this  hopeful  aspect — that  incoordination  rarely  follows  and  tlie 
•  progress  nuiy  be  arrested.  The  optic  atrophy  itself  is  occasionally  (diwdved. 
On  the  whole,  the  prognosis  in  tabes  is  bad.  The  experience  of  such  men 
as  Weir  Mitchell,  Charcot,  and  Gowers  is  distinctly  opposed  to  the  lielief 
that  locomotor  ataxia  is  ever  completely  cured.*  No  such  instance  luis 
come  under  my  personal  observation. 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possil)le,  the 
symptoms  are  the  objects  which  the  practitioner  should  have  in  view.    A 

*For  a  study  of  the  reputed  cures,  see  L.  C.  Gray,  N.  Y.  Medical  Journal,  Nov.,  1889. 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


847 


f|uiot,  wcll-rof^ulati'd  mothod  of  life  in  os^^ontial.  It  i.s  not  well,  as  a  rule, 
for  !i  patient  to  jrivc  up  hia  oceupation  so  loujj  as  ho  i.s  able  to  keep  about 
anil  perform  ordinary  work.  I  know  tabetics  who  have  for  years  conducted 
hirure  businesses,  and  there  liave  l)een  .several  notable  instances  in  our  pro- 
|V.->ion  of  men  who  have  risen  to  distinction  in  spite  of  tl>e  existence  of  this 
disease.  Exeesses  of  all  sorts,  more  parti(Milarly  in  hitrrho  el  rciirrt;  should 
be  carefully  avoided.     A  man  in  the  pre-ataxic  sta,<re  shouI<l  not  nuirry. 

Care  should  be  taken  in  the  diet,  })articidarly  H"  ,i,'astric  crises  have  oc- 
curred. To  secure  arrest  of  the  disease  many  remedies  have  been  eni- 
pluyed.  Although  8y))hilis  play.s  such  an  im])ortant  role  in  the  etiolo<fy, 
it  is  utnversally  acknowledged  that  neither  mercury  nor  the  io(li(h>  of  po- 
tMssium  have  as  a  rule  the  slightest  influence  over  tin;  tabetic  lesions.  To 
this  tliere  is  but  one  exception — when  the  syi)hilis  is  com])aratively  recent ; 
when  the  symptoms  develop  Avithin  two  year.s  of  the  primary  infection, 
ihi're  is  then  a  po.ssibility  of  arrest  by  mercury  and  iodide  of  p<itassium. 
However,  they  do  not  always  relieve.  In  two  cases  of  very  rapidly  pro- 
irrcssing  tabes  following  syphilis  this  medication  was  of  no  avail.  A'ot 
only  is  an  anti-merourial  treatment  of  no  benefit  in  the  majority  of  cases 
of  locomotor  ataxia,  but  my  experience  tallies  with  that  of  (lowers  in  that 
it  may  even  hasten  the  progress  of  the  disease.  Of  remedies  which  nuiy 
W  tried  and  are  believed  l)y  some  writers  to  retard  the  progress,  the  fol- 
lowing are  recommended  :  Arsenic  in  full  doses,  nitrate  of  sdver  in  (puirter- 
prain  doses.  Calabar  bean,  ergot,  and  the  preparations  if  gold. 

The  treatment  by  suspension  introduced  a  few  years  ago  has  already 
Iioen  practically  abandoned,  (ioodelfccts  certainly  have  followed  m  a  few 
cases,  but  it  was  unreasonable  from  the  outset,  eitiu'r  on  therapeutic  or 
scientific  grounds,  to  hope  that  by  such  a  measure  ])ermanent  changes  could 
lie  induced  in  the  pathological  condition.  The  benefits  were  due  in  great 
I)art  to  suggestion  and  to  psychical  effects.  In  any  ease  it  must  be  used 
with  caution. 

For  the  pains,  complete  rest  in  bed,  as  advised  by  AVeir  ^litchell,  and 
counter-irritation  to  the  sj)ine  (either  blisters  or  the  thermo-cautery)  may 
ho  employed.  The  severe  spells  Avhich  come  on  particularly  after  excesses 
of  any  kind  are  often  promptly  relieved  by  a  hot  bath  or  by  a  Turkish  bath. 
A  prolonged  course  of  nitrate  of  silver  seems  in  some  cases  to  allay  the 
pains  and  lessen  the  liability  to  the  attacks.  I  have  never  seen  ill  effects 
from  its  use  in  the  spinal  scleroses.  Antipyrin  and  antifebrin  may  be  em- 
ployed, and  occasionally  do  good,  but  their  aiuUgesic  powers  in  this  disease 
have  been  greatly  overrated.  Cannabis  indica  is  sometimes  useful.  In 
the  severe  paroxysms  of  pain  hypodermics  of  mori)hia  or  of  cocaine 
must  be  used.  The  use  of  morphia  should  be  postponed  as  long  as  possi- 
hle.  Electricity  is  of  very  little  benefit.  For  the  severe  attacks  of  gas- 
tralgia,  morphia  is  also  required.  The  laryngeal  crises  are  rarely  danger- 
ous. An  application  of  cocaine  may  be  made  during  the  spasm,  or  a  few 
uhifTs  of  chloroform  may  be  given,  or  nitrite  of  amyl.     In  all  cases  of  tabes 


:n1 


'■    :i  1,1 . 


m '' 


■' 1 1 


1' 

is    1^ 

''''m 

■■'  '■  r 


HI 


if  ^i'  :'i 


ii  in'.- 


818 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


with  inoroiisod  artoriiil  toiision  tlio  prolonged  iiso  of  iiitronrlycorin,  ;;iven 
in  incrwising  doses  until  tlio  |)liysiolo<ficHl  cITi'd  is  jirodiicod,  is  of  i^noat 
servic'o  in  iilliiying  tlio  nounilgic!  pains  and  diininisliing  the  frc'(|U('iiiy  of 
the  erises.  Its  use  must  bo  guarded  wlien  there  is  aortic  insulliiicncv. 
The  special  indication  is  increased  tension.  Tiie  biadih'r  symptoms  dc- 
mand  constant  care.  When  the  organ  cannot  l)e  jjcrfcctly  empticil  tin; 
catheter  should  he  nsed,  and  the  patient  may  bo  taught  its  use  and  huw 
to  keep  it  thoroughly  sterilized. 

III.  IIiCKEDiTAUY  ATAXIA  {Fric'dreicli^s  Ataxia). 

In  18G1  Friedreich  rei)ortod  six  eases  of  a  form  of  hereditary  ataxin, 
and  the  alTection  has  usually  gone  by  hi.s  name.  Unfcn'tunately,  panuinji,- 
clonuK  iiuillii)h:t  is  also  called  Friedreich's  disease  ;  so  it  is  best,  if  his  naiiiu 
is  used  in  connection  with  this  all'ection,  to  term  it  Friedreich's  ataxia.  It 
is  a  very  diU'erent  disease  in  many  respects  from  ordinary  tabes.  It  iiiuy 
or  may  not  be  hereditary.  It  is  really  a  family  disease,  several  ln'nihcrs 
and  sisters  being,  as  a  rule,  alTected.  The  14!}  cases  analyzed  by  (irillith 
occurred  in  Tl  unrelated  families.  In  his  series  inheritance  of  the  diseasf 
itself  occurred  in  only  33  cases.  Various  influences  in  the  parents  liavu 
been  noted  ;  alcoholism  in  only  7  cases.  Syi)hilis  has  rarely  been  i)rosciit. 
Of  the  14;')  cases,  80  were  males  and  57  females.  The  disease  sets  in 
early  in  life,  and  in  (JritHtirs  series  15  occurred  before  the  age  of  two 
years,  31)  before  the  sixth  year,  45  between  the  sixth  and  tenth  years,  ;'ii 
between  the  eleventh  and  fifteenth  years,  18  between  the  sixteenth  and 
twentieth  years,  and  5  between  the  twentieth  and  twenty-fifth  years. 

The  morbid  aiiatoiny  shows -an  extensive  sclerosis  of  the  posterior 
and  lateral  columns  of  the  spinal  cord.  The  periphery,  and  the  ci'iv- 
bellar  tracts  are  usually  involved.  The  recent  observations  of  Dcjc'rine 
and  LetuU'i  are  of  special  interest,  since  they  seem  to  indicate  that  the 
change  in  this  disease  is  a  neurogliar  (ectodermal)  sclerosis,  differing  en- 
tirely from  the  ordinary  spinal  sclerosis.  According  to  this  view,  I'Vied- 
reich's  disease  is  a  gliosis  of  the  posterior  columns  due  to  developnuiital 
errors. 

Ssnuptoms. — The  ataxia  is  unlike  the  ordinary  form.  The  inco- 
ordination begins  in  the  logs,  but  the  gait  is  peculiar.  It  is  swaying, 
irreguhir,  and  more  like  that  of  a,  drunken  man.  Tliere  is  not  the  ehar- 
actoristic  stamj)ing  gait  of  the  true  tabes.  Romberg's  symptom  may  or 
may  not  be  present.  The  ataxia  of  the  arms  occurs  early  and  is  very 
nuirked  ;  the  movements  are  almost  choreiform,  irregular,  and  souiewliat 
swaying.  In  making  any  voluntary  movement  the  action  is  ovenlono, 
the  prehension  is  claw-like,  and  the  fingers  may  be  spread  or  overex- 
tended just  before  grasping  an  object.  The  hand  frequently  nnnos  about 
an  object  for  a  moment  and  then  suddeidy  pounces  upon  it.  There  are 
irregular,  swaying  movements,  some  of  which  arc  choreiform,  of  the  head 


CIIUONIC  AFKKCTIONS  OP  THE  SPIXAL  CORD. 


849 


1111(1  shouldora.  Tlioro  is  i)r(vs(Mit  in  many  ciiscs  what  is  ktiowti  as  stiitio 
ataxia,  that  is  to  say,  ataxia  of  quiet  action — irrej^'ular,  slow  niovomonts  of 
tlic  liiij^ors  or  tlic  hands  while  at  rest. 

Sensory  symptoms  are  not  usnally  present.  'I'lie  reflexes  may  he  lost. 
In  (irillitirs  tahle  tiiey  were  abolished  in  !)1  eases. 

Nystagmus  is  a  eharaeteristic!  symptom.  Atrophy  of  the  optic  nervc! 
nuvly  occurs.  A  striking  feature  is  early  deformity  of  the  feet.  'I'lu're 
is  talipes  ecpiinus,  and  the  patient  walks  on  the  outer  edgi'  of  the  feet. 
The  big  toe  is  flexed  dorsally  on  the  tirst  i)hahiux.  Lateral  curvature  of 
the  spine  is  very  common. 

Trophic  lesions  are  rare.  As  the  disease  advances  paralysis  comes  on 
and  may  ultimately  he  eomi)lete.     Some  of  the  patients  never  walk. 

I>isturhaiu;e  of  speech  is  common.  It  is  usually  slow  and  scanning; 
the  exi)ression  is  often  dull ;  the  mental  power  is,  as  a  rule,  maintained, 
l)Ul  late  in  the  disease  becomes  imjjaired. 

The  (liiff/nosis  of  the  disease  is  not  dilVicult  when  several  nicmhers  of 
;i  family  are  atfeettul.  The  onset  in  childhood,  the  curious  form  of  iiu'o- 
unlination,  the  early  talipes  e([uinus,  the  })osition  of  the  great  toe,  the 
scoliosis,  the  nystagmus,  and  scanning  speech  nuike  u[)  an  uumistakahle 
picture.  The  disease  is  often  confounded  with  chorea,  with  tlu'  ordinarv 
form  of  which  it  has  nothing  in  common.  With  hereditary  chorea  it  has 
frrtain  similarities,  hut  usually  this  disease  does  not  set  in  until  after  the 
thirtieth  year. 

The  disease  lasts  for  many  years  and  is  incurable.  Care  should  be 
taken  to  prevent  contractures. 

IV.    SYKIXGO-MyELIA. 

Definition. — A  gliomatous  new  fornuition  about  the  central  canal  of 
the  spinal  cord,  with  cavity  formation. 

The  disease  has  attracted  a  good  deal  of  attention  within  the  past  few 
voiU's,  and  has  a  definite  clinical  interest  since  cases  eau  now  be  diair- 
liosed. 

Etiology  and  Morbid  Anatomy.— Syringo-myelia  must  be  dis- 
tinguished from  dilatation  of  the  central  canal — hydromyelus— slightgrades 
of  wliieli  are  not  very  uncommon  either  as  a  congenital  coiulitiou  or  as  a 
result  of  the  pressure  of  tumors.  The  cavity  of  syringo-myelia  has  a  vari- 
ahle  extent  in  the  cord,  sometimes  existing  in  the  entire  length,  but  in 
iiumy  eases  involving  only  the  cervical  and  dorsal  regions  or  a  more  linuted 
iirea.  It  is  usually  in  the  posterior  portion  of  the  cord  and  extends  into 
one  posterior  cornu.  The  transverse  secition  may  be  ov;d  or  circular  or 
narrow  and  fissure-like.  It  varies  at  diifercnt  levels.  The  condition  is 
now  regarded  as  a  gliosis,  a  development  of  embryonal  neurogliar  tissue 
iii  which  liaimorrhage  or  degeneration  takes  piace  with  the  formation  of 
mities. 


I  lih  111 


1 


\\  J: 


(!  i 


850 


DISKASKS  OP  TIIK  NERVOUS  SVSTKM. 


Symptoms. — Tlu"  (lis(>iis(>,  wliidi  is  of  slow  (Icvclopmcnt,  niiikc-!  Its 
uppeiiruiirc,  its  :i  nilo,  about  iidolcscciH'c,  and  may  persist  for  (ifiirii  dp 
twenty  years.  TlitTo  uro  irrof,Milar  pains,  cliielly  in  the  cervical  n;:i(iii; 
muscular  atro})hy  (leveloi)S,  wliicli  may  he  conliiieil  to  the  arms,  or  >(iiii(.. 
times  exteiitls  to  the  lej^s.  'I'he  rellexes  are  increased  and  a  spastie  ruiKJi. 
lion  di'vclops  in  the  le<,'s.  I'ltiniately  the  clinical  picture  may  he  that  df 
un  amyotroi»hi(;  lateral  sclerosis.  The  tactile  sensation  is  usually  iiiiiirt 
and  the  muscular  sense  is  retained,  hut  i)ainful  and  thermic  sensations  urc 
not  recojfuizcd,  or  there  may  he  in  rare  instances  com)»lete  ana'sthr>ia  df 
the  skin  and  of  the  miu'ous  memhraiies  (Dejerinc).  This  cond)inatiiin  nf 
loss  of  i)ainful  and  thermii!  sensations  with  i)aralysis  (tf  an  amyotro)iliic 
type  is  rej^arded  an  pathognomonic  of  the  disease.  The  special  sense-;  arc 
usually  intact  and  the  sphincters  uninvolved.  Tro[)hic  trouhles  aic  imt 
uncommon.  Owini^  to  tia^  loss  of  the  painful  and  heat  sensations,  the 
patients  are  apt  to  injure  themselves.  A  man  aged  seventy,  whom  1  saw 
with  Dcjerine  at  the  Hicetre,  had  had  the  .syujittoms  for  over  twenty-live 
years.  Loss  of  sensation  had  preceded  the  atrophy,  and  the  termiuiil 
})halanx  of  the  middle  tinjifer  was  charred,  as  he  experienced  no  sensatidii 
whatever  when  the  hot  end  of  the  ci<;arette  iieared  his  linger.  ScolidsLs 
also  may  he  present  in  these  cases.  The  loss  of  painful  and  thermic  im- 
pressions is  due  to  the  fact  that  these  pass  to  the  brain  in  the  peri-e|icnily- 
mal  gray  matter,  particularly  that  portion  in  the  posterior  roots,  which  is 
almost  <'onstantly  involved  in  syringo-myelia.  'i'he  tactile  sensation  is  re- 
tained because  the  postero-external  column  is  uninvolved. 

In  typical  cases  the  (liai/nosix  is  easy.  I'he  combination  of  an  ainyolro- 
phic  paralysis,  the  picture  of  progressive  muscular  atro^diy  of  the  Araii- 
Duchenne  type,  with  retention  of 'tactile  and  loss  of  thermic  and  painful 
sensation,  is  probably  pathognomonic  of  the  disease.  Of  affections  with 
which  it  may  be  confounded,  ana>sthetic  leprosy  is  the  most  impoitant, 
since  the  ana'sthesia  and  the  wasting  may  closely  simulate  it ;  but,  as  a  nilc, 
in  leprosy  trophic  changes  are  more  or  less  marked.  There  is  often  l(»ss  uf 
phalanges  and  there  is  no  characteristic  dissociation  of  sensory  impi'cs<iens. 

There  is  a  remarkable  alfection  confined  to  a  district  of  Brittany  ami 
known  as  Morvan's  disease,  after  the  physician  who  described  it.  The 
disease  is  clironic  and  characteri?;ed  by  neuralgic  pains,  cutaneous  ana's- 
thesia,  and  painless  and  destructive  whitlows.  In  (lombault's  autopsy 
neuritis  was  found,  but  it  could  not  ))e  decided,  owing  to  the  state  of  the  cord 
when  examined,  whether  cavities  existed  or  not.  Joffroy  reports  a  case  in 
which  syringo-myelia  was  present  and.  claims  the  affections  are  identical. 
The  curious  distribution  of  the  disease  and  the  fact  that  at  least  ^'n  cases 
have  occurred  in  a  population  of  ,5,000,  suggest  that  it  is  possibly  a  pci'i|»li- 
eral  neuritis  of  infectious  origin.  Church,  of  ('hicago,  has  reported 
case  in  which,  with  features  believed  to  be  characteristic  of  .syringo-myelia, 
the  patient  had  the  painless  and  destructive  whitlows  which  form  so  special 
a  feature  in  Morvan's  disease. 


i...' 


CURONIC  AFFKCTIONS  OF  THE  Sl'lXAL  COUP. 


851 


V.  CoMPUKssiox  OF  TiiK  Spinal  Coui)  {ComprcsKton  Miji'Utis). 

Deflnition.— -Interrui)tion  of  the  functions  of  the  cord  hy  «low  coni- 
pnssion. 

Etiolog^y. — Varies  of  tlio  spine,  now  j^rowths,  aneurism,  and  pani- 
KJtcs  are  the  iinportunt  euuscs  of  Kh)W  compression.  Caries,  or  I'ott's  dis- 
I'lisc,  as  it  is  usually  called,  after  the  surj,'eon  who  first  desi-rihed  it,  is  in 
the  },'rcut  majority  of  instuncea  a  tuhenuilous  alTection.  In  a  few  cases  it 
is  due  to  8y])hilis  and  occasioiudly  to  <'xtension  of  disease  from  the  phar- 
ynx. It  is  most  common  in  early  life,  but  may  occur  aft(>r  middle  ago. 
it  follows  trauma  in  a  few  cases.  Compression  occasionally  results  from 
luu'urism  of  tlu;  thoracic  aorta  or  the  abdominal  aorta,  in  the  neighb(jrhooU 
of  the  cadiuc  axis. 

Maligjumt  growths  frequently  cause  a  compression  paraplegia.  A 
n'tr(i[)eritoneal  sarcoma  or  the  lymphadenomatous  growths  of  Ilodgkin's 
(lisoiiso  may  invade  the  vertebra).  More  commonly,  however,  the  involve- 
ment is  secondary  to  scirrhus  of  the  breast. 

Of  parasites,  the  echiuoooccus  and  the  cysticercus  occasioiuiUy  occur 
in  Die  spinal  canal. 

Symptoms. — These  may  be  considered  as  they  aflect  the  boiu's,  the 
nci'vcs,  and  the  cord. 

(1)  Vertebral. — In  malignant  disease  and  in  aneurism  erosion  of  the 
bodies  may  take  jdaco  without  producing  any  deformity  of  the  spine.  In 
caries,  on  the  other  hand,  it  is  the  rule  to  find  more  or  less  deformity, 
amounting  often  to  angular  curvature.  The  compression  is  largely  due  to 
the  thickening  of  tlio  dura  and  the  presence  of  caseous  and  inflammatory 
products  between  this  membrane  and  the  bone.  The  compression  is  rare- 
ly produced  directly  by  the  bone.  Pain  is  a  constant  and,  in  the  case  of 
unenrism  and  tumor,  agonizing  feature.  In  caries,  the  spinal  processes  of 
the  affected  vertebra)  are  tender  on  pressure,  and  pain  follows  jarring 
movements  or  twisting  of  the  spine.  There  may  be  extens've  tuberculous 
disease  withont  much  dotonr.ity,  particularly  in  the  cervical  region. 

{i)  Nerve-root  Symptoms. — These  result  from  compression  (>f  the 
nerve-roots  as  they  pass  out  between  the  vertebras.  It  is  remarkable  how 
freriuently,  even  in  extensive  caries,  they  escape  and  the  patient  does  not 
eomplain  of  radiating  pains  in  the  distribntion  of  the  nerves  from  the 
iifTected  segment.  Pains  are  more  common  in  cancer  of  the  spine  second- 
ary to  that  of  the  breast,  and  in  such  cases  may  be  agonizing.  There  may 
bo  acutely  painful  areas  of  hypernesthesia  of  the  skin  or  anssthesia — the 
anwxthcsia  dolorosa.  Trophic  disturbances  may  occur,  particularly  herpes. 
In  the  cervical  or  lumbar  regions  pressure  on  the  anterior  roots  may  give 
rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves. 

(■0  Cord  Symptoms,  (a)  Cervical  Region. — Not  infrequently  the 
caries  is  high  up  between  the  axis  and  the  atlas  or  between  the  latter  and 
the  occipital  bone.  In  such  instances  a  retropharyngeal  abscess  may  be 
64 


\ 

i  1 

i 


1i 

I 

\i 

-J 


nm 


'ill 


.§lft 


'i-f.f -I''-!' 


;  a;.ii 


852 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


present,  giving  rise  to  difficulty  in  swallowing.  There  may  he  spasm  or 
the  cervical  muscles,  the  head  may  be  fixed,  and  movements  may  citlu  r 
be  impossible  or  cause  groat  pain.  In  a  case  of  this  kind  in  the  Montroiil 
General  Hospital  movement  was  liable  to  be  foUoweil  by  transient,  iiii^taii- 
taneous  j)aralysis  of  all  four  extremitic!,  owing  to  compression  of  the  cord. 
In  one  of  these  attacks  the  patient  diid. 

In  the  lower  cervical  region  there  may  be  signs  of  interference  with 
the  cilio-spinal  centre  and  dilatation  of  the  pupils.  Occasionally  there  is 
flushing  of  the  face  and  car  of  one  side  or  unilateral  sweating.  Deform- 
ity is  not  so  common,  but  healing  may  take  plr.ce  with  the  production  of 
a  callus  of  enormous  breadth,  and  complete  rigidity  of  the  neck.  The 
nerves  of  the  upper  extremities  may  be  involved,  and  shooting  pains  may 
occur  in  the  arm. 

{b)  Dorsal  Rerjion. — The  deformity  is  here  more  marked  and  pres.^^iirt 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifest.  More  commoidy  it  is  late,  occurring  many  month.s  after  the 
cyrvature  has  developed.  The  paraplegia  is  slow  in  its  develoj)niont;  the 
patient  at  first  feels  weak  in  the  legs  or  has  disturbance  of  sensation, 
numbness,  tingling,  pins  and  needles.  The  girdle  sensation  may  be 
marked,  or  severe  pains  in  the  course  of  the  intercostal  nerves.  Motion 
is,  as  a  rule,  more  quickly  lost  than  sensation.  Finally,  there  is  crmiplete 
interruption  with  the  production  of  paraplegia,  usually  of  the  spastii;  type, 
with  exaggeration  of  the  reflexes.  This  may  persist  for  months,  or  even 
for  more  than  a  year,  and  recovery  still  be  possible. 

(c)  Lumbar  Region. — In  the  lower  dorsal  and  lumbar  regions  the 
symptoms  are  practically  the  same,  but  the  sphincter  centres  are  involved 
and  the  reflexes  are  not  exaggerated. 

Diagnosis.  — Caries  is  by  far  the  most  frequent  cause  of  slow  com- 
pression of  the  cord,  and  when  there  are  external  signs  the  recognition  is 
easy.  There  are  cases  in  which  the  exudation  in  the  spinal  canal  between 
the  dura  and  the  bone  leads  to  compression  before  there  are  any  si.iriis  of 
caries,  and  if  the  root  symptoms  are  absent  it  may  be  extremely  ditlieult 
to  arrive  at  a  diagnosis.  Janeway  has  called  attention  to  persistent  lum- 
bago as  a  symptom  of  importance  in  masked  Pott's  disease,  particularly 
after  injury.  Brown-Sequard's  paralysis  is  more  common  in  tumor  and 
in  injuries  than  in  caries.  Pressure  on  the  nerve-roots,  too,  is  less  fre- 
quent in  caries  than  in  malignant  disease.  The  cervical  form  of  |)a(liy- 
meningitis  also  produces  a  pressure  paralysis,  the  symptoms  of  whidi  have 
already  been  detailed.  Pressure  from  cancer  is  naturally  suggesteil  whe:. 
spinal  symptoms  follow  within  a  few  years  after  an  operation.  In  para- 
plegia following  tumor  of  the  vertebra  secondary  to  cancer  of  the  breast, 
and  in  the  erosion  of  the  spine  by  retroperitoneal  growths,  the  sulTeriiig 
is  most  intense.  The  condition  has  been  well  termed  paraplfjia  dolo- 
rosa. .    ..  , 


'^^h-^ 


fSTEM. 

riiero  may  be  spasm  of 
movomeuts  may  either 
lis  kind  in  tlie  >Iontroal 
rod  by  transient,  iiistan- 
compression  of  tlie  cord. 

ns  of  interference  with 
i.  Occasionally  there  is 
ral  sweating.  Deform- 
with  the  iiroduction  of 
tlity  of  the  neck.  The 
and  shooting  ])aiii.s  may 

re  marked  and  pressure 
b  of  the  paralysis  varies 
before  the  curvature  is 
many  months  after  the 
in  its  development;  the 
sturbanoe  of  sensation, 
rdle  sensatidn  may  he 
rcostal  nerves.  Motion 
inally,  there  is  complete 
lally  of  the  spastii;  type, 
dst  for  months,  or  even 

id  himbar  regions  the 
;er  centres  are  involved 

ent  cause  of  slow  coin- 
signs  the  rocognitioii  is 
10  spinal  canal  between 
there  are  any  signs  of 
be  extremely  ditllcult 
ion  to  persistent  lum- 
t's  disease,  particularly 
ommon  in  tumor  ami 
-roots,  too,  is  loss  fre- 
rvical  form  of  pachy- 
tnptoms  of  which  have 
urally  suggest<'(l  whe:. 
operation.     In  para- 
>  cancer  of  the  breast, 
growths,  the  sulTcriiij,' 
rned  paraplegia  dolu- 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


853 


Treatment.— In  compression  by  aneurism  or  tumor  the  condition  is 
ho[ielcss.  In  the  former  the  pains  are  often  not  very  severe,  but  in  the 
latter  morphia  is  always  necessary.  On  the  other  hand,  compression  by 
caries  is  often  successfully  relieved  even  after  the  paralysis  has  persisted 
for  a  long  period.  AVhen  caries  is  recognized  early,  rest  and  support  to 
the  spine  by  the  various  methods  now  us(h1  by  surgeons  may  do  much  to 
prevent  the  onset  of  paraplegia.  When  paralysis  has  developed,  rest  with 
extension  gives  the  best  hope  of  recovery.  It  is  to  be  remembered  that 
restoration  may  occur  after  compression  of  the  cord  has  lasted  for  many 
months,  or  even  more  than  a  year.  Cases  have  been  cured  by  rest  alone; 
the  extradural  and  inflammatory  products  are  absorbed  and  the  caries  heal. 
The  most  brilliant  results  in  these  cases  have  been  obtained  by  suspension,  a 
method  introduced  by  J.  K.  Mitchell  in  182G,  and  pursued  with  remarkable 
success  by  his  son,  Weir  Mitchell.  During  my  association  with  the  Intirnniry 
for  Nervous  Diseases  I  had  numerous  opportunities  of  witnessing  the  really 
remarkable  effects  of  persistent  suspension,  even  in  ajiparently  desperate 
and  protracted  cases.  Mitchell's  conclusions  are  that  suspension  should 
he  employed  early  in  Pott's  disease;  that  used  with  care  it  enables  us 
slowly  to  lessen  the  curve ;  that  in  these  cases  there  must  be,  in  some 
form,  a  replacement  of  the  crumpled  tissues ;  that  unless  there  is  great 
loss  of  power  the  use  of  the  spine-car  or  chair  of  J.  K.  Mitchell  enables 
suspension,  especially  in  children,  to  be  combined  with  some  exercise; 
tliat  no  case  of  Pott's  disease  should  be  considered  desperate  without  its 
trial ;  that  suspension  has  succeeded  after  failures  of  other  accepted  meth- 
ods ;  that  the  pull  probably  acts  more  or  less  directly  on  the  cord  itself, 
and  that  the  gain  is  not  explicable  merely  by  obvious  effects  on  the  angu- 
lar bony  curve ;  that  the  methods  of  extension  to  be  used  in  carious  cases 
may  be  very  varied,  provided  only  we  get  active  extension ;  that  the  plan 
and  the  length  of  time  of  extension  must  be  made  to  conform  to  the 
needs,  endurance,  and  sensation  of  the  individual  case.  It  may  be  months 
beft)re  there  arc  any  signs  of  improvement.  In  protracted  cases,  after 
suspension  has  been  tried  for  months,  laminectomy  may  be  considered, 
and  has  in  some  instances  been  successful.* 

The  general  trea  tment  of  caries  is  that  of  tuberculosis — fresh  air,  good 
food,  cod-liver  oil,  and  arsenic.  Counter-irritiition  in  these  instances  is 
of  doubtful  value. 

Unilateral  Lesions  of  the  Spinal  Cord  (Brown-Sfiquard's  Paralysis). - 
Tumors,  stab  wounds,  and  less  frequently  fracture  or  caries,  may  destroy 
one  half  of  the  cord,  causing  a  peculiar  and  definite  palsy,  which  was  first 
recognized  by  Browu-Sequard.  after  whom  it  has  been  named.  In  a  uni- 
lateral lesion  the  motor  fibres  are  interrupted  after  their  decussation  in 
the  medulla,  consequently  there  is  paralysis  of  the  leg,  or,  if  the  lesion  is 
in  the  cervical  cord,  of  the  arm  and  leg  on  the  same  side — spinal  hemi- 

*  See  full  discussion  of  the  subject  by  J.  William  White,  Therapeutic  Gazette,  1891. 


M 


i  I 


U 


1 
i 


854 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


plegia.  As  the  sensory  fibres,  entering  the  cord  through  the  posterior 
roots,  decussate  at  once  and  ascend  in  the  opposite  half  of  the  cord,  there 
is  loss  of  sensation  on  the  side  opposite  to  the  lesion,  so  that  in  hcmi- 
section  of  the  cervical  cord  above  the  brachial  enlargement  there  is  motor 
j)aralysis  of  the  arm  and  leg  of  the  same  side  and  anaesthesia  of  the  arm 
and  leg  of  the  opposite  side.  The  anajjsthesia  may  be  only  to  painful  and 
to  thermic  sensation.  In  many  cases  the  tactile  sensation  is  uninipairod. 
The  muscular  sense  is  diminished  on  the  same  side  as  the  lesion,  and  on 
this  side  also  the  skin  is  hyperaesthetic,  so  that  a  slight  irritation  is  felt 
very  acutely.  Of  this  phenomenon,  which  may  persist  for  years,  no  satis- 
factory explanation  has  been  given.  Just  above  the  level  of  the  hyperes- 
thesia there  is  a  narrow  zone  of  anaesthesia,  which  is  at  the  exav.t  physio- 
logical level  of  the  lesion  and  corresponds  to  the  fibres  coming  from  the 
same  side,  which  are  involved  at  once  on  entering  the  cord.  Ahove  tliis 
again  there  is  a  narrow  zone  of  hyperapsthesia.  The  reflexes  are  usually 
increased  on  the  side  of  the  lesion  and  the  temperature  is  slightly  raised. 

The  following  table  of  Gowers  illustrates  the  distribution  of  these  vari- 
ous symptoms  in  a  hemi-lesion  of  the  cord : 

Cord. 


Zone  of  cutaneous  hyperaesthesia. 
Zone  of  cutaneous  anajsthesia. 


Motor  palsy. 
IlyperiEsthesia  of  skin. 
Muscular  sense  impaired. 
Reflex  action  first  lessened  and 

then  increased. 
Temperature  raised. 


Lesion, 


Muscular  power  normal. 
Ijoss  of  sensibility  of  skin. 
Muscular  sense  normal. 
Reflex  action  noriniil. 
Temperature  same  as  that  abore 
lesion. 


It  is  only  in  exceptional  cases  that  all  these  features  are  met  with  in  a 
case  of  Brown-Sequard's  paralysis,  and  the  condition  may  be  transitory 
and  rapidly  replaced  by  paraplegia. 


VI.    Lesions  of  the  Cauda  Equixa  and  Conus  Medull.uiis. 

The  spinal  cord  extends  only  to  the  second  lumbar  vertebra.  Injury, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  itself,  hut 
the  bundle  of  nerves  known  as  the  cauda  equina  and  the  terminal  portion 
of  the  cord,  the  conus  meduUaris,  Much  attention  has  been  given  re- 
cently to  lesions  of  this  part.  The  whole  subject  is  admirably  discussed  in  a 
recent  work  by  Thorburn.*  Fractures  and  dislocations  are  common  in  thj 
lumbo-sacral  region,  tumors  not  infrequently  involve  the  filamentc  of  the 
Cauda  equina,  and  some  of  the  nerves  may  be  entangled  in  the  cicatrix  of 
a  spina  bifida. 


*  A  Contribution  to  the  Surgery  of  the  Spinal  Cord.    By  William  Thorburn.    Lon- 
don, 1890, 


CHRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


856 


Tn  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conus  me- 
dulliiris  may  be  compressed  with  the  last  sacral  nerves  given  oi?  from  it. 
In  a  case  recently  reported  by  Kirchhoff  there  was  laceration  of  the  conus 
with  complete  paralysis  of  the  bladder  and  rectum,  a  case  which  is  held  to 
favor  the  view  that  the  ano-vesical  centre  in  man  is  situated  in  this  region 
of  the  cord.  There  are  several  instances  on  record  in  which  injury  of  the 
Cauda  equina  has  produced  paralysis  of  the  bladder  and  rectum  alone, 
sometimes  with  a  slight  patch  of  anaesthesia  in  the  neighborhood  of  the 
coccyx  or  the  perinaeum.  More  commonly  branches  of  the  sacral  or  lum- 
bar nerve  roots  are  involved  producing  an  irregularly  distributed  motor 
and  sensory  paralysis  in  the  legs.  When  the  lumbar  nerve-roots  from  the 
second  to  the  fifth  are  compressed  there  is  paralysis  of  the  muscles  of  the 
legs,  with  the  exception  of  the  flexors  of  the  ankles,  the  pcrona^i,  the  long 
flexors  of  the  toes,  and  the  intrinsic  muscles  of  the  feet,  and  loss  of  sensa- 
tion in  the  front,  inner,  and  out^r  part  of  tlie  thighs,  the  inner  side  of  the 
legs,  and  the  inner  side  of  the  foot.  The  sacral  roots  may  alone  be  in- 
volved. Thus  in  a  case  which  I  have  reported  the  patient  fell  from  a  bridge 
and  had  paralysis  of  the  legs  and  of  the  bladder  and  rectum.  When  seen 
sixteen  years  after  the  injury,  there  was  slight  weakness,  with  wasting  of  the 
left  leg;  there  was  complete  loss  of  the  function  in  the  ano-vesical  and  gen- 
ital centres,  and  anaasthesia  in  a  strip  at  the  back  part  of  the  thigh  (in  the 
distribution  of  the  small  sciatic),  and  of  the  perinaeum,  scrotum,  and 
penis.  The  urethra  was  also  insensitive.  In  a  second  case,  in  a  young 
man  with  a  healed  spina  bifida  there  was,  with  a  small  area  of  anaesthesia, 
involvement  of  the  bladder  and  rectum,  but  retention  of  the  sexual 
power. 

Starr's  table,  given  in  the  section  on  motor  localization,  will  be  found 
usefid  in  determining  the  nerve  fibres  and  segments  involved  in  these  cases 
of  injury  of  the  cauda  equina. 


W-ll 


^1  ^ 


•bum.    I'i>ii- 


VII.  TuMOiis  OF  THE  Spinal  Cord  and  its  Membranes. 

New  growths  may  develop  in  the  cord  or  in  its  membranes,  or  may 
extend  into  them  from  the  spine.  The  first  two  alone  will  be  considered. 
Occiisionally  lipoma  and  parasites  occur  in  the  extradural  space.  Within 
the  dura  fibromata,  sarcomata,  and  syphilitic  and  tuberculous  growths  are 
most  common.  In  the  cord  itself,  aiid  attached  to  the  i)ia  mater,  the 
tuberculous,  syphilitic,  and  gliomatous  growths  are  most  frequent.  Of 
M  cases  of  tumor  of  the  spinal  cord  and  its  envelopes  analyzed  by  Mills 
and  Lloyd,  only  3  were  parasitic.  Of  these  '?G  were  some  form  of  neo- 
plasm, of  which  sarcomata  were  most  common,  5  were  gummatous,  and  4 
tuberculous.  Ilerter  has  recently  reported  3  cases  of  solitjiry  tubercle  in 
the  cord,  and  has  analyzed  others  from  the  literature.  Of  24  cases  in 
whicli  the  age  was  given,  15  occurred  between  the  ages  of  fifteen  and 
thirty-five,  and  5  before  the  fifth  year.     The  tumor  is  most  common  ia 


iiil  '.-:.:},  Wt- 


;■.;§ 


866 


DISKASES  OP  THE  NERVOUS  SYSTEM. 


the  dorsal  and  lumbar  regions,  and  is  usually  met  with  in  connection  wit!i 
tuberculous  lesions  elsewhere. 

The  anatomical  effects  of  tumors  are  very  varied.  Slow  compression 
is  usually  produced  by  growths  external  to  the  cord,  aTid  it  is  roniiu-kiiblo 
what  a  high  grade  of  compression  the  cord  will  bear  without  serious  inter- 
ference with  its  functions.  In  cases  of  prolonged  interruption  ascendin"' 
and  descending  degenerations  occair.  Tumors  developing  within  the  cord 
may  lead  to  syringo-myelia.  And,  lastly,  tumors  not  infrequently  exeito 
intense  myelitis. 

Symptoms. — These  will  naturally  vary  a  good  deal  with  the  segment 
involved  and  with  the  degree  of  pressure  and  the  extent  of  implication  of 
the  nerve-roots. 

AVithin  the  cord  the  symptoms  are  those  of  a  gradually  progressing 
paraplegia,  which  may  at  first  have  tlie  picture  of  a  Brown-Sequard  paral- 
ysis. Atrophy  follows  tlie  involvement  of  the  anterior  cornua,  and  vaso- 
motor disturbances  may  be  marked.  The  reflexes  are  lost  at  the  level  of 
tlie  lesion,  but  if  in  the  dorsal  cord,  the  reflexes  are  retained  in  the  lejjs. 
The  symptoms  are  apt  to  be  complicated  with  those  of  acute  or  subacute 
myelitis,  which  may  completely  alter  the  clinical  picture.  1'umors  of  the 
spinal  membranes  are  characterized  by  the  early  onset  and  persistence  of 
the  root  symptoms,  which  consist  of  radiating  pains,  girdle  sensation, 
hyperaesthesia,  or  anjesthesia  in  various  portions  of  the  trunk.  There  may 
even  be  severe  pain  in  the  aniesthetic  areas.  Irritation  of  the  motor  roots 
may  cause  spasm  of  the  muscles  supplied,  or  wasting  with  ])aralysis.  The 
paraplegia  supervenes  some  time  after  the  occurrence  of  the  root  symp- 
toms. In  the  dorsal  region  the  level  of  the  growtli  is  usually  accurately 
defined  by  the  level  of  the  pain  and  the  condition  of  the  reflexes. 

The  diagnosis  of  tumor  within  tlie  cord  is  sometimes  easy,  the  charac- 
teristic features  being  tlie  constancy  and  severity  of  the  root  symptoms  at 
the  level  of  the  growth  and  the  progressive  paralysis.  Caries  may  eauso 
identical  symptoms,  bu .  the  radiating  pains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  reality  produces  identical 
effects,  but  the  very  slow  progress  and  the  bilateral  character  from  the 
outset  may  be  sufficient  to  distinguish  this. 

In  chronic  transverse  myelitis  the  symptoms  may,  according  to  (row- 
ers, simulate  tumor  very  closely  and  present  radiating  pains,  a  sense  of 
constriction,  and  progressive  paralysis. 

The  nature  of  the  tumor  can  rarely  be  indicated  with  precision.  With 
a  marked  syphilitic  history  gumma  may  naturally  be  suspected,  and  with 
coexisting  tuberculous  disease  a  solitary  tubercle. 

Treatment. — If  the  possibility  of  syphilitic  infection  is  present  the 
iodide  of  potassium  should  be  given  in  large  and  increasing  doses.  For 
the  severe  pains  counter-irritation  is  sometimes  beneficial,  jiarticularly  the 
thermo-cautery ;  morphia  is,  however,  often  necessary. 

In  a  few  instances  tumors  of  the  cord  or  of  the  membranes  are  anienu- 


CHRONIC   AFFECTIONS  OP  THE  SPINAL  CORD. 


857 


ble  to  surgical  treutment.  Tlie  removal  by  Victor  Ilorsloy  of  a  growth 
from  the  membranes  of  the  cord  in  a  patieut  of  Gowcri'  waj  ono  of  the 
most  brilliaut  operations  of  modern  surgery. 


I'}        ^ 


4' 


>m     ill 


VIII.  Proouessive  (Spixal)  Muscular  Atrophy 

{Chronic  Degeneration  of  the  Motor  Nuclei — Poliomyelitis  Anterior 

Chronica). 

Definition. — A  disease  characterized  by  degeneration  of  groups  of 
the  motor  nuclei  in  the  cord  and  medulla,  with  wasting  of  the  correspond- 
ing muscles.  The  pyramidal  tracts  are  usually  involved,  and  the  paralysis 
may  have  a  spastic  character.  In  some  cases  the  degeneration  has  been 
traced  to  the  ganglion  cells  of  the  motor  cortex. 

Three  affections,  as  a  rule  described  apart,  belong  together  in  this 
category :  {a)  Progressive  muscular  atrojjhy  of  sjjinal  origin ;  [b)  amyo- 
trophic lateral  sclerosis ;  and  (r)  progressive  bulbar  ptiralysis.  A  slow 
atrophic  change  in  the  motor  nuclei  is  the  anatomical  basis,  and  the  dis- 
ease, as  Charcot  states,  is  one  of  the  whole  motor  path,  involving,  in  many 
cases,  the  cortical,  bulbar,  and  S2)inal  centres.  There  may  be  simple  mus- 
cular atrophy  with  little  or  no  spasm,  or  progressive  wasting  with  marked 
spasm  and  great  increase  in  the  reflexes.  In  otliers,  there  are  added  symp- 
toms of  involvement  of  the  motor  nuclei  in  the  medulla — a  glosso-labio- 
laryngeal  paralysis ;  while  in  others,  again,  with  atrophy  (especially  of  the 
arms),  a  spastic  condition  of  the  legs,  and  bulbar  phenomena,  tremord 
develop  and  signs  of  cortical  lesion.  These  various  stages  may  be  traced 
in  the  same  case.  I  have  for  ten  years  had  under  observation  a  man  M'hoso 
illness  began  with  M'eakness  and  atrophy  of  the  hand  muscles.  (Iradually 
the  legs  began  to  get  stiff  and  the  gait  spastic ;  the  arms  subsequently 
wasted  and  the  reflexes  were  increased.  After  these  symptoms  had  per- 
sisted with  increasing  intensity  for  six  or'  seven  years,  certain  of  tho 
motor  nuclei  of  the  medulla  became  involved,  the  speech  became  thick, 
and  the  movements  of  the  lips  and  tongue  Avere  impaired.  Tremor  has 
developed  of  late  in  the  arms  and  hands.  With  these  chronic  changes  tho 
visceral  functions  have  remained  unimpaired  and  the  mind  uiuiffeeted. 
It  has  been  a  lesion  of  the  motor  segments,  beginning  in  the  lower  and 
gradually  extending  upward.  The  disease  began  as  progressive  atroph}', 
and  gradually  assumed  a  typical  picture  of  amyotrophic  lateral  sclerosis, 
and  now  the  bulbar  features  are  well  msjrked  and  the  tremor  would  in- 
dicate that  the  cortex  is  also  involved. 

For  convenience,  bulbar  paralysis  will  be  considered  separately,  and  I 
bIuiII  here  take  up  iogei\\fiT progressive  muscular  atrophy  and  amyotrophic 
hifcral  sclerosis. 

The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive  mus- 
cular atrophy,  after  the  French  physicians  who  early  described  it,  and  as 
Cruveilhier's  palsy.     Lockhard  Clarke  demonstrated  that  it  was  a  spinal 


5-" 


1  ■' 


11 


'aM 


858 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


lesion.  Charcot  separated  the  two  types — one  with  simple  wastiii<r,  in 
which  the  anterior  horns  are  alone  involved  ;  and  the  other  in  wliicli,  wiili 
degeneration  of  the  cornua,  the  pyramidal  tracts  are  affected,  ciui.siii<r 
wasting  plus  a  spastic  condition.  To  this  he  gave  the  name  of  iinivotro- 
phic  lateral  sclerosis.  There  is  but  little  evidence,  however,  to  show  that 
the  anterior  liorns  are  ever  affected  without  secondary  changes  in  tlu- 
pyramidal  tracts,  and  Leydeu  and  Gowers  regard  the  two  diseases  as  iden- 
tical. 

Etiology. — The  cause  of  tlie  disease  is  unknown.  It  is  more  frofiuont 
in  males  than  in  females.  It  attacks  adults,  developing  after  the  tliii'tieth 
year,  though  occasionally  younger  persons  are  attacked.  A  large  nmjority 
of  all  cases  of  progressive  muscular  atrophy  under  twenty-five  years  of  uge 
are  of  myopathic  (i.  e.,  muscular),  not  myelopathic  (i.  e.,  spinal)  origin. 
Cold,  wet,  exposure,  fright,  and  mental  worries  are  mentioned  as  ixtssihlc 
causes.  Hereditary  influences  are  present  in  certain  cases.  The  fallior  of 
the  man  whose  case  is  referred  to  above  died  of  progressive  wasting  of  tlie 
muscles,  but  there  have  been  no  other  cases  in  the  family.  It  is  liighly 
probable  that  when  many  members  of  a  family  are  affected  the  disease  is 
not  spinal,  but  an  idiopathic  muscular  atrophy;  and  yet,  in  the  Fun- 
family,  which  I  recorded  a  few  years  ago,  in  which  thirteen  members  wore 
affected  in  two  generations,  with  the  exception  of  two,  the  cases  occurred 
or  proved  fatal  above  the  age  of  forty,  and  the  late  onset  speaks  rather 
for  a  spinal  affection.  The  amyotrophic  form  may  develop  late  in  life- 
after  seventy — as  a  senile  "liange. 

Morbid  Anatomy. — The  following  are  the  important  anatomiciil 
changes  :  {a)  The  muscles  waste  and  undergo  fatty  and  sclerotic  clianges. 
The  terminal  branches  of  the  motor  nerves  are  degenerated,  {h)  The 
anterior  roots  are  atrophied  in  those  sections  of  the  cord  corresponding  to 
the  wasted  muscles,  {c)  The  gray  matter  shows  the  most  marked  altera- 
tion. The  hirge  ganglion  cells  of  the  anterior  horns  are  atrophied,  or,  in 
places,  have  entirely  disappeared,  the  neurogliar  tissue  is  increased,  and 
the  fibres  of  the  anterior  nerve-root  passing  through  the  white  matter  are 
wasted,  {d)  In  a  majority  of  all  the  cases  there  is  sclerosis  in  the  antero- 
lateral tracts,  but  the  direct  cerebellar  and  the  antero-lateral  ascending,' 
tracts  are  spared.  It  was  to  this  combination  of  atrophy  of  the  anterior 
horns  and  sclerosis  of  the  antero-lateral  columns  that  Charcot  gave  the 
name  amyotrophic  lateral  sclerosis.  '  (e)  The  degeneration  of  the  gray 
matter  is  rarely  confined  to  the  cord,  but  extends  to  the  medulla;  the 
motor  nuclei  are  found  extensively  wasted  in  cases  which  have  sliowii 
bulbar  symptoms  during  life.  (/)  Cerebral  changes  also  occur.  'I'lio 
pyramidal  tracts  have  been  found  degenerated  through  the  pons  and  cap- 
sule, and  in  the  motor  cortex  the  large  ganglion  cells  are  wasted. 

The  essential  anatomical  change  is  a  slow  degeneration  of  the  motor 
path,  involving  specially  the  nerve-cells  of  the  anterior  cornua  and  the 
anterior  root-fibres,  to  which  the  loss  of  power  and  wasting  in  the  muscles 


'f 


JW^  .ft 


CHRONIC  AFFECTIONS  OP  THE  SPINAL  CORD. 


869 


are  secondary.  The  upper  segment  is  also  involved,  cither  simultaneously 
or  iit  a  later  period. 

S3nnptoms.— Irregular  pains  may  precede  the  onset  of  the  wasting. 
In  one  case  the  pains  were  about  the  hip  and  shoulder  joints  and  the  pa- 
tient was  treated  for  chronic  rheumatism.  The  hands  are  lirst  affected, 
and  there  isdifiiculty  in  performing  delicate  manipulations.  Tlie  muscles 
of  the  ball  of  the  thumb  waste  early,  then  the  interossei  and  Inmbricules, 
leaving  marked  depressions  between  the  metacarpal  bones.  Ultimately  the 
contraction  of  the  flexor  and  extensor  muscles  and  the  extreme  at.ophy 
of  the  thumb  muscles,  the  interossei,  and  lumbricalcs  produces  the  claw- 
hand — inai7i,  en  yriffe  of  Duchenne.  The  flexors  of  the  forearm  are  usu- 
ally involved  before  the  extensors.  In  the  shoulder-girdle  the  deltoid 
wastes  first ;  it  may  waste  even  before  the  other  muscles  of  the  uj)])er  ex- 
tremity. The  trunk  muscles  are  gradually  attacked  ;  the  u])per  i)art  of 
the  trapezius  long  remains  unaffected.  Owing  to  the  feebleness  of  the 
muscles  which  support  it,  the  head  tends  to  fall  forward.  The  platysma 
inyoides  is  unaffected  and  often  hypertrophies.  The  arms  and  the  trunk 
nuiseles  may  be  much  atroi)hied  before  the  legs  are  attacked.  The 
glutei,  the  vasti,  and  the  tibialis  amicus  are  first  attacked  when  the  dis- 
ease begins  in  the  legs.  In  the  member  of  the  Farr  family  who  came 
under  my  notice  (if  this  was  really  a  myelopathic  disorder)  the  wasting 
began  in  the  gluteal  and  hamstring  muscles  of  the  left  leg.  'J'he  face 
muscles  are  attacked  late.  Ultimately  the  intercostal  and  abdominal 
muscles  may  be  involved,  the  wasting  proceeds  to  an  extreme  grade,  and 
the  patient  may  be  actually  "  skin  and  bone,"  and,  as  "  living  skeletons," 
the  cases  are  not  uncommon  in  "  museums  "  and  "  side-shows."  Deforn)!- 
ties  and  contractures  result,  and  lordosis  is  almost  always  present.  A 
curious  twitching  of  the  muscles  (fibrillation)  is  a  common  symptom,  and 
may  occur  in  muscles  which  are  not  yet  attacked.  It  is  not,  as  was  for- 
merly supposed,  a  characteristic  feature  of  the  disease.  The  irritability 
of  the  muscle  is  increased.  Sensation  is  unimpaired,  but  the  patient  may 
complain  of  numbness  and  coldness  of  the  affected  limbs.  The  galvanic^ 
and  faradic  irritability  of  the  muscles  progressively  dimiinslies  and  may 
become  extinct,  the  galvanic  persisting  for  the  longest  time.  In  cases  of 
rapid  wasting  and  paralysis  there  may  be  the  reaction  of  degeneration. 
The  excitability  of  the  nerve-trunks  may  persist  after  the  muscles  have 
ceased  to  respond.  The  loss  of  power  is  usually  proportionate  to  the  de- 
gree of  wasting. 

The  foregoing  description  apiilies  to  the  group  of  cases  in  which  the 
iitropliy  and  paralysis  are  flaccid — atonic,  as  (Jowers  calls  it.  In  other  cases, 
those  which  Charcot  describes  as  amyotrophic  lateral  sclerosis,  with  the 
wasting  there  is  more  or  less  spasm,  which  may  exist  from  the  outset. 
Tliis  tonic  atrophy  may  involve  the  legs  chiefly  or  is  present  in  the  arms 
and  legs.  The  reflexes  are  greatly  increased.  The  most  typical  condition 
of  spastic  paraplegia  may  be  produced.     On  starting  to  walk,  the  patient 


IM-P 


•'■ 


}f-'t 


-3       t 

-  \i 

'■I 


I-  t^«^ 


1    1 

I*       kl 


n>.' 


8G0 


DISEASES  OP  THE  NKHVOUS  SYSTEM. 


seems  glued  to  the  ground  aiul  nuikos  inofToctual  attempts  to  lift  tlie  toes- 
tlicn  four  or  five  short,  quick  steps  are  taken  on  the  toes  with  tlio  body 
thrown  forward;  and  finally  ho  starts  olT,  sometimes  witli  great  rapiditv. 
Some  of  the  patients  can  walk  up  and  down  stairs  better  than  on  llio  level. 
The  wasting  is  never  so  extreme  as  in  the  atonic  form,  and  the  loss  of 
I)ower  may  bo  out  of  proportion  to  it.  I'ho  sphincters  arc  uimlTocteil. 
Sexual  power  may  be  lost  early. 

As  tlie  degeneration  extends  ui)ward  an  important  change  takes  place 
from  the  development  of  bulbar  symptoms,  which  may,  however,  precede 
the  spinal  manifestations.  The  lips,  tongue,  face,  pharynx,  and  larynx 
may  be  involved.  The  li[)S  may  be  affected  atul  articulation  impaired  for 
years  before  serious  symptoms  occur.  In  the  final  stage  there  may  be 
tremor,  the  memory  fails,  and  a  condition  of  dementia  may  develop. 

Gowcrs  gives  the  following  useful  classification  of  the  varieties  of  this 
affection:  (1)  Atonic  atrojdiy,  becoming  extreme ;  (2)  muscular  weakness 
with  spasm,  but  without  wasting  or  with  ouly  slight  wasting;  and  (3) 
atonic  atrophy,  rarely  extreme  in  degree,  with  excess  of  the  reflexes. 
These  conditions  may  "  coexist  in  every  degree  and  combination — between 
universal  atonic  atrophy  on  the  one  hand  aiul  universal  spastic  paralysis 
without  wasting  on  the  other." 

Diagnosis. — The  affection  must  be  distinguished  from  tlio  primary 
muscular  atrophies  which  usually  occur  in  younger  persons,  oft'ii  affect 
many  members  of  a  family,  and  have  a  different  distribution,  beginning 
cither  in  the  muscles  of  the  shoulder  girdU' — sparing  the  hands  or  involv- 
ing the  face  and  upper-arm  muscles — or  the  peroneal  group.  Muscular 
atrophy  in  the  adult,  beginning  in  -the  muscles  of  the  tliumbs,  gradually 
involving  the  interossei  aiul  lumbricales,  as  a  rule  is  of  myelopathic  origin. 

Treatment. — The  disease  is  incurable.  I  have  never  seen  the 
slightest  benefit  from  drugs  or  electricity.  The  downward  progress  is 
slow  but  certain,  though  in  a  few  cases  a  temporary  arrest  may  take  place. 
With  a  history  of  syphilis,  mercury  and  iodide  of  potassium  may  be  tried, 
and  GoAvers  recommends  courses  of  arsenic  and  strychnine.  Probably  the 
most  useful  means  is  systematic  massage,  particularly  in  the  spastic  c.ises. 


Bulbar  Paralysis  {Glosso-labio-larynffeal  Paralysis). 

An  affection  of  the  motor  nuclei  of  the  medulla  oblongata,  rarely  pri- 
mary, more  commonly  a  part  of  a  general  degenerative  affection  of  the 
nuclei  of  the  motor  path.  The  disease  is  sometimes  called  by  the  name  of 
Duchenne.    Acute  and  chronic  forms  may  be  recognized. 

(1)  Acute  bulbar  paralysis  may  be  due  to  {a)  hsemorrhagic  or  embolic 
softening  in  the  pons  and  medulla;  {b)  acute  inflammatory  softening, 
analogous  to  polio-myelitis,  occurring  occasionally  as  a  post-febrile  affec- 
tion. 

The  onset  is  usually  sudden,  hence  the  term  apoplectiform.    The  cases 


.^\ 


CnRONIC  AFFECTIONS  OF  THE  SPINAL  CORD. 


861 


are  almost  invariably  bijuteral.  As  the  nuclei  })resi(iing  over  the  muscles 
of  the  tongue  and  lips  are  involved  the  speech  is  almost  or  entirely  lost. 
The  saliva  drools,  the  li])8  arc  llabby  and  fla(!cid,  swallowing  may  be  ditli- 
ciilt,  and  there  may  be  loss  of  power  in  the  laryngeal  nuiseles.  Usually 
these  cases  rapidly  prove  fatal,  but  occasionally  a  case  with  a  sudden  onset, 
like  that  figured  by  Cowers,  may  become  chronic.  In  these  acute  cases 
there  may  be  loss  of  power  in  one  arm,  or  hemiplegia,  sometimes  alternate 
hemiplegia,  with  paralysis  on  one  side  of  the  face  and  loss  of  power  on  the 
otlier  side  of  the  body. 

{•i)  Chronic  bulbar  jmraly sis  is  an  affection  of  adult  life,  rarely  bogin- 
iiiiig  under  the  fortieth  year,  and  in  a  great  majority  of  the  cases  it  is  only 
part  of  a  general  degeneration  of  the  motor  nuclei.  The  disease  usually 
begins  with  slight  defect  in  the  speech,  and  the  patient  has  ditliculty  in 
pronouncing  the  dentals  and  Unguals.  The  paralysis  starts  in  the  tongue, 
and  tlie  superior  lingual  muscle  gradually  becomes  atrophied,  and  finally 
the  mucous  membrane  is  thrown  into  transverse  folds.  In  the  process  of 
wasting  the  fibrillary  tremors  are  seen.  Owing  to  the  loss  of  power  in  the 
tongue,  the  food  is  with  difficulty  pushed  back  into  tlie  pharynx.  The 
saliva  also  may  be  increased,  and  is  apt  to  accumulate  in  the  mouth.  When 
the  lips  become  involved  the  patient  can  neither  whistle  nor  pronounce 
the  vowels  o  and  u.  The  mouth  looks  large,  the  lips  are  prominent,  and 
there  is  constant  drooling.  The  food  is  masticated  with  ditliculty.  Swal- 
lowing becomes  difficult,  owing  jmrtly  to  the  regurgitation  into  the  nos- 
trils, partly  to  the  involvement  of  the  pharyngeal  muscles.  The  muscles 
of  the  vocal  cords  waste  and  the  voice  becomes  feeble,  but  the  laryngeal 
paralysis  is  rarely  so  extreme  as  that  of  the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  results 
from  an  aspiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  respiratory  centres.  The  mind  usually  remains  clear. 
The  patient  may  become  emotional.  In  a  majority  of  the  cases  the  dis- 
ease is  only  part  of  a  progressive  atrophy,  either  simi)le  or  associated  with 
a  spastic  condition.  In  the  latter  stage  of  amyotrophic  lateral  sclerosis 
tlie  bulbar  lesions  may  paralyze  the  lips  long  before  the  pharynx  or  larynx 
becomes  affected. 

The  diagnosis  of  the  disease  is  readily  made,  either  in  the  acute  or 
chronic  form.  The  involvement  of  the  lips  and  tongue  is  usually  well 
marked,  while  that  of  the  palate  may  be  long  deferred.  A  condition  has 
been  described,  however,  which  may  closely  simulate  bulbar  paralysis. 
This  is  the  so-called  pseudo-bulbar  form  or  bulbar  palsy  of  cerebral  origin. 
Bilateral  disease  of  the  motor  cortex  in  the  lower  part  of  the  ascending 
frontal  convolution  may  cause  paralysis  of  the  lips  and  tongue  and  pharynx, 
which  closely  simulates  a  lesion  of  the  medulla.  Sometimes  the  symptoms 
appear  on  one  side,  but  in  many  instances  they  develop  suddenly  on  both 
sides.  A  bilateral  lesion  has  usually  been  found,  but  in  several  instances 
the  disease  was  unilateral.  ,.  . 


I 


^^1  f: 


\.t^. 


i  ! 


802 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Progressive  bulbar  panilysis  is  an  incurable  affection.  Transient  im- 
provement may  occur.  Strychnine  may  be  tried.  Electricity  is  of  doubt- 
ful benefit.  Special  care  must  be  taken  in  feeding  these  patients,  arid 
when  deglutition  becomes  much  impaired  the  stomacli-tube  sIkjuKI  lie 
employed. 


III.    DISEASES  OF  THE   BRAIN. 

I.    AFFECTIONS  OF  THE   MENINGES. 

Diseases  of  the  Duka  Mater  {Pachymcninr/iiin). 

(a)  Pachymeningitis  Externa. — Ilajmorrhage  often  occurs  as  a  result 
of  fracture.  Inflammation  of  the  external  layer  of  the  dura  i.s  nire. 
Caries  of  the  bone,  either  extension  from  middle-car  disease  or  due  to 
syphilis,  is  the  principal  cause.  In  the  syphilitic  cases  there  miiy  be  a 
great  thickening  of  the  inner  table  and  a  largo  collection  of  pus  between 
the  dura  and  the  bone.  In  a  remarkable  case  of  this  kind  at  the  Mont- 
real General  Hospital  tlie  frontal  lobes  were  so  compressed  by  the 
thickened  skull,  and  the  purulent  effusion  between  the  bone  and  the  dura, 
that  the  anterior  vertical  measurement  of  the  brain  was  only  2'5  cm.,  while 
that  of  the  posterior  part  was  8  cm. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura 
mater  or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the 
syphilitic  cases  there  may  be  a  small  sinus  communicating  with  the  ex- 
terior.    Compression  symptoms  may  occur  with  or  without  paralysis. 

(b)  Pachymeningitis  Interna. — T'his  occurs  in  three  forms :  (1)  Pseudo- 
membranous, (2)  purulent,  and  (3)  haemorrhagic.  The  first  two  are  un- 
important. Pseudo-membranous  inflammation  of  the  lining  membrane 
of  the  dura  is  not  usually  recognized,  but  a  most  characteristic  exanijile 
of  it  came  under  my  observation  as  a  secondary  process  in  pneumonia. 
Purulent  pachymeningitis  may  follow  an  injury,  but  is  more  commoid) 
the  result  of  extension  from  inflammation  of  the  pia.  It  is  renuu-kable 
how  rarely  pus  is  found  between  the  dura  and  arachnoid  membranes. 

« 

HiEMORKnAGic  Pachymexingitis  {[[mmatoma  of  the  Dura  Mater). 

This  remarkable  condition,  first  described  by  Virchow,  is  very  rare  in 
general  medical  practice.  During  ten  years  no  instance  of  it  came  under 
my  observation  at  the  Montreal  General  Hospital.  On  the  other  hand. 
in  the  post-mortem  room  of  the  Philadelphia  Hospital,  which  received 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  uncom- 
mon, and  within  three  months  I  saw  four  characteristic  examples,  three 
of  which  came  from  the  medical  wards.    On  the  other  hand,  the  frequency 


AFFECTIONS  OP  THE  MENINUES. 


868 


nf  tlio  condition  in  uaylum  work  may  be  gatliercd  from  the  fact  tliat  Wij,'- 
crlc-iworth  found  42  examples  in  a  series  of  -100  unaelected  post-mortem 
examinations. 

'I'he  disease  is  found  chiefly  in  males  and  in  persons  over  fifty  years  of 
at;".  It  is  most  frequent  in  forms  of  chronic  insanity  and  in  chronic 
alcoliolism.  It  lias  also  been  found  in  profound  ana'mia  and  other  blood 
conditions,  and  is  said  to  have  followed  certain  of  the  acute  fevers. 

The  morbid  anatomy  is  interesting.  Virchow's  view  that  the  delicate 
vascular  membrane  ])recedes  the  hannorrhage  is  undoubtedly  correct. 
Priu'tically  we  see  one  of  throe  conditions  in  these  cases :  {a)  Subdural 
vascular  membranes,  often  of  extreme  delicacy;  {/))  simple  subdural  luem- 
orrliage  ;  {c)  combination  of  the  two,  vascular  membrane  and  blood-clot. 
Certainly  the  vascular  membrane  may  exist  without  a  trace  of  Inemorrhagc 
—simply  a  fibrous  sheet  of  varying  thickness,  pernunited  with  large  vessels, 
which  may  form  beautiful  arborescent  tufts.  On  the  other  hand,  there 
arc  instances  in  which  the  subdural  hannorrhagc  is  found  alone — in  15  out 
of  Wigglesworth's  42  cases— but  it  is  possible  that  in  some  of  these  at 
least  the  hiDmorrhage  may  have  destroyed  all  trace  of  the  vascular  mem- 
brane. In  some  cases  a  series  of  lamimited  clots  are  found,  forming  a 
layer  from  3  to  5  mm.  in  thickness.  Cysts  may  occur  within  this  mem- 
brane. The  source  of  the  hemorrhage  is  probably  the  dural  vessels.  IIu- 
genin  and  others  hold  that  the  bleeding  comes  from  the  vessels  of  the  pia 
mater,  but  certainly  in  the  early  stage  of  the  condition  there  is  no  evi- 
dence of  this ;  on  the  other  hand,  the  highly  vascular  subdural  membrane 
may  be  seen  covered  with  the  thinnest  possible  sheeting  of  clot,  which  has 
evidently  come  from  the  dura.  The  subdural  haemorrhage  is  usually  asso- 
ciated with  atrophy  of  the  convolutions,  and  it  is  held  that  this  is  one 
reason  Avhy  it  is  so  common  in  the  insane ;  but  there  must  be  some  other 
factor  than  atrophy,  or  we  should  meet  with  it  in  phthisis  and  various 
cachectic  conditions  in  which  the  cerebral  wasting  is  as  common  and  almost 
as  marked  as  in  cases  of  insanity. 

The  symptoms  are  indefinite,  and  the  diagnosis  cannot  be  made  with 
certainty.  Headache  has  been  a  prominent  symptom  in  some  cases,  and 
when  the  condition  exists  on  one  side  there  may  be  hemiplegia.  Exteri' 
sive  bilateral  disease  may  exist  without  any  symptoms  whatever. 


Diseases  of  the  Pia  Mater. 


{(t)  Acute  Leptomeningitis. — In  this  form  the  exudation  is  between 
the  pia  and  the  arachnoid  membranes. 

Etiology. — Acute  inflammation  of  the  pia  mater  occurs  under  the 
following  circumstances :  (1)  As  a  result  of  an  eruption  of  tubercles,  most 
frequently  in  the  basal  meninges,  forming  the  basilar  or  tuberculous  men- 
iiisiti'-'  which  has  been  already  considered  (see  tuberculosis).  (2)  In  the 
epidemic  cerebro-spinal  fever.     (3)  Secondary  to  acute  general  diseases, 


8M 


DISEASES  OK  THE  NERVOUS  SYSTEM. 


h  \' 


i- ., 


moro  particularly  pnoutnonia,  loss  frequently  small-pox,  typlioiil  fovcr, 
rluMimatic  fever,  wh(»()i)inj,'  cou'jlijHcurlet  fever,  and  incaHles.  In  crvsihclus 
TnoniM<,'itis  may  arise  eillier  hy  infection  tlirouf,'h  the  Itlood  or  hy  direct 
extension.  Cases  in  which  the  inflammation  passes  throncri,  ♦;„.  i„„„, 
are  extremely  rare;  on  the  other  lumd,  there  are  instaneeH  of  cxtcii- 
Bive  erysipelas  of  the  face  in  which  the  disease  travels  aloni,'  the  ucrvc- 
roots  and  so  reacdies  the  nieniufjes.  In  this  j,'roup  pneumonia  is  tiic  oiilv 
disease  which  is  fretpiently  followed  hy  meninj^dtis.  In  one  hiiiuhiil 
autopsies  at  the  Montreal  (Jeneral  Hospital  in  pnennu)iua,  nieuiufritis  was 
found  eight  times,  and  I  had  several  ojtportunities  of  seeinjf  cases  of  Am']- 
lar  character  in  I'hiludelphia.  In  septicaunia  and  pyaemia,  incliuliii},' 
ulcerative  endocarditis  in  this  category,  acute  meningitis  is  not  vcrv  rare. 
In  ulcerative  endocarditis  it  is  common,  as  jnay  be  judged  from  the  statis- 
tics which  I  collected  of  5*09  cases,  of  which  lio  were  complicated  with 
meningitis.  No  instance  has  fallen  under  my  observation  in  connection 
with  typhoid  fever  or  rheumatic  fever. 

(4)  Injury  or  disease  of  the  bones  of  the  skull,  perforating  wouiuls  of  tlio 
orbit,  or  as  a  sequence  of  abscess  which  is  tlie  result  of  injury.  Under  this 
section  by  far  the  moat  frequent  cause  is  necrosis  in  the  petrous  ])ortion  of 
the  temporal  bone,  which  may  excite  either  extensive  inflammation  of  tlie 
pia  mater  or  abscess  of  the  brain.  (.'))  In  certain  constitutional  conditions, 
such  as  gout  and  liright's  disease.  This  form  is  usually  basilar  and  comes 
on  insidiously.  Gout  is  usually  mentioned  as  a  cause  of  meningitis,  but  it 
must  bo  extremely  rare.  Duckworth  does  not  refer  to  it  in  his  work,  ami 
the  symptoms  of  the  so-called  cerebral  gout  can  scarcely  be  se2)aratc(l  from 
those  of  uraemia.  On  the  other  hand,  in  liright's  disease,  I  have  met  with 
at  least  three  instances  of  well-marked  meningitis,  chiefly  of  the  base. 

(0)  While  in  a  great  majority  of  all  cases  of  basilar  meningitis  in  chil- 
dren tubercles  may  be  found,  a  simple  JeptomenirujUiH  iufantum  must  also 
be  recognized.  Cases  are  not  very  uncommon.  Two  occurred  in  debili- 
tated children  under  my  care  at  the  Infants'  Home  in  Montreal,  and  1  saw 
at  least  two  specimens  of  the  kind  at  the  Philadelphia  Hospital.  The 
coiiditiou  may  be  limited  t:)  tiiu  meninges  at  the  base,  particularly  at  the 
posterior  part,  and  to  the  uruler  surface  of  the  cerebellum.  It  has  also 
boon  termed  occlusive  meningitis,  owing  to  the  fact  that  involving  chiefly 
the  posterior  portion  of  the  meninges  about  the  cerebellum  and  medulla, 
the  foramen  of  Magendie  may  be  closed,  with  the  result  of  acute,  some- 
times purulent  hydrocephalus,  as  described  by  Gee  and  Barlow.*  (1) 
Other  causes  mentioned  are  sun-stroke  and  excessive  study,  which  arc 
probably  doubtful.  Syphilis,  which  is  a  common  cause  of  chronic  menin- 
gitis, rarely  induces  the  acute  form. 

Morbid  Anatomy. — The  basal  or  cortical  meninges  may  be  involved. 
In  the  form  associated  with  pneumonia  and  ulcerative  endocarditis  tho 


*  On  the  Cervical  Opisthotonos  of  Infants,  St.  Bartholomew's  Hospital  Reports,  1878. 


APFKCTIONS  OP  THK   MKNINOKS. 


8<;5 


(lisciiso  is  hiliitoriil  and  usimlly  liiniti'il  to  tliocdrU-x.  In  cxtctisioii  from 
(list'iiso  of  the  car  it  is  usually  unilateral  aiul  iiuiy  !»('  accoiMitaiiicd  with 
iilisct'Ms  or  with  tlironihosis  of  tlio  sinuses.  In  thu  iioti-tuluTculouH  form 
ill  children,  in  the  nu'iiin^'itis  of  cliroiiic  Hriirht's  disease,  aiul  in  eachectio 
(■{(lulitions  the  base*  is  usually  involve(l.  The  vessels  are  injected,  the 
siiharachnoid  lluid  is  inereaseil  and  bei-oiues  opa(|ue.  'I'he  arachnoid  is 
also  turbid,  and  tlierc  may  be  a  yellowish-white,  creamy  exiulate.  or  a  <rray- 
isli-ijreen  purident  matter  beiu'ath  the  araehnoid.  'i'he  iiiter[>('(Iuncular 
xpace  may  be  completely  filled  with  the  exudate,  which  extends  upon  the 
under  surface  of  the  cerebellum.  In  the  eases  secondary  to  pneumonia 
the  I'lTusion  beneath  the  arachnoid  may  be  very  thick  and  purident,  eom- 
|)lotely  liiding  the  convolutions.  The  ventricles  also  may  be  involved, 
th()iif,di  in  these  simple  forms  they  rarely  present  the  distention  and  soft- 
I'liiiii;  which  is  so  fre(|uent  in  the  tuberculous  meningitis. 

Tiie  It'pfoinrniiif/ififi  infantuni  may  present  a  jjicture  very  similar  to 
the  lid)erculous  disease.  There  is  exudation  about  the  optic  (diiasma  and 
in  the  Sylvian  fissures  and  toward  the  cerebellum.  In  some  instances  we 
ran  say  detinitely  that  the  ctindition  is  not  tuberculous  oidy  after  the  nuwt 
careful  search  in  the  menin<?es  and  central  arteries,  and  when  no  tubercles 
are  found  in  i\w  lungs  and  bronchial  glands.  In  otluu-  instaiu'es  the  men- 
ingitis may  be  limited  to  the  posterior  part  of  the  base,  about  the  pons, 
cerebellum,  and  fourth  ventricle,  and  the  lateral  ventricUiS  may  present  a 
most  renuirkable  ei)endymitis.  In  a  specimen  recently  shown  to  me  by 
W.  T.  Howard,  Jr.,  from  a  child  aged  three  months  (which  had  had  an 
operation  performed  for  imperforate  anus),  there  Avas  posterior  bavsilar 
meningitis,  the  fourth  ventricle  was  filled  with  pus,  the  walls  thickened, 
rough,  and  infiltrated  with  pus ;  the  lateral  ventricles  were  enormously 
distended  with  pus,  and  the  ependynia,  which  was  from  two  to  three  milli- 
metres in  diameter,  was  softened  and  in  a  condition  of  purulent  iidiltra- 
tion.  A  coccus  and  the  hncternim  coli  commune  were  fouiul  in  the  ])uh. 
In  a  somewhat  similar  case  at  the  Philadelphia  Hospital  the  opeiulymitis 
was  limited  to  the  ])osterior  and  descending  cornua,  which  were  greatly 
distended  and  ccmtained  i)us.  'J'hc  anterior  cornua  were  little,  if  at  all, 
affected,  owing  doubtless  to  the  influence  of  gravity.  This  coiulition  of 
intense  purulent  ependymitis  is  rare  in  the  adult,  but  T  remember  to  have 
seen  an  histance  of  it  in  a  patient  of  Pepper's  at  the  University  Hospital, 
Philadelphia. 

Symptoms. — I  have  already  spoken  at  length  of  the  clinical  features 
of  tuberculous  meningitis,  which  is  by  far  the  most  common  and  impor- 
tant form.  The  other  varieties  have  a  general  resemblance  to  it,  })articu- 
larly  those  in  which  the  base  ia  affected.  I  have  already,  on  several  occa- 
sions, called  attention  to  the  fact  that  cortical  meningitis  is  not  to  be 
recognized  by  any  symptoms  or  set  of  symptoms  from  a  condition  which 
may  be  produced  by  the  poison  of  many  of  the  specific  fevers.  In  the 
cases  of  so-called  cerebral  pneumonia,  unless  the  base  is  involved  and  the 


i 


•'X\ 


;  '-■  ~'i{» 


i; 


K 


ii 


8  JO 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


nerves  affected,  the  disease  is  unrecognizabK ,  since  identical  syniptonig 
may  be  produced  by  intense  engorgement  of  the  meninges.  In  typhoid 
fever,  in  which  meningitis  is  very  rare,  the  twitchings,  spasms,  and  re- 
tractions of  the  neck  are  almost  invariably  associated  with  cerebro-siiinal 
congestion,  not  with  meningitis. 

A  knowledge  of  the  etiology  gives  a  very  important  clow.  Tims,  in 
middle-ear  d'sease  the  development  of  high  fever,  delirium,  vomiting, 
c^onvulsions,  and  retraction  of  the  head  and  neck  would  be  extreincly  sjug- 
gestive  of  meningitis  or  abscess.  Headache,  which  may  be  severe  iiiul  con- 
tinuous, is  the  most  common  symptom.  In  the  fevers,  particularly  in 
pneumonia,  there  may  be  no  complaint  of  headache.  Delirium  is  fre- 
quently early,  and  is  most  marked  when  the  fever  is  high.  Convulsiftns 
arc  less  common  in  simple  than  in  tuberculous  meningitis.  Tlicy  were 
not  present  in  a  single  instance  in  the  cases  which  I  have  seen  in  pneu- 
monia, ulcerative  endocarditis,  or  septicaemia.  In  the  simple  meningitis 
of  children  they  may  occur.  Rigidity  and  spasm  or  twitchings  of  the 
muscles  are  more  common.  )Stitl'ness  and  retraction  of  the  nuiseles  of 
the  neck  are  important  symptoms;  but  they, are  by  no  means  constant, 
and  are  most  frequent  when  the  inflammation  extends  to  the  meninges 
of  the  cervical  cord.  Vomiting  is  a  common  symptom  in  the  early  stages, 
particularly  in  basilar  meningitis.  Constipation  is  usually  present.  Optic 
neuritis  is  rare  in  the  meningitis  of  the  cortex,  but  is  not  uncommon  wiien 
the  base  is  involved. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  hase. 
Strabismus  or  ptosis  may  occur.  The  facial  nerve  may  be  involved,  pro- 
ducing slight  paralysis,  or  there  may  be  damage  to  the  fifth  nerve,  pro- 
ducing ana3sthesia  and,  if  the  Gasserian  ganglion  is  affected,  tro])hic  changes 
in  the  cornea.  The  jjupils  are  at  first  contracted,  subsequently  dilated, 
and  perhaps  unequal. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  10;i°.  In  the 
non-tuberculous  leptomeningitis  of  debilitated  children  and  in  Brigiit's 
disease  there  may  be  little  or  no  fever.  The  pulse  may  be  increased  in 
frequency  at  first  and  subsequently  is  slow  and  irregular. 

Treatment. — There  are  no  remedies  which  in  any  way  control  tlie 
course  of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head 
and,  if  the  subject  is  young  and  full-blooded,  general  or  local  deph  tion 
may  be  practised.  Absolute  rest  and  quiet  should  be  enjoiucil.  When 
disease  of  the  ear  is  present,  a  surgeon  should  bo  early  called  in  con- 
sultation, aiul  if  there  are  symptoms  of  meningo-cncephalitis  which  can 
in  any  way  be  localized  trephining  should  be  practised.  An  occasion- 
al saline  purge  will  do  more  to  relieve  the  congestion  than  blisters  and 
local  depletion.  I  have  no  belief  whatever  in  the  efficacy  of  counter- 
irritation  to  the  back  of  the  neck,  and  to  apply  a  blister  to  a  patient 
suffering  with  agonizing  headache  in  meningitis  is  needlessly  to  adtl  to 
the  sulTeriiig.     If  counter-irritation  is  deemed  essential,  the  thernio-cau- 


AFFECTIONS  OP  THE  BLOOD-VESSELS. 


8G7 


terv,  liglitly  applied,  is  more  satisfactory,  because  the  pain  inflicted  is 
transient. 

The  gastro-intestinal  symptoms  should  receive  api)roi)riate  treatment. 
Gowers  states  that  in  two  instances  of  septic  meningitis  which  recovered 
the  good  effects  seemed  to  be  duo  to  large  doses  of  the  perchlorido  of 
iron.  Iodide  of  potassium  aiid  mercury  are  recommended  by  somo 
autliors. 

The  application  of  an  ice-cap,  attention  to  the  bowels  and  stomach, 
and  keeping  the  fever  at  a  moderate  height  by  sponging,  are  the  necessary 
measures  in  a  disease  recognized  as  almost  invariably  fatal,  and  in  which 
the  cases  of  recovery  are  extremely  doubtful. 

(/;)  Chronic  Leptomeningitis. — 'I'his  is  rarely  seen  apart  from  syphilis 
or  tuberculosis,  in  which  the  meningitis  is  associated  with  the  growth  of 
the  granulomata  in  the  meninges  and  about  the  vessels.  The  symptoms 
in  such  cases  are  extremely  variable,  depending  entirely  upon  the  situa- 
tion of  the  growth.  They  may  closely  resemble  those  of  tumor  and  bo 
iissociated  with  localized  convulsions.  The  leptomeningitis  infantum  may 
he  chronic.  In  tlic  cases  reported  by  Gee  and  Barlow  the  duration  in 
some  instances  extended  even  to  a  year  and  a  half.  The  involvement  of 
the  posterior  part  of  the  meninges  and  of  the  ventricles  may  lead  to  dilata- 
tion and  hydrocephalus.  The  symptoms  upon  which  these  authors  lay 
?tross  arc  ccmvulsions,  and  retraction  of  the  head,  which  is  particularly 
marked  when  the  child  is  made  to  sit  up.  There  may  be  rigidity  of  the 
limbs  and  epileptiform  convulsions. 


II.    AFFECTIONS  OF  THE   BLOOD-VESSELS. 

IIyi'Ku.kmia. 

Congestion  of  the  brain  has  played  an  important  part  in  cerebral 
pathology.  Undoubtedly  there  are  great  variations  in  the  amount  of 
blood  in  the  cerebral  vessels ;  this  is  universally  conceded,  but  how  far 
these  cliunges  are  associated  with  a  definite  group  of  symptoms  is  not 
quite  Ko  clear.     The  hyperaimia  may  be  either  active  or  passive. 

Active  hyperwmia  is  associated  with  febrile  conditions,  with  increased 
iiftion  of  the  heart,  chilling  of  the  surface,  contraction  of  the  superficial 
vessels,  and  with  the  suppression  of  certain  customary  discharges.  Among 
'itlier  recognized  causes  arc  plethora,  functional  irritation,  such  as  is  asso- 
tiated  with  excessive  brain  work,  and  the  action  of  certain  substances,  sucli 
as  alcohol  and  nitrite  of  amyl. 

Passive  hyperwmia  results  from  obstruction  in  the  cerebral  sinuses 
and  veins,  engorgement  in  the  lesser  circulation,  as  in  mitral  stenosis, 
tnipliysema,  from  pressure  on  the  superior  cava  by  aneurisms  and  tumors, 
and  in  the  venous  cngorgomeut  which  takes  place  in  prolonged  straining 

66 


I     I 


868 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


efforts.  In  it3  most  intense  form  it  is  seen  in  the  compression  of  tho 
superior  cava  by  tumors  and  in  death  from  stranf,nilati()n. 

The  anatomical  changes  in  congestion  of  the  brain  are  by  no  means 
striking.  Active  hyperiemia  is  never  visible  post  mortem.  The  veins  of 
tho  cortex  are  distended,  the  gray  matter  has  a  deeper  color,  and  its 
vessels  arc  full.  The  arteries  at  the  base  and  in  the  Sylvian  fissures  eon- 
tain  blood.  Nothing,  however,  can  be  more  uncertain  or  indefinite  tluiu 
the  post-mortem  appearances  of  hyperemia  of  the  brain.  Tlie  most  intense 
distention  of  the  vessels  is  seen  in  early  death  during  the  specific  fevers, 
or  in  the  secondary  passive  congestion  due  to  olxstraction  in  the  superior 
cava  or  in  the  lesser  circulation. 

Symptoms. — There  are  no  characteristic  or  constant  features  of 
cerebral  hyperemia.  It  may  exist  in  the  most  extreme  grade  without  tlio 
slightest  distui'bance  of  the  cerebral  functions,  as  is  witnessed  freciuently 
in  the  pressure  of  tumors  on  tlie  superior  vena  cava.  IIow  far  the  head- 
ache and  delirium  of  the  early  stage  of  the  infectious  fever,-,  Is  !o  !)e 
assigned  to  hyperiemia  of  tlie  Ijlood-vessels  of  the  brain  it  i  ".ot  ■  lo 
determine.  The  hoaduche,  dizziness,  and  unpleasant  sensati^  ■  i.  .  ,,.o 
insufficiency  and  in  some  instances  of  hypcrtrojjhy  of  the  lie;u  t  liiuy  be 
due  to  the  cerebral  congestion. 

As  a  separate  clinical  entity,  congestion  of  the  brain  rarely  ("ines 
under  observation.  I  have  no  knowledge  of  instiinees  associated  with 
delirium,  fever,  insomnia,  and  convulsion.s,  or  of  the  so-called  apopleetiforiii 
variety  described  by  some  writers.  Very  plethoric  persons  are  subject  to 
attacks  of  headache  with  flushing  of  tlie  face  and  irritability  of  temper, 
attiicks  which  may  recur  frequently  and  are  sometimes  relieved  by  lileed- 
ing  at  the  nose.  These  are  usually  attributed  to  congestion  of  the  brain. 
AVhen  passive  hypenemia  reaches  a  high  grade,  there  may  be  torpor,  Jul- 
ncss  of  the  intellect,  and  ultimately  deep  coma. 

AXTEMIA. 

This  may  be  induced  by  loss  of  blood,  either  quickly,  as  in  haemor- 
rhage, or  gradually,  as  in  the  severe  primary  and  co  idary  anieniias. 
The  antemia  may  be  local  and  due  to  causes  which  interfere  with  the  Ijleod 
supply  to  the  brain,  as  narrowing  of  the  ves-seis  by  endarteritis,  pressu  , 
narrowing  of  the  aortic  oriliro,  or'  it  may  follow  an  unequal  distril)ution 
of  tho  blood  in  consequence  of  dilatation  of  certain  vascular  tenitories. 
Thus,  rapid  distontion  of  the  intestinal  ve^wds,  such  as  occurs  aftiT  tho 
removal  of  ascitic  fluid,  may  causti  sudden  death  from  cerebral  anaMniii. 
Tho  commonest  illustration  of  this  is  the  fainting  fit  from  eindtioii.  ■' 
which  the  blood  supply  to  the  brain  is  insufTicient  on  account  of  ti 
diminished  arterhd  jiressure.  Anjumia  of  tlic  cerebral  vessels  may  ho 
caused  by  pressure  of  fluid  in  the  ventri'dcs.  'j'he  par'ial  an.^:'u;i  results 
from  obliteration  of  brancdies  of  the  circle  of  Wilii.^  bv  ^,Iu.Jolisln  )r  throni- 


■f,t : 


^■',f'. 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


8C9 


!Ssion  of  tlio 


bosis.     Ligature  of  one  carotid  sometimes  causes  a  transieut  marked  auaj- 
mi:i  and  disturbance  of  function  on  one  side  of  the  brain. 

The  anatomical  condition  of  tlie  brain  in  anaemia  is  very  striking. 
The  membranes  are  pale,  only  the  large  veins  arc  full,  the  small  vessels 
■over  the  gyri  are  empty,  and  an  unusual  amount  of  ccrebro-spinal  fluid  is 
present.  On  section  both  the  gray  and  white  matter  look  extremely  pale 
and  the  cut  surface  is  moist.    Very  few  puiicta  vasculosa  are  seen. 

Symptoms. — Thu  effects  of  anaemia  of  the  brain  are  well  illustrated 
by  a  fainting  lit  in  which  loss  of  consciousness  follows  the  heart  weakness. 
Wlien  the  result  of  haemorrhage,  there  are  drowsiness,  giddiness,  inability 
to  stand,  flashes  of  light,  and  noises  in  the  ear ;  the  respiration  becomes  hur- 
ried ;  the  skin  is  cool  and  covered  with  sweat ;  and  gradually,  if  the  bleed- 
ing continues,  consciousness  is  lost  and  death  may  occur  with  convulsions. 
Ill  ordinary  syncope  the  loss  of  consciousness  is  usually  transient  and 
the  recumbent  posture  alone  may  suffice  to  restore  the  patient  to  con- 
sciousness. In  the  more  chronic  forms  of  brain  anaemia,  such  as  result 
from  the  gradual  impoverishment  of  the  blood,  as  in  protracted  illness  or 
in  starvation,  the  condition  known  as  irritable  weakness  results,  ilental 
effort  is  difficult,  the  slightest  irritation  is  followed  by  undue  excitement, 
the  patient  complains  of  giddiness  and  noises  in  the  ears,  or  there  may  be 
hallucinations  or  delirium.  These  symptoms  are  met  with  in  an  extreme 
griicle  as  a  result  of  prolonged  starvation. 

An  interesting  set  of  symptoms,  to  which  the  term  liydrocepUaloid  was 
!ip})liod  by  Marshall  Hall,  occurs  in  the  debility  produced  by  prolonged 
diarrho'a  in  children.  The  child  is  in  a  semi-comatose  condition  with  the 
eyes  open,  the  puj)ils  contracted,  and  tlie  fontanelle  depressed.  In  the 
earlier  period  there  may  be  convulsions.  The  coma  may  gradually  deepen, 
the  pupils  become  dilated,  and  there  may  be  strabismus  and  even  retrac- 
tion of  the  head,  symptoms  which  closely  simulate  basilar  meningitis. 

(Edema  of  the  Brain. 

[a  the  pathology  of  brain  lesions  uidema  formerly  played  a  role  almost 
i,1'iul  in  importance  to  congestion.  It  occurs  under  the  following  condi- 
tions: In  general  atrophy  of  the  convolutions,  in  which  case  the  anlema 
is  reprcsonted  by  an  increase  in  the  cerebro-spiual  fluid  and  in  that  of  the 
meshes  ol  the  pia.  In  extreme  hyperosmia  from  obstruction,  as  in  mitral 
ftenosia  or  in  tumors,  there  may  be  a  condition  of  congestive  a'dema,  in 
which,  in  addition  to  great  filling  of  the  blood-vessels,  the  substance  of 
the  hv'Axn  itself  is  unusually  moist.  The  most  acute  aidema  is  a  local  pro- 
fess found  around  tumors  and  abscesses.  An  intense  infiltration,  local  or 
jroiivral,  may  occur  in  liright's  disease,  and  to  it,  as  Traube  suggested,  cer- 
tain of  the  ursemic  symptoms  may  be  due. 

The  anatomical  changes  are  not  unlike  those  of  anaemia.  ♦Vhen  a 
t^equouce  of  progressive  atrophy,  the  fluid  is  chiefly  within  and  beneatl- 


■  ?,;.'    t 


.     E    ^1 


I 


IS 


870 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


the  membranes.  The  brain  substance  is  anaemic  and  moist,  and  lias  a 
wet,  glistening  appearance,  which  is  very  characteristic.  In  some  in- 
stances the  oedema  is  more  intense  and  local  and  the  brain  substance  may 
look  infiltrated  with  fluid.  The  amount  of  fluid  in  the  ventricles  is  usu- 
ally increased. 

The  symptoms  are  in  great  part  those  of  anaemia,  and  arc  not  well 
defined.  As  just  stated,  some  of  the  cerebral  features  of  unvniia  may 
depend  upon  it.  Of  late  years  cases  have  been  reported  by  Kaymoud, 
Tenneson,  and  Dercum,  in  which  unilateral  convulsions  or  paralysis  have 
occurred  in  connection  with  chronic  Bright's  disease,  and  in  wliich  the 
condition  appeared  to  be  associated  with  oedema  of  the  brain.  The  older 
writers  laid  great  stress  upon  an  apoplexia  serosa,  which  may  really  have 
been  a  general  oedema  of  the  brain. 

Cerkbual  ILtjmokuiiage. 

The  bleedmg  may  come  from  branches  of  either  of  the  two  great 
groups  of  cerebral  vessels — the  basal,  comprising  the  circle  of  Willis  and 
the  central  arteries  passing  from  it,  or  the  cortical  group,  the  anterior. 
middle,  and  the  posterior  cerebral  vessels.  In  a  majority  of  the  cases  tin- 
haemorrhage  is  from  the  central  branches,  more  particularly  from  those 
given  olf  by  the  middle  cerebral  arteries  in  the  anterior  perforated  spaces, 
and  which  supply  the  corpora  striata  and  internal  capsules.  One  of  the 
largest  of  these  branches  which  passes  to  the  third  division  of  the  lenticular 
nucleus  and  to  tlie  hinder  part  of  the  internal  capsule  is  so  frequently  in- 
volved in  haemorrhage  that  it  has  been  called  by  Charcot  the  artt'ri/  of 
cerebral  hmynorrhage.  The  bleeding  may  be  into  the  substance  of  the 
brain,  to  which  alone  the  term  cerebral  apoplexy  is  applied,  or  into  the 
membranes,  in  which  case  it  is  termed  meningeal  haemorrhage;  both, 
however,  are  usually  included  under  the  terms  intracranial  or  cerel)ral 
haemorrhage. 

Etiology. — The  conditions  which  produce  lesions  of  the  blood-ves- 
sels play  a  very  important  part ;  thus  the  natural  tendency  to  degeneration 
of  the  vessels  in  advanced  life  makes  apoplexy  much  more  common  after 
the  fiftieth  year.  It  may,  however,  occur  in  children  under  ten.  On 
account  of  the  greater  liability  to  arterial  disease  (associated  probably 
with  muscular  exertion  and  the  abuse  of  alcohol),  men  are  more  sul)ject 
to  cerebral  hemorrhage  than  women.  Heredity  was  formerly  thought. 
to  be  an  important  factor  in  this  affection,  and  the  apoplectic  Iiahi/iis  or 
build  is  still  referred  to.  By  this  is  meant  a  stout,  plethoric  body  of  me- 
dium size,  with  a  short  neck.  Heredity  influences  cerebral  haemorrhage 
entirely  through  the  arteries,  and  there  are  families  in  which  they  degenor- 
•ite  early,  usually  in  association  Avith  renal  changes.  The  secondary  hyper- 
trophy of  the  heart  brings  with  it  serious  dangers,  which  have  already 
been  discussed  in  the  section  upon  arteries.     The  three  special  factors  m 


!:«• 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


871 


inducing  artcrio-sclerosis — the  abuse  of  alcohol,  syphilis,  and  prolonged 
muscular  exertion — are  found  to  be  important  antecedents  in  a  large  num- 
ber of  cases  of  cerebral  haemorrhage. 

The  endocarditis  of  rheumatism  and  other  fevers  may  indirectly  lead 
to  iii)oplexy  by  causing  embolism  and  aneurism  of  the  vct-sels  of  the 
brain.  Cerebral  haemorrhage  occurs  occasionally  in  the  specific  fevers 
and  in  profound  alterations  of  the  blood,  as  in  leukaemia  and  pernicious 
iinamiia.  The  actual  exciting  cause  of  the  haemorrhage  is  not  evident  in 
the  majority  of  cases.  The  attack  may  be  sudden  and  without  any  pre- 
liminary symptoms.  In  other  instances  violent  exertion,  particularly 
^training  efforts  or,  the  excited  action  of  the  heart  in  emotion  may  cause 
a  rupture. 

Morbid  Anatomy. — The  lesions  causing  apoplexy  are  almost  in- 
variably in  the  cerebral  arteries,  in  which  the  following  changes  may  lead 
directly  to  it : 

(a)  Periarteritis  with  the  production  of  miliary  aneurisms,  rupture  of 
which  is  the  most  common  cause  of  cerebral  hasmorrhage.  They  occur  most 
frequently  on  the  central  arteries,  but  also  on  the  smaller  branches  of  the 
cortical  vessels.  On  section  of  the  brain  substance  they  may  be  seen  as 
localized,  small  dark  bodies  about  the  size  of  a  pin's  head.  Sometimes 
tiicy  are  seen  in  numbers  upon  the  arteries  carefully  withdrawn  from  the 
anterior  perforated  spaces.  According  to  Charcot  and  Bouchard,  who  have 
described  them,  they  are  most  frequent  in  the  central  ganglia.  In  apo- 
plexy after  the  fortieth  year  if  sought  for  they  are  rarely  missed. 

{b)  Aneurism  of  the  branches  of  the  circle  of  Willis.  These  are  by 
no  means  uncommon,  and  will  be  considered  subsequently. 

(c)  Endarteritis  and  periarteritis  in  the  cerebral  vessels  most  commonly 
lead  to  apoplexy  by  the  production  of  aneurisms,  either  miliary  or  coarse. 
There  are  instances  in  which  the  most  careful  search  fails  to  reveal  any- 
thing but  diffuse  degeneration  ol"  the  cerebral  vessels,  particularly  of  the 
smaller  branches ;  so  that  we  must  conclude  that  spontaneous  rupture 
may  occur  without  the  previous  formation  of  aneurism. 

The  haemorrhage  may  be  meningeal,  cerebral,  or  intraventricular. 

Mriii)H/eal  Ummorrhage  may  be  outside  the  dura,  between  tliis  mem- 
brane and  the  bone,  or  between  the  dura  and  arachnoid,  or  between  the 
aracliuoid  and  the  pla  mater.  The  following  are  the  chief  causes  of  this 
form  of  haemorrhage  :  Fracture  of  the  skull,  in  which  case  the  blood  usu- 
ally comes  from  the  lacerated  meningeal  vessels,  sometimes  from  the  torn 
sinuses.  In  these  cases  the  blood  is  usually  outside  the  dura  or  between  it 
and  the  arachnoid.  The  next  most  frequent  cause  is  rupture  of  aneurisms 
on  the  larger  cerebral  vessels.  The  blood  is  usually  subarachnoid.  An 
iiitraeorobral  haemorrhage  may  burst  into  the  meninges.  A  special  form 
(if  nieiiingeal  haemorrhage  is  found  in  the  new-born,  associated  with  injury 
during  birth.  And  lastly,  meningeal  haemorrhage  may  occur  in  the  con- 
stitutional diseases  and  fevers.     The  blood  may  bo  in  a  large  quantity  at 


872 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


I* 


1 


the  base ;  in  cases  of  ruptured  aneurism,  particularly,  it  may  extend  into 
the  cord  or  upon  the  coch  x.     Owing  to  tlie  greater  frequency  of  tlie  aneu- 
risms in  the  middle  cerebral  vessels,  the  Sylvian  fissures  are  often  di.-; 
tended  with  blood. 

Intrncerebral  hmmorrhagc  is  most  frequent  in  the  neighborhood  of  tin; 
cor])us  striatum,  particularly  toward  tiie  outer  section  of  the  lenticular 
nucleus.  The  hfemorrhage  may  be  small  and  limited  to  the  lenticuhir 
body  and  the  internal  capsule,  or  it  may  break  the  centrum  ovale,  or  hurst 
into  the  lateral  ventricle,  or  extend  to  the  insula,  lliemorrluigos  con- 
fined to  the  white  matter — the  centrum  ovale — are  rare.  Localized  b]cc(l- 
ing  may  occur  in  the  crura  or  in  the  pons.  Ilaimorrluige  into  the  ccn;- 
bellum  is  not  uncommon,  and  usually  comes  from  the  superior  corehcllar 
artery.  The  extravasation  may  bo  limited  to  the  substance  or  ruptui'o 
into  the  fourth  ventricle.  'I'wice  I  have  known  sudden  dcatli  in  <rirls 
under  twenty-five  to  be  due  to  cerebellar  hosmorrhage. 

Ventricular  Hwmorrhnge. — This  rarely  comes  from  the  vessels  of  the 
plexuses  or  of  the  walls.  It  is  luit  infrequent  in  early  life  aiul  may  occur 
during  birth.  Of  94  cases  collocated  by  Edward  Sanders,  7  occurred  during 
the  first  year,  aiul  14  uiuler  the  twentieth  year.  In  the  cases  which  I  havo 
seen  in  adults  it  has  almost  always  been  caused  by  rupture  of  a  ha^nior- 
rhage  in  the  neighborhood  of  the  caudate  nucleus.  The  blood  may  he 
found  in  one  ventricle  only,  but  more  commonly  it  is  in  both  laterul  ven- 
tricles, aiul  may  pass  into  the  tliird  ventricle  and  through  t])e  aijuedtict 
of  Sylvius  into  the  fourth  ventricle,  forming  a  complete  mould  in  ])]ood 
of  the  ventricular  system. 

Subsequent  CJinnr/es. — The  bloml  gradually  changes  in  color,  and  ulti- 
mately the  ha?moglobin  is  converted  into  the  reddish-brown  httnnatoidiu. 
Inflammati(m  occurs  about  the  apoplectic  area,  limiting  and  confining  it, 
and  ultimately  a  definite  wall  may  be  produced,  inclosing  a  cyst  with  fluid 
contents.  In  otlier  instances  a  cyst  is  not  formed,  but  the  connectivi'-tissuo 
proliferates  and  leaves  a  })igmonted  scar.  In  meningeal  luvmorrhagc  the 
effused  blood  may  be  gradually  absorbed  and  leave  only  a  staining  of  the 
membranes.  In  other  cases,  particularly  in  infants,  when  the  effusion  is 
cortical  and  abundant,  there  may  be  localized  wasting  of  the  convolutions 
and  the  productioii  of  a  cyst  in  the  meninges.  Possibly  certain  of  the 
cases  of  porencephaly  are  caused  in  ^his  way. 

Secondary  degeneration  follows  when  the  motor  cortex  or  motor  path 
is  involved.  Thus,  in  persons  dying  some  years  after  a  cerebral  apoplexy 
which  has  produced  hemiplegia,  the  degeneration  may  bo  traced  in  tiio 
cms,  in  the  anterior  part  of  the  pons,  in  the  pyramidal  fibres  of  the  me- 
dulla, in  the  direct  fibres  of  the  cord  of  the  same  side,  and  in  the  crossnl 
pyramidal  fibres  of  the  opposite  side  (Fig.  3). 

Symptoms. — These  may  be  divided  into  primary,  or  those  connected 
with  the  onset,  and  secondary,  or  those  wliich  develop  later  after  the  early 
manifestations  hivve  passed  away. 


AFFECTIONS  OF  TDE  BLOOD-VESSELS. 


873 


Primary  Symptoms. — Premonitory  imlications  are  raro.  As  a  rule, 
the  ])atient  is  seized  while  in  full  healtii  or  about  the  performance  of  some 
cvery-day  action,  occasionally  an  action  rc(]uiring  strain  or  extra  exer- 
tion. Now  and  then  instances  are  found  in  which  there  are  sensations  of 
numbness  or  tingling  or  pains  in  the  limbs,  or  even  clioreiform  movements 
in  the  muscles  of  the  opposite  side,  the  so-called  preheniiplegic  chorea. 
The  onset  of  the  apoplexy,  as  cerebral  haimorrlmge  is  usually  called,  varies 
greatly.  There  may  be  sudden  loss  of  consciousness  and  complete  relaxa- 
tion of  the  extremities.  In  such  instances  the  name  apoplectic  stroke  is 
liarlic'uliirly  api)ropriatc.  In  other  cases  the  onset  is  more  gradual  and 
the  loss  of  consciousness  may  not  occur  for  a  few  minutes  after  the  patient 
has  fallen,  or  after  the  i)aralysis  of  the  limbs  is  manifest.  In  the  apoplec- 
tic attack  the  condition  is  as  follows:  There  is  deep  unconsciousness;  the 
patient  cannot  bo  roused.  The  face  is  injected,  sometimes  cyanotic,  or 
of  an  ashen-gray  hue.  The  pupils  vary;  usually  they  are  dilated  and  in- 
active. The  respirations  arc  slow,  noisy,  and  accomparued  with  stertor. 
Sometimes  the  Choyne-Stokes  rhythm  may  be  present.  The  pulse  is  usu- 
ally full,  slow,  and  of  increased  tension.  The  temperature  may  be  normal, 
but  is  often  found  subnormid,  and,  as  in  a  case  re2)orted  by  Hastian,  may 
sink  below  95°.  In  cases  of  basal  hemorrhage  the  tempei'ature,  on  the 
otluT  hand,  may  be  higii.  The  urine  and  fa?ces  are  usually  passed  invol- 
untarily. Convulsions  are  not  common.  It  may  be  dillicult  to  dccido 
whether  tlic  condi  Ion  is  apoplexy  associated  with  henui)legia  or  sudden 
oonui  from  other  causes.  An  indication  of  hcmijilegia  may  be  discovered 
in  the  diiference  in  the  tonus  of  the  muscles  on  the  two  sides.  If  the  arm 
or  the  leg  is  lifted,  it  drops  "  dead  "  on  the  alTected  side,  while  on  the 
other  it  falls  more  slowly.  Rigidity  also  may  be  ])resent.  In  watching 
tlif  movements  of  the  facial  muscles  in  the  stertorous  respiration  it  will 
1)0  seen  that  on  the  paralyzed  side  the  relaxation  permits  the  cheek  to  be 
blown  out  in  a  more  nuirked  manner.  Tlie  head  and  eyes  may  be  turned 
strongly  to  one  side — conjugate  deviation. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  j)aticnt  may 
not  lose  consciousness,  but  iiv  the  course  of  a  few  hours  there  is  loss  of 
power,  unconsciousness  gradually  develops,  and  deepens  into  profound 
coma.  This  is  sometimes  termed  ingravescent  apoplexy.  The  attack  may 
occur  during  sleep.  The  patient  may  be  found  unconscious,  or  wakes  to 
iind  that  the  power  is  lost  on  one  side.  Small  luvmorrhages  may  cause 
hemiplegia  without  loss  of  consciousness,  more  particularly  wiicn  they  are 
in  the  territory  of  the  central  arteries. 

Usually  within  forty-eight  hours  after  the  onset  of  an  attack  there  ia 
febrile  reaction,  and  more  or  less  constitutional  disturl)anco  associated 
with  inflammatory  changes  about  the  haemorrhage.  The  patient  may 
(lie  in  this  reaction,  or,  if  consciousness  has  been  re!,'aijied,  there  may  bo 
delirium  or  recurrence  of  the  coma.  At  this  period  the  so-called  early 
rigidity  may  develop  in  the  paralyzed  limbs.     Trophic,  changes  may  occur, 


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874 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Buch  as  sloughing  or  the  formation  of  vesicles.  The  most  soviou.s  of  tlioso 
is  the  sloughing  eschar  of  the  lower  part  of  the  back,  or  on  the;  iiaialyzcd 
side,  which  may  ii])pear  within  forty-eiglit  hours  of  the  onset  and  is  iisualK' 
of  grave  significance.  The  congestion  at  the  bases  of  the  lungs  so  com- 
mon in  apoplexy  is  regarded  by  some  as  a  trophic  change. 

Conjiigatc  Devialiun. — In  a  right  hemiplegia  the  eyes  and  luad  mav 
be  turned  to  the  left  side  ;  that  is  to  say,  the  eyes  look  toward  tlio  cere- 
bral lesion.  This  is  almost  the  rule  in  conjugate  deviation  of  tlio  head 
and  eyes  which  occurs  early  in  hemiplegia.  When,  however,  convulsions 
or  spasm  develop  or  the  state  of  so-called  early  rigidity  in  hemii)lcgia,  tlie 
conjugate  deviation  of  the  head  and  eyes  maybe  in  the  opposite  direction; 
that  is  to  say,  the  eyes  look  away  from  the  lesion  and  the  head  is  rotated 
toward  the  convulsed  side.  This  symptom  may  be  associated  with  cortical 
lesions,  particularly,  according  to  some  authors,  when  in  the  neiglibor- 
hood  of  the  supramarginal  and  angular  gyri.  It  may  also  occur  in  a 
lesion  of  the  internal  capsule  or  in  the  pons,  but  in  the  latter  situation 
the  conjugate  deviation  is  the  reverse  of  that  which  occurs  in  otlier 
cases,  as  the  patient  looks  away  from  the  lesion,  and  in  spasm  or  con- 
vulsion looks  toward  the  lesion.  In  cases  in  which  consciousness  is  ro- 
fitored  and  the  patient  improves,  the  unilateral  paralysis  which  persists  is 
known  as 

JIenu'ph'(/in. — Hemiplegia  is  complete  when  it  involves  face,  arm,  and 
leg,  or  partial  when  it  involves  only  one  or  other  of  these  parts.  This 
may  be  the  result  of  a  lesion  (a)  of  the  motor  cortex  ;  (b)  of  the  pyramidal 
fibres  in  corona  radiata  and  in  tlio  internal  capsule;  (c)  of  a  lesion  in  the 
crus  cerebri ;  or  (cl)  in  the  pons  V.arolii  (see  Fig.  3,  x,  y,  z).  Ilaimorrliage 
is  perhaps  the  most  common  cause,  but  tumors  and  spots  of  softening  may 
also  induce  it.  The  special  details  of  the  hemiplegia  may  here  be  coiisid 
ered.  The  face  is  involved  on  the  same  side  as  the  arm  and  leg.  Tliis 
results  from  the  fact  that  the  facial  muscles  stand  in  precisely  the  same  re- 
lation to  the  cortical  centres  as  those  of  the  arm  and  leg,  the  fibres  of  the 
upper  motor  segment  of  the  facial  nerve  from  the  cortex  decussating  just 
as  do  those  of  the  nerves  of  the  limbs.  The  facial  paralysis  is  partial,  in- 
volving only  the  lower  portion  of  the  nerve,  so  that  the  orbicularis  oculi 
and  the  frontalis  muscles  are  uninvolved.  The  signs  of  the  facial  paralvsis 
are  usually  well  marked.  There  may  be  a  slight  difficulty  in  elevating  the 
eyebrows  or  in  closing  the  eye  on  the  paralyzed  side.  The  hypoglossal 
nerve  also  is  involved.  In  consqucnce,  the  patient  cannot  put  out  tlu! 
tongue  straight,  but  it  deviates  toward  the  paralyzed  side,  inasnuich  as 
the  genio-hyo-glossus  of  the  sound  side  is  unopposed.  When  the  hemi- 
plegia is  on  the  right  side  there  may  be  aphasia. 

The  arm  is,  as  a  rule,  more  completely  paralyzed  than  the  leg.  The 
loss  of  power  may  be  absolute  or  partial.  In  severe  cases  it  is  at  first 
complete.  In  others,  when  the  paralysis  in  tho'face  and  arm  is  com- 
plete that  of  the  leg  is  only  partial.     The  face  and  arm  may  alone  be  par- 


AFFECTIONS  OP  THE  BLOOD-VESSELS. 


875 


ulyzcd,  while  the  leg  csoupos.  licss  commonly  the  leg  is  more  alTectcd 
than  the  arm,  and  the  face  may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  associated  in 
BViunietrical  movements,  as  the  thoracic  and  abdominal  nuisclos,  a  fact 
whirh  Broadbent  explains  by  supposing  that  as  the  spinal  nuclei  control- 
ling these  movements  on  both  sides  constantly  net  together,  they  may,  by 
means  of  this  intimate  connection,  be  stimulated  by  impulses  coming  from 
only  one  side  of  the  brain. 

Crossed  hemiplegia  occurs  when  a  lesion  is  in  the  lower  section  of  the 
pons  Varolii  (Fig.  3,  «),  in  which  the  facial  nerve  is  involved  as  it  passes 
through  the  pons  after  it  has  left  its  nucleus;  Avhereas,  the  motor  fibres 
involved  in  the  lesion  are  above  the  point  of  their  decussation,  f-o  that 
facial  paralysis  occurs  on  the  same  side  as  the  lesion,  and  paralysis  of  the 
arm  and  leg  on  the  opposite  side. 

The  sensory  disturbances  are  variable.  Ilemianaisthcsia  may  coexist 
with  hemi])legia,  but  in  many  instances  there  is  only  slight  numbness  of 
nensation.  When  the  hemiana?sthesia  is  marked,  it  is  usually  the  result 
of  a  lesion  in  the  internal  capsule.  In  C.  L.  Dana's  study  of  sensory 
localization  he  found  that  anaesthesia  of  organic  cortical  origin  Avas  always 
limited  or  more  pronounced  in  certain  parts,  as  the  face,  arm,  or  leg,  and 
was  generally  incomplete.  Total  ana;sthesia  was  either  of  functu)nal  or 
subcortical  origin.  Marked  anaesthesia  was  much  more  common  in  soft- 
ening thi'.n  in  haemorrhage.  Complete  hemiunaesthesia  is  certainly  rare 
in  haemorrhage. 

Disturbance  of  the  special  senses  is  not  common,  llemianopia  may 
oxist  on  the  same  side  as  the  lesion,  and  there  may  be  diminution  in  the 
acutcness  of  the  senses  of  hearing,  taste,  and  smell. 

As  a  rule,  there  is  no  wasting  of  the  paralyzed  limbs.  'J'he  deep 
reflexes  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  bo 
present.  The  plantar  and  other  sujierficial  reflexes  are  usually  dimin- 
ished.    The  sphincters  are  not  affected. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of 
the  lesion.  If  slight,  the  hemiplegia  may  disajipear  completely  within  a 
few  days  era  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually 
recovers  before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  uj)per 
arm  l)cfore  those  of  the  forearm  and  hand.    The  face  may  reccner  quickly. 

Except  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  which  may  be  grouped  as 

Secondary  Symptoms. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  place  within  eiglit  or  ten 
weeks,  it  will  bo  found  that  tlie  paralyzed  limbs  uiulergo  certain  changes. 
The  leg,  as  a  rule,  recovers  enough  power  to  enable  the  patient  to  get 
about,  although  the  foot  is  dragged.  In  both  arm  and  leg  the  condition 
of  secondary  contraction  or  late  rigidity  comes  on  and  is  always  most 
marked  in  the  upper  extremity.     The  arm  becomes  permanently  Hexed  at 


f  |i   i 


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,^!l';j 
"^'f* 


87G 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


tho  elbow  and  resists  all  attempts  at  extension.  The  wrist  i:^  flexed 
upon  the  forearm  and  the  fln;,fers  npon  the  hand.  The  position  of  the 
arm  and  liand  is  very  characteristic.  There  is  frequently,  as  the  ■\,i\- 
traetures  develop,  a  great  deal  of  pain.  In  the  leg  tho  coiitraetiire  is 
rarely  so  extreme.  The  loss  of  ])ower  is  most  marked  in  the  iiuiselis  nf 
the  foot,  and  to  prevent  tho  toes  from  dnijrjjfing  tho  knee  in  walkini;  is 
much  Hexed,  or  more  commonly  the  foot  is  swung  round  in  a  half- 
circle. 

The  reflexes  arc  at  this  .stage  greatly  increased.  Those  contnutures 
arc  permanent  and  incurable,  aud  are  associated  with  a  secoiulary  descend- 
ing sclerosis  of  the  motor  path.  There  are  instances,  however,  in  which 
rigidity  and  contracture  do  not  occur,  but  the  arm  renuiins  llaeeid,  tlie 
log  having  regained  its  power.  'J'his  hvnnplcf/ie  Jlasrjue  oi  Houehard  is 
found  most  commonly  in  children.  Among  other  secondary  chan^^ns  in 
late  hemiplegia  may  be  mentioned  the  following :  Tremor  of  the  all'eeted 
limbs,  post-paralytic  chorea,  the  mobile  s])asm  known  as  athetosis,  artlu'opa- 
thies  in  ttie  joints  of  the  affected  side,  and  muscular  atroj)hy.  Athet(l^is 
and  post-hemiplegic  chorea  will  be  considered  in  the  hemiplegia  of  eliil- 
dren.  A  word  may  here  be  said  upon  the  subject  of  muscular  atr(ii)liy  of 
cerebra;  origin. 

As  t;  rule,  atroj^ny  is  nof  a  marked  feature  in  hemiplegia,  but  in  some 
instancas  it  does  develop.  It  has  been  shown  to  be  due  in  some  cases  tn 
secondary  alterations  in  the  gray  nuitter  of  the  anterior  horns,  as  in  a  case 
reported  by  Charcot.  T'toccntly,  however,  attention  has  been  called  liy 
Quincke  to  the  fact  th.it  atrojjhy  may  follow  as  a  direct  result  of  the  cere- 
bral lesion.  In  his  case,  atrophy  o£  the  arm  followed  the  development  of 
a  glioma  in  the  anterior  central  convolutions.  The  gray  matter  of  the 
anterior  horns  was  normal.  This  wasting  of  cerebral  ori<Tin  occurs  most 
frequently  in  children. 

Diagnosis. — There  are  three  groups  of  cases  which  offer  increasing 
difliculty  in  recognition. 

(1)  Cases  in  which  the  onset  is  gradual,  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are 
readily  recognized,  though  it  may  be  difficult  to  determine  whether  the 
lesion  is  due  to  thrombosis  or  to  ha?morrha<ie. 

(2)  In  the  sudden  apoplectic  stroke  in  whicli  the  patient  rapidly  loses 
consciousness,  the  difficulty  in  diagnosis  may  be  still  greater,  particularly 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  Tlii-^  may 
be  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted ;  Avhoreas,  on 
the  non-paralyzed  side  the  muscles  retain  some  degree  of  tonus.  Tlie 
/eflexes  may  bo  increased  on  the  affected  side  and  there  may  be  conjnpite 
deviation  of  the  head  and  eyes.  Rigidity  in  thO  limbs  of  one  side  is  in 
favor  of  a  hemiplegic  lesion.     It  is  practically  impossible  in  a  majority  of 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


877 


is  iU'xod 
Lion  (if  the 
•<  Uk'  ••wii- 
tructun'  is 
inusclis  (if 
walkiiiL:  is 
ill   a  lialf- 

jMtniotures 
IT  (U'si'oiid- 
r,  in  wliicli 
llaccid,  till' 
loucliiird  is 
cliaiifics  in 
Llic  alTccted 
ri,  ai'tliniiia- 
Atlu'tosia 
?giii  (if  cliil- 
'  atnipliy  (if 

hut  in  soiiio 

)iiu'  cases  to 

us  ill  a  cast' 

called  by 

f  tlu'  ccrc- 

opllicilt  of 

ittcr  of  the 

DC'cui's  most 

increasing 

sing  before 
y  lost,  arc 
iiuther  the 

apidly  lo^es 
particularly 

This  miiy 
11  the  ]iiir!i- 
wlioreas,  on 
onus.    The 

coiijiigiitc 
lie  side  is  in 
Imujority  of 


these  capoa  to  say  wliethcr  tho  lesion  is  duo  to  lincmorrliagc,  cmi)clism,  or 
tlirombosiH. 

(:{)  liiirgo  hinniorrliago  into  tlio  vcntridi's  or  into  tlio  pons  may  pro- 
duce sudden  loss  of  consciousness  with  complete  relaxation,  so  that  tho 
condition  may  simulate  coma  from  uramna,  ulcoholisiii,  opiiim  poisoning, 
(ir  epilepsy.  Tho  previous  history  and  tlie  mode  of  onset  may  give  vahia- 
hle  information.  In  epilepsy  convulsions  have  jireceded  the  coma;  in 
iileoholism  there  is  a  history  of  constant  drinking,  while  in  opium  poison- 
ing thecoma  develops  more  gradually;  but  in  numy  instances  tho  diHl- 
eiilty  is  practically  very  great,  and  on  more  than  one  occasion  I  have  seen 
mortifying  post-mortem  disclosures  under  these  circumstances.  In  ven- 
tricular hncmorrhago  tho  conui  is  sudden  and  develops  rapidly.  The 
heniiplegio  symptoms  may  bo  transient,  quickly  giving  place  to  com])I('to 
relaxation.  Convulsions  occur  in  many  cases,  and  may  he  the  very  symj)- 
tom  to  lead  astray — as  in  a  case  of  ventricular  luiiniorrhage  which  occurred 
in  u  jiuerporal  patient,  iix  whom,  naturally  enough,  tin;  condition  was 
thought  to  be  urtemic.  IJigidity  is  often  present.  In  hannorrhago  into 
the  pons  convulsions  are  frequent.  'I'he  pupils  may  bo  strongly  con- 
tracted, conjugate  deviation  may  occur,  and  the  tom|)eratiire  is  apt  to  rise 
rapidly.  The  contraction  of  the  luijiils  in  pontine  luvniorrhage  naturally 
suggests  opium  poisoning,  '{'he  dilTcrcnco  in  temperature  in  the  two  con- 
ditions is  a  valuable  diagnostic  point. 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  In  admissicms 
to  liospitals  or  in  emergency  cases  tho  physician  should  be  particularly 
careful  about  tho  following  points:  Tho  examimition  of  the  head  for  in- 
jury or  fracture ;  the  urine  should  bo  tested  for  albumen  and  examined 
for  sugar;  a  careful  examination  should  bo  made  of  the  limbs  Avith  refer- 
ence to  their  degree  of  relaxation  or  the  presence  of  rigidity,  and  tho  con- 
dition of  tho  reflexes ;  the  state  of  tho  pupils  should  be  noted  and  the 
temperature  taken.  The  most  serious  mistakes  are  made  in  tlu;  case  of 
patients  who  are  drunk  at  tho  time  of  the  attack,  a  combination  l)y  no 
means  uncommon  in  the  class  of  patients  admitted  to  hospital.  Under 
these  circumstances  the  case  may  be  looked  upoti  as  one  of  al('oh()li(^  coma. 
It  is  best  to  regard  each  case  as  serious  and  to  bear  in  mind  that  this  is  a 
condition  in  which,  above  all  others,  mistakes  are  (;ommon. 

Prognosis. — From  cortical  hosmorrhage,  unless  very  extensive,  tho 
recovery  may  be  complete  without  a  trace  of  contracture.  This  is  more 
oommon  when  the  haemorrhage  follows  injury  than  when  it  results  from 
liisease  of  the  arteries.  Infantile  meningeal  hasmorrhago,  on  the  other 
luind,  is  a  condition  which  may  produce  idiocy  or  spastic  diplegia. 

Large  haemorrhages  into  the  corona  radiata  and  those  which  rupture 
into  the  ventricles  rapidly  prove  fatal. 

The  hemiplegia  which  follows  lesions  of  the  internal  capsule,  the  re- 
sult of  rupture  of  the  artery  of  the  corpus  striatum,  is  usually  persistent 
and  followed  by  contracture.     When  the  posterior  fibres  arc  involved 


h 


all 


878 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


|U;1 


tlioro  may  bo  homiannRsthoHia,  iii'd  later  lioiniclior.'a  or  aUiotosis.  Tii  niiv 
case  of  cerobral  apoplexy  tiio  followiiifj  Hyinptoiiis  arc  of  f^nivc  (niicn  ;  inr- 
Bistonco  or  tl(H'poiiiti<j  of  the  ('onia(liiriii<,'  tlio  kccoiuI  and  third  dav;  laimi 
rise  in  temperature  within  the  first  f()rty-ei<,'lit  hours  after  the  iiiitiiil  fall. 
In  the  reaeticm  which  takes  place  on  tiie  second  or  third  day,  the  tem- 
perature usually  rises,  and  its  gradual  fall  on  the  third  or  fourth  day  with 
return  of  consciousness  is  a  favorable  indication.  The  rapid  furinatioii  of 
bed-sores,  particularly  the  malignant  decubitus  of  Charcot,  is  a  fatal  iiidi- 
cation.  The  occurrence  of  albumen  and  sugar,  if  abundant,  in  the  urine 
is  an  unfavorable  symptom. 

When  consciousness  returns  and  the  patient  is  im{)roving,  the  ques- 
tion is  anxiously  asked  as  to  the  paralysis.  'I'he  extent  of  this  caunol  be 
determined  for  some  weeks.  With  slight  lesions  it  may  pass  off  entirely. 
If  persistent  at  the  end  of  a  month  some  grade  of  j)ernuinent  palsy  is  eer- 
tain  to  remain,  and  gradually  the  late  rigidity  supervenes. 

Emuolism  AN!)  Tjiuojiijosih  (Cerebral  Softeniiuj). 

{(i)  Embolism  — The  embolus  usually  enters  the  carotid,  rarely  the 
vertebral  artery.  In  the  great  majority  of  cases  it  comes  from  the  left 
heart  and  is  either  a  vegetation  of  a  fresh  endocarditis  or,  mor  ')m- 
moldy,  of  a  recurring  endocarditis,  or  from  the  segments  im  in 

an  ulcerative  process.  Less  often  the  embolus  is  a  portion  u.  ..  eiet 
which  has  formed  in  the  auricular  appendix.  Portions  of  clot  from  ai> 
aneurism,  thrombi  from  atheroma  of  the  aorta,  or  from  the  territdry 
of  the  pulmonary  veins,  may  also  cause  blocking  of  the  branches  of  the 
circle  of  Willis.  In  the  puerperal  condition  cerebral  embolism  is  not  in- 
frequent. It  may  occur  in  women  Avith  lieart-disease,  but  in  otlier  in- 
stances the  heart  is  uninvolved,  and  the  condition  has  been  thought  to  bo 
associated  with  the  development  of  heart-clots,  owing  to  increased  coajru- 
lability  of  the  blood.  A  majority  of  cases  of  embolism  occur  in  chronic 
heart-disease.  Cases  arc  rare  in  the  acute  endocarditis  of  rheumatism, 
chorea,  and  febrile  conditions.  It  is  much  more  common  in  the  secomlary 
recurring  endocarditis  which  attacks  old  sclerotic  valves.  The  embolus 
most  frequently  passes  to  the  left  middle  cerebral  artery,  as  it  enters  tlio 
left  carotid  oftener  than  the  right  because  of  the  more  direct  course  of  the 
blood  in  the  former.  The  posterior  cerebral  and  the  vertebral  are  les.^ 
often  affected.  A  large  plug  may  lodge  at  the  bifurcation  of  the  basilar. 
Embolism  of  the  cerebellar  vessels  is  rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  tlio 
greater  frequency  of  mitral  stenosis.  Contrary  to  this  general  statement, 
Newton  Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  however. 
that  males  are  more  frequently  affected ;  for  in  this  scries  there  were  44 
males  and  35  females. 

ip)  Thrombosis.— Clotting  of  blood  in  the  cerebral  vessels  occurs  about 


l. 


AFFECTIONS  OF  THE   BLOOD-VESSELS. 


870 


an  ombolus,  iiH  the  roHult  of  a  losion  of  tho  iirtoriiil  wall  (oithor  omliirtcritis 
with  or  without  uthororim  or,  inirticuhirly,  tho  Hyphililic  arteritis),  in  auou- 
risma  both  courao  and  miliary,  and  vory  rarely  as  a  result  of  ahnoruuil  con- 
ditions of  the  blood,  Thrombosis  of  tho  cerebral  vessels oecusionally  fol- 
lows lijjatlon  of  the  earotid  artery,  'i'he  thrombosi.s  is  most  common  in  tho 
iiiiildle  cerebral  and  in  tho  basilar  arteries. 

Anntomieal  (^hnmjeH  foUowiiuj  Thrombosis  and  EmbnHsm. — Depenea- 
tion  and  softejiinj^  of  the  territory  supplied  by  the  vessels  is  the  ultiruat) 
result  of  tho  arterial  obstruction.  Hlockinpf  in  a  terminal  artery  nniy  bo 
followed  by  a  cojulition  resembling  infarct,  in  which  the  territory  is  deep- 
ly infiltrated  with  blood.  More  commonly  tho  cliange  is  much  less  strik- 
in},',  and  tho  aiTccted  region  may  look  only  a  little  paler  than  normal  or 
slijjlitly  softer,  (iradually  tho  process  of  softening  proceeds,  tho  tissue 
is  infiltrated  with  serum  and  is  moist,  the  nervo-iibres  degenerate  and 
beconio  fatty.  Tho  neuroglia  is  swollen  and  a.>dematous.  The  color  of 
tliL'  softened  area  depends  upon  the  amount  of  blood.  Tho  hiemoglobm 
uiulorgoes  gradual  transformation,  and  tho  early  red  color  may  give  place 
to  yellow.  Formerly  much  stress  was  laid  upon  the  dilTerenco  between 
m/,  i/rllon',  and  while  softening.  Tho  red  un^'  yellow  are  seen  chiefly 
on  tiie  cortex.  Sometimes  the  rod  softening  is  particularly  nuirked  in 
cases  of  embolism  and  in  tho  neighborhood  of  tumors.  Tlie  gray  matter 
sliows  many  punctiform  luvinorrhages — capillary  apoplexy.  There  is  a 
variety  of  yellow  softening — the  phtques  jauni's — common  in  elderly 
persons,  which  occuirs  in  tho  gray  matter  of  tiie  convolutions.  Tho  spots 
are  from  one  to  two  centimetres  in  diameter,  the  edges  cleanly  cut,  and 
the  softened  area  is  represented,  by  cither  a  turbid,  yellow  nuiterial,  or  in 
some  instances  there  is  a  space  crossed  by  fine  trabecuht,  in  tho  nioshcs  of 
which  there  is  fluid.  They  result  from  fatty  degeneration  of  tho  peri[ih- 
oral  cortical  arteries;  less  often  the  hyaline  change  is  present.  White 
softening  occurs  most  frequently  iii  tho  white  matter,  and  is  seen  best 
about  tumors  and  abscesses.  Inflammatory  changes  are  common  in  and 
about  the  softened  areas.  AVhen  the  embolus  is  derived  from  an  infected 
focus,  as  in  ulcerative  endocarditis,  suppuration  may  follow.  1'he  final 
changes  vary  very  muCii.  The  degenerated  and  dead  tissue  elements  are 
irradually  but  slowly  removed,  and  if  the  region  is  small  may  be  rci)laccd 
by  growth  of  connective  tissue  and  the  formation  of  a  scar.  In  larger 
regions  the  resorption  results  in  tlio  formation  of  a  cyst,  which  may  be 
crossed  by  connective-tissue  trabeculrc.  It  is  surprising  for  how  long  an 
area  of  softening  may  persist  without  much  change. 

The  position  and  extent  of  tho  softening  depend  upon  tho  obstructed 
artery.  An  embolus  which  blocks  tho  middle  cerebral  at  its  origin  in- 
volves both  the  arteries  in  the  anterior  perforated  space  and  the  cortical 
branches,  and  in  such  a  case  there  is  softening  in  tho  neighborhood  of  tho 
corpus  striatum,  as  well  as  in  part  of  the  region  supplied  by  tho  corti- 
c:'.l  vessels.     Tho  freedom  of  anastomosis  between  these  branches  varies 


ii: 


t  \% 


mil 


880 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


a  good  deal.  Thus,  there  arc  insuinccs  of  embolism  of  the  middle  cere- 
bral artery  in  whieh  the  softcniiig  has  only  involved  the  territciry  of  llio 
central  branches,  in  which  case  blood  has  reached  the  cortex  tliroiigh  tlic 
anterior  and  posterior  cerebrals.  When  the  middle  cerebral  is  blocked  (;ih 
i  i  ])erhaps  of tenest  the  case)  beyond  the  point  of  origin  of  tlie  central 
arteries,  f)ne  or  other  of  its  branches  is  usually  most  involved.  Tiie  embo- 
1  IS  may  lodge  in  the  vessel  passing  to  the  third  fnmtal  convolution,  or  iu 
the  artery  of  the  ascending  frontal  or  ascending  pariotid  ;  or  it  nmy  lodgi- 
in  the  branch  passing  to  the  supramarginal  and  angular  gyri,  or  it  may 
enter  the  lowest  branch  which  is  distributed  to  the  upper  convolutions  of 
the  temporo-sphenoidal  lobe.  These  are  practically  terminal  arteries,  and 
instances  frecpumtly  occur  of  softening  limited  to  a  part,  at  any  rate,  of 
the  territory  supplied  by  them.  Some  of  the  most  accurate  focalizing' 
lesions  are  in  this  way  ])roduced. 

Symptoms. — Extensive  thrombotic  softening  may  exist  without  any 
symptoms.  It  is  not  uncommon  in  the  post-mortem  examination  of  tlic 
bodies  of  elderly  persons  to  find  the  plaques  jaunes  scattered  over  tlie 
convolutions.  So,  too,  softening  may  take  place  iu  the  "silent"  regions, 
a-i  they  are  termed,  without  exciting  any  symptoms.  When  the  central  or 
cortical  branches  of  the  middle  cerebral  arteries  are  involved  the  symii- 
toms  are  similar  to  those  of  htemorrhage.  Permanent  or  transient  hemi- 
plegia results.  Wlien  the  central  arteries  are  involved  the  softening  iu 
the  internal  capsule  is  commonly  followed  by  permajient  heniipK'gia. 
There  arc  certain  peculiarities  associated  u  ith  embolism  and  with  throm- 
bosis respectively. 

In  embolism  the  patient  is  usually  the  subject  of  heart-trouble,  or  thin' 
exist  some  of  tlie  conditions  already  mentioned.  The  onset  is  sudden, 
without  premonitory  symptoms.  When  the  embolism  blocks  the  left 
middle  cerebral  artery  the  hemiplegia  is  usually  associatetl  with  ajiha^ia. 
In  t/iruml/osis,  on  the  other  hand,  the  onset  is  more  gradual;  the  jiaticnl 
has  previously  complained  of  headache,  vertigo,  tingling  in  the  fingi-rs; 
the  Biieech  may  have  been  embarrassed  for  some  days ;  the  patient  lias 
liad  loss  of  memory  or  is  incoherent,  or  f)aralysis  begins  at  one  jiart,  as 
the  liand,  and  extemls  slowly,  and  the  hemijilegia  maybe  iucom|il(tf  or 
variable.  Abrupt  loss  of  consciousness  is  much  less  common,  and  when 
the  lesion  is  small  consciousness  is  retained.  Thus,  in  thrombosis  due  to 
syphilitic  disease,  the  hemiplegia  may  come  on  gradually  without  tin' 
slightest  disturbance  of  cciisciousness. 

The  hemiplegia  following  thromi)osis  or  embolism  has  ijraclically  'he 
characteristics,  both  primary  and  secondary,  described  uiuler  hu'niorrliaj.n'. 

The  following  mav  bo  the  eflfects  of  blocking  tlie  dilTerent  vessels: 
{(i)  Vcrtrbrn\ — The  >  ft  branch  is  more  frequently  jilugged.  The  elTccts 
iire  involvement  of  the  nuclei  in  the  medulla  and  symptoms  of  acute 
bulbar  paralysis.     It  rarely  occurs  alone  ;  more  commonly  with 

{b)  Blocking  of  the  basilar  artery.     When  this  is  entirely  oeehideil 


AFFECTIONS  OP  THE  BLOOD-VESSELS. 


881 


'/' 


there  may  bo  bilateral  paralysis  from  iuvolvjmoiit  of  both  motor  paths. 
IJulbar  symptoms  may  bo  present;  ri,i,M(lity  or  spa^m  mayocc..  TIio 
tsiiiperaturo  may  rise  rapidly.  Tlie  symptoms,  in  fact,  are  those  )t  apo- 
plexy of  the  pons. 

{(■)  The  ^^o.v/f'/'/o/vrrri/v/?  supplies  tlio  occipital  lobe  on  its  'incrface 
ami  the  greater  part  of  tho  t?'npor<)-s[)lien()i(lal  lobe.  Localizcui  areas  (f 
softening  may  exist  without  symptoms.  IMocking  of  tlie  brancli  passing 
to  the  cuncus  may  bo  followed  by  hcmianopia.  llemiuna^sthesia  may  re- 
suh  from  involvement  of  tlie  posterior  \rdvi  of  the  internal  (;a{)sule. 

{(I)  Internal  Carulid. — The  symptoms  arc  variable.  As  is  well  known, 
the  vessel  is  in  a  majority  of  eases  ligated  without  risk.  In  other  in- 
stances transient  hemiplegia  follows;  in  others  again  the  hemiplegia  is  ])er- 
maiient.  These  variations  dej)end  on  the  anastomoses  in  llie  circle  of  Wil- 
lis. If  these  are  large  and  free,  no  2>aralysis  follows,  but  in  cases  in  which 
the  posterior  <'ommunicating  and  tlie  anterior  coninninicaling  vessels  are 
small  or  absent,  tho  paralysis  may  persist.  In  No.  7  of  my  Elwyi\  series 
of  eases  of  infantile  hemiplegia,  tho  woman,  aged  twenty-four,  when  six 
years  old,  had  tho  right  carotid  ligated  for  abscess  following  scarlet  fever, 
with  tho  result  of  pernument  hemi])lcgia.  blocking  of  tho  internal  ca- 
rotid within  the  skull  by  throndjo'^is  or  end)olism  is  followed  l)y  ]ienni)lcgia, 
oonia,  and  usually  death.  Tho  I'lot  is  rarely  confined  to  the  carotid 
itsel.,  but  spreads  into  its  branches  and  may  involve  tho  ophthalmic 
iirtri-y. 

)  Middle  Cerebral. — This  is  the  vessel  most  commoidy  involved,  ami, 
itf  alieady  mentioned,  if  ])lugged  before  the  central  arteries  are  given  off, 
permanent  hemii)legia  usually  follows  from  softening  of  the  internal  cap- 
sule. Blocking  of  tho  brunches  beyond  this  point  may  bo  followed  by 
hemiplegia,  which  is  more  likely  to  be  transient,  invohcs  chiefly  tho  arm 
ami  face,  ami  if  on  the  left  side  is  associated  with  aphasia.  The  individual 
hraiiehos  passing  to  the  third  frontal,  ascending  parietal,  io  the  sujjranuir- 
piial  and  angular  gyri,  or  to  the  temporal  gyri  may  be  ])luggod. 

(f)  Anterior  Cerebral. — Nosym])tojns  may  follow,  and  even  when  tho 
liraiiches  which  sui)ply  the  paraccntal  lobule  and  the  to|)  of  the  as(;ending 
convolutions  are  plugged  tho  branches  from  tho  middle  cerebral  are  usu- 
ally able  to  effect  a  collateral  circulation  in  thco  ))arts.  llcbi'tiide  and 
(liihiess  of  intellect  may  occur  with  obstruction  'f  the  viissel. 

There  is  unquestionably  greater  freedom  of  conununication  in  the 
":)rtical  branches  of  the  dillereiit  arteries  than  is  usually  admitted,  al- 
ihdiijih  it  is  not  possible,  for  example,  to  inject  the  posterior  cerel)ral 
tlinnigh  the  middle  cerebral,  or  the  middle  cerebral  from  the  anterior ; 
I'lU  tho  al)sence  of  S(<ftening  in  sonu-  instaiu'cs  in  which  j-iuallcr  brnnchea 
arc  hloi'ked  shows  how  eomitletely  nuiy  be  the  compensation.  Tlu;  dila- 
latiim  of  the  collateral  branches  niay  lake  place  very  rapidly  ;  thus  a  pa- 
tient with  chronic  nephritis  died  about  twenty-four  hours  after  the  hemi- 
I'li'gie  attiick.  There  were  recent  vegetations  on  the  mitral  and  ancndiolus 


n 


■  Si, 
■  mi 


i 


882 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


jSli- 


I 


iu  the  right  middle  cerebral  artery  just  beyond  the  first  two  bninclics 
(temporal).  The  central  portion  of  the  hemisphere  was  swollen  and 
(edematous.  The  right  anterior  cerebral  was  greatly  dilated,  and  bv 
measurement  its  diameter  was  found  to  be  nearly  three  times  that  of  the 
left. 

Treatment  of  Cerebral  Haemorrhage.— The  patient  slimild  be 
placed  with  the  head  high,  and  measures  immediately  taken  to  reduce  the 
arterial  pressure.  Of  these  the  most  rapid  and  siitisfactory  is  venesection, 
which  should  be  practiced  whenever  the  arterial  tension  is  nuicli  in- 
creased. With  a  small  pulse  of  low  tension  and  signs  of  cardiac  weak- 
ness it  is  contra-indicated.  The  chief  difficulty  is  in  determining  wliethor 
the  apoi^lexy  is  really  due  to  ha}morrhage,  or  to  thrombosis  or  enil)()lisin, 
since  in  the  latter  group  of  cases  bleeding  probably  does  harm.  As  a  rule, 
however,  in  middle-aged  men  with  arterio-sclerosis,  an  accentuated  aortic 
second  sound,  and  hypertrophy  of  the  left  ventricle,  bleeding  is  indicated. 
Ilorsley  and  Spencer  have  recently,  on  experimental  grounds,  recom- 
mended the  practice,  formerly  employed  empirically,  of  compression  of 
the  carotid,  particularly  in  the  ingravescent  form  ;  or  even,  in  suital)le 
cases,  passing  a  ligature  I'ound  the  vessel.  An  ice-bag  may  be  placed  on 
the  head  and  hot  bottlijs  to  the  feet.  1'he  bowels  should  be  freely  oiiened, 
either  by  calomel,  or  ( roton  oil  plii':ed  on  the  tongue.  Counter-inilation 
to  the  neck  or  to  the  'eet  is  not  necessary.  When  dyspna?a,  sterlor,  and 
signs  of  mechanical  obsirnntion  are  present,  the  patient  should  be  turned 
on  the  side,  as  recommended  by  Bfjwles.  This  procedure  also  lessens 
the  liability  to  congestion  of  the  lungs. 

Special  care  should  be  taken  to  a-void  bed-.sores  ;  and  if  bottles  are  used 
to  the  feet,  they  should  not  be  too  hot,  since  blisters  may  be  readily 
caused  by  much  lower  temperature  than  in  health.  In  the  fever  of  reac- 
tion, aconite  may  be  indicated,  but  should  be  cautiously  used.  Stimu- 
lants are  not  necessary,  unless  the  pulse  becomes  feeble  and  signs  of  col- 
lapse supervene. 

The  treatment  of  softening  from  thrombosi-s  or  embolism  is  very  un- 
satisfactory. Venesection  is  not  indicated,  as  it  lowers  the  tension  and 
rather  promotes  clotting.  If,  as  is  often  the  ca.se,  the  heart's  action  is 
feeble  and  irregular,  stimulants  and  small  doses  of  digitalis  may  be  irivcn 
with,  if  necessary,  other  or  ammonia.  The  bowels  should  be  kej).  )pcn, 
but  it  is  not  well  to  purge  actively,  as  in  haEmorrhage. 

In  the  thrombosis  which  follows  syphilitic  disease  of  the  artpric>'.  anti 
which  is  met  with  most  frequently  in  men  Iwtwcen  twenty  and  forty  (in 
whom  the  hemiplegia  often  sets  in  without  loss  of  consciousness),  the 
iodide  of  ])otassium  should  be  freely  used,  giving  from  twenty  to  thirty 
grains  three  times  a  day,  or,  if  necessiiry,  larger  doses.  If  the  syphilis  Inis 
been  recent,  mercurials  arc  also  in<licated.  Practically  these  are  the  only 
cases  of  hemiplegia  in  which  we  see  satisfactory  results  from  treatnu  ut. 

Operative  treatment  has  been  suggested,  and  when  the  diagno-is  of 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


tr 


anches 
Ml  and 
iiid  by 
,  of  the 

nulil  bo 
uce  tlie 
sc'ctioii, 
uc'li  in- 
c  weak- 
wht'ther 
iiholWm, 
s  a  rule, 
3d  aortic 
uUcalcd. 
,  recom- 
^ssioii  of 
I  suitable 
)laced  on 
V  opeMied, 
irritation 
M'lor,  and 
)c  turned 
,0  lessens 

are  used 
10  readily 
|r  of  reac- 
Stinui- 
is  of  col- 
very  un- 
lision  and 
1  action  is 
be  uiven 
U),    ijien, 

Iries,  and 
Iforty  (in 
less),  the 

Ito  thirty 
Ihirw  hii.^ 

jthc'i'iy 

Itinciit. 

IrilO-iS   of 


subdural  haemorrhage  can  be  made  it  is  justifiable.  An  attempt  to  reach 
a  central  ]ia;morrhage  in  the  neighborhood  of  the  internal  cai)sule  would 
only  increase  the  damage  to  the  brain-substance.  Very  little  can  be  done 
for  the  hemiplegia  which  remains.  The  damage  is  too  often  irreparable 
ami  permanent,  and  it  is  very  improbable  that  iodide  of  potassium,  or  any 
other  remedy,  hastens  in  the  slightest  degree  Nature's  dealing  with  the 
blood-clot. 

The  paralyzed  limbs  may  be  gently  rubbed  once  or  twice  a  day,  and 
this  should  be  systematically  carried  out,  in  order  to  maintain  the  nutri- 
tion of  the  muscles  and  to  prevent,  if  possible,  contractures.  After  the 
lapse  of  a  fortnight  the  muscles  may  be  stimulated  by  the  faradic  current ; 
but  when  contractures  develop,  electricity  is  useless,  and  the  j)assive  move- 
ments and  frictions  are  alone  indicated. 

In  a  case  of  complete  hemiplegia,  the  friends  should  at  the  outset  bo 
frankly  told  that  the  chances  of  full  recovery  are  slight.  Power  is 
usually  restored  in  the  leg  sufficient  to  enable  the  patient  to  get  about, 
but  in  the  majority  of  insUmces  the  finer  movements  of  the  hand  are  per- 
manently lost.  The  general  health  should  be  looked  after,  the  bowels 
regulated,  and  the  secretions  of  the  skin  and  kidneys  kept  active.  In 
perniunent  hemiplegia  in  persons  above  the  middle  period  of  life,  more  or 
less  mental  weakness  is  apt  to  follow  the  attack,  and  the  patient  may  be- 
come irritable  and  emotional. 

And,  lastly,  when  hemi[)legia  has  persisted  for  more  than  three  months 
and  contractures  have  developed,  it  is  the  duty  of  tlu  physician  to  explain 
to  the  patient,  or  to  his  friends,  that  the  conditi(m  is  past  relief,  that  medi- 
cines and  electricity  will  do  no. good,  and  tl  there  is  no  possible  hope 
of  cure. 

Aneurism  of  tue  Ceuebual  Auteuies. 

Miliary  aneurisms  are  not  included,  but  reference  is  made  only  to 
aneurism  of  the  larger  branches.  The  condition  is  not  uncommon.  There 
were  twelve  instances  in  my  first  eight  hundred  autopsies  in  Montn  al.* 
Tliis  is  a  considerably  larger  ])roportion  than  in  Newton  Pitt's  colle<  lion 
from  (iuy's  Hospital,  nineteen  times  in  nine  thousand  inspections. 

Etiology. — Males  are  more  freciuently  affected  than  females.  Of 
my  twelve  cases  seven  were  males.  The  disease  is  most  common  at  tin- 
middle  i)eriod  of  life.  One  of  my  cases  was  a  lad  of  si.x.  Pitt  describes 
'ine  at  the  same  age.  The  chief  causes  are  (a)  endarteritis,  either  simple 
'^rsypliilitic,  which  leads  to  weakness  of  the  wall  and  dilatation;  and  {/>) 
''"ibolisin.  As  pointed  out  by  Church,  these  aneurisjus  are  often  found 
*nth  endocarditis.  Pitt,  in  his  recent  study  of  the  subject,  concludes  that 
it  is  exce])tional  to  find  ccrel)ral  aneurism  unassociated  with  fungating 


.!;    1 


PM  I 


ml 


*  CHnadu  Medical  and  Surgical  Journal,  vol.  xiv. 


66 


'  V 


884 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


endocarditis.  The  embolus  disappears,  and  dilatation  follows  the  second- 
ary inflammatory  changes  in  the  coats  of  the  vessel. 

Morbid  Anatomy. — The  middle  cerebral  branches  are  most  fio- 
quently  involved.  In  my  twelve  cases  the  distribution  on  the  arteries  was 
as  follows:  Internal  carotid,  1;  middle  cerebral,  5;  basilar,  3;  iuiterior 
commujiicatinsif,  3.  "With  the  exce])tion  of  one  case  they  were  saceular 
and  communicated  with  the  lumen  of  the  vessel  by  an  orifice  smaller  than 
the  circumference  of  the  sac.  In  the  154  cases  which  make  up  the  statis- 
tics of  Lebert,  Durand,  and  Bartholow  the  middle  cerebral  was  involved 
in  44,  the  basilar  in  41,  internal  carotid  in  23,  anterior  cerebral  in  14,  j)os- 
terior  communicating  in  8,  anterior  communicating  in  8,  vertebral  in  7, 
posterior  cerebral  in  G,  inferior  cerebellar  in  3  (Gowers).  The  size  of  the 
aneurism  varies  from  that  of  a  pea  to  that  of  a  walnut.  The  hieniorrhatje 
may  be  entirely  meningeal  with  very  slight  laceration  of  the  brain  sub- 
stance, but  the  bleeding  may  be,  as  Coats  has  shown,  entirely  within  the 
substance. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause 
no  symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupt- 
ure and  the  fatal  apoplexy.  Distinct  symptoms  are  most  frequently  caused 
by  aneurism  of  the  internal  carotid,  which  may  compress  the  optic  nerve 
or  the  commissure,  causing  neuritis  or  paralysis  of  the  third  nerve.  A 
murmur  maybe  au(liI)lo  on  auscultation  of  the  skull.  Aneurism  in  this 
situation  nuiy  give  rise  to  irritative  and  pressure  symptoms  at  the  l)ase  of 
the  brain  or  to  hemianopsia.  In  the  remarkable  case  reported  by  Weir 
Mitchell  and  Dercum  an  aneurism  compressed  the  chiasma  and  produced 
bilateral  temporal  hemianopsia. 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  tlie 
symptoms  of  tumor,  and  their  rupture  is  usually  fatal. 

KXDARTERITIS. 

In  no  group  of  vessels  do  we  more  frequently  see  chronic  degenera- 
tive changes  than  in  those  of  the  circle  of  Willis.  The  con(liti(jn  oc- 
curs as : 

(a)  Arferio-sriei'osis,  producing  localized  or  diffused  thickening  (»f  the 
intima  with  the  formation  of  atheromatous  patches  or  areas  of  calcilica- 
tion.  In  the  later  stages,  as  seen  in  elderly  people,  the  arteries  of  the 
circle  of  Willis  may  be  dilated,  stiff,  or  almost  universally  calcified. 

(Z>)  Syphilitic  Endarteritis. — As  already  mentioned  under  the  section 
of  syphilis,  gummatous  endarteritis  is  six'cially  prone  to  attack  the  cere- 
bral vessels.  It  has  in  itself  no  specific  characters — that  is  to  say,  it  is 
impossible  in  given  sections  to  pick  (-nt  an  endarteritis  syphilitieii  from 


1    -t 


AFFECTIONS  OF  THE   BLOOD-VESSELS. 


885 


an  ordinary  endarteritis  obliterans.     On  the  other  liand,  as  already  stated, 
till'  nodular  periarteritis  is  never  seen  except  in  syphilis. 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins. 

The  condition  may  be  primary  or  secondary. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare.  It  occurs  («) 
in  children,  particularly  during  the  first  six  months  of  life,  usually  in  con- 
nection with  diarrhroa.  It  has,  in  my  experience,  been  a  rare  condition. 
I  have  never  seen  an  example  of  spontaneous  thrombosis  of  the  sinuses  in 
a  (^liild,  and  only  two  instances,  both  in  connection  with  meningitis,  in 
which  the  cortical  veins  contained  clots.  Gowers  believes  that  it  is  of  fre- 
quent occurrence,  and  that  thrombosis  of  the  veins  is  not  an  uncommon 
cause  of  infantile  hemiplegia. 

{/})  In  connection  with  chlorosis  and  anaemia.  Brayton  liall  has  recently 
called  attention  to  this  interesting  association,  and  has  rej)orted  one  case 
and  collected  ten  or  eleven  others  from  the  literature.  All  were  in  girls 
witli  anaemia  or  chlorosis. 

{(■)  In  the  terminal  stages  of  cancer,  phthisis,  and  other  chronic  dis- 
eases thrombosis  may  gradually  occur  in  the  sinuses  and  cortical  veins. 
To  the  coagulum  developing  in  these  conditions  the  term  marantic  throm- 
bus is  applied. 

Secondary  Thrombosis  is  much  more  frequent  and  follows  extension 
of  inflammation  from  contiguous  parts  to  the  sinus  wall.  The  com- 
mon causes  are  disease  of  the  internal  ear,  fracture,  compression  of  the 
ginnses  by  tumor,  or  suppurative  disease  outside  the  skull,  particularly 
erysipelas.  In  these  cases  the  lateral  sinus  is  most  frequently  involved. 
Of  r»7  fatjil  cases  in  which  ear-disease  caused  death  with  cerebral  lesions, 
there  were  23  in  which  thrombosis  existed  in  the  lateral  sinuses  (Pitt). 
The  thrombus  may  be  small,  or  may  fill  the  entire  sinus  and  extend  into 
the  internal  jugular  vein.  In  more  than  one  half  of  these  instances  the 
thr<»nil>us  wsis  suppurating.  Tlie  disease  spreads  directly  from  the  necro- 
sis on  the  posterior  wall  of  the  tymj)anum.  It  is  not  so  common  in  disease 
of  the  mastoid  cells. 

Symptoms. — Primary  thrombosis  of  the  longitudinal  sinus  may 
occur  without  exciting  symptoms  and  is  found  accidentally  at  the  post- 
niortcm.  There  may  be  mental  dulness  with  headache.  Convulsions  and 
Vomiting  may  occur.  In  other  instances  there  is  nothing  distinctive.  In 
a  (Kitient  who  died  under  my  care,  at  the  Philadelphia  Hospital,  of  ])hthisis, 
thciv  was  a  gradual  torpor,  deepening  to  coma,  without  convulsions,  local- 
iziui,'  symptoms,  or  optic  neuritis.  The  condition  was  thought  to  be 
(l;u'  to  a  terminal  meningitis.  In  the  chlorosis  cases  the  head  symp- 
toms have,  as  a  rule,  been  marked.  Ball's  patient  was  dull  and  stupid, 
tmd  vomiting,  dilatation  of  the  pupils,  and  do\ible  choked  disks.  Slight 
liaresis  of  the  left  side  occurred.     An  interesting  feature  in  her  case  was 


!1 

>■       '             li 

M 

'm'  1 

( ■  ■' 

1  ''  ■ 

1  ,' 

»  '  •'[        ( 

i'?< 

1 

1:1 


'J 


II     K 


M 


I  ' 


886 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


the  development  of  swellinjof  of  the  left  leg.  In  the  cases  reported  l)v  An- 
drew, Church,  Tuckwell,  Isambiird  Owen,  and  VVilks  the  patients  Jnid 
headache,  vomiting,  and  delirium.  Paralysis  was  not  present.  In  Doiiir- 
las  Powell's  case,  with  similar  symptoms,  there  was  loss  of  power  (ui  the 
left  side.  Bristowe  reports  a  ease  of  great  interest  in  an  anaMuic  <,nil  of 
nineteen,  who  had  convulsions,  drowsiness,  and  vomiting.  Tenderness 
and  swelling  developed  in  the  position  of  the  right  internal  jugular  vein, 
atul  a  few  days  later  on  the  opposite  side.  The  diagnosis  was  rendenil 
definite  by  the  occurrence  of  phlebitis  in  the  veins  of  the  right  leg.  The 
patient  recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  anivinie 
or  chlorotic  girl  should  lead  to  the  suspicion  of  cerebral  thromlxtsis.  In 
infants  the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous 
sinus  may  cause  oedema  about  the  eyelids  or  prominence  of  the  eyes. 

In  the  secondary  thrombi  the  symptoms  are  commonly  those  of  septi- 
cajmia.  For  instance,  in  over  seventy  per  cent  of  Pitt's  cases  the  mode  of 
death  was  by  pulmonary  pyaemia.  This  author  draws  the  following  im- 
portant conclusions :  (1)  The  disease  spreads  oftener  from  the  posterior 
wall  of  the  middle  ear  than  from  the  mastoid  cells.  (2)  The  otorrhaa 
is  generally  of  some  standing,  but  not  always.  (3)  The  onset  is  sudden, 
the  chief  symptoms  being  pyrexia,  rigors,  pains  in  the  occipital  region  and 
in  the  neck,  associated  with  a  septicajmic  condition.  (4)  Well-niarlied 
optic  neuritis  may  be  present.  (5)  The  appearance  of  acute  local  puhno- 
nary  mischief  or  of  distant  suppuration  is  almost  conclusive  of  thrombosis. 
(0)  The  average  duration  is  about  three  weeks,  and  death  is  generally 
from  pulmonary  pyaemia.  The  chief  points  in  the  diagnosis  may  be  giitii- 
ered  from  these  statements. 

Pitt  records  an  interesting  case  of  recovery  in  a  boy  of  ten,  who  had 
otorrhoea  for  years  and  was  admitted  with  fever,  earache,  tenderiu'ss,  and 
a3dema.  A  week  later  he  had  a  rigor,  and  optic  neuritis  developed  on  the 
right  side.  The  mastoid  was  explored  unsuccessfully.  The  fever  and 
chills  persisting,  two  days  later  the  lateral  sinus  was  explored.  A  mass  of 
foul  clot  was  removed  and  the  jugular  vein  was  tied,  after  which  the  boy 
made  a  satisfactory  recovery. 


'V      li 


AFFECTIONS  OF  THE  SUBSTAN'OE. 


III.   AFFECTIONS  OF  THE  SUBSTANCE. 


887 


I.  Topical  Diagnosis. 

A  majority  of  the  lesions  of  the  nervous  system  whioli  permit  of  a 
local  diagnosis  have  as  an  important  part  of  their  symptomatology  dis- 
turlcince  of  muscular  action,  and  as  our  knowledge  of  the  mechanism 
fjdvt'niing  the  movements  of  muscles  is  comparativi  'y  ;'.iact,  we  shall 
take  this  system  as  a  basis  for  local  diagnosis. 

The  motor  system  is  made  up  of  two  segments,  each  consisting  of 
crroups  of  nerve-cells,  and  their  prolongations  into  nerve-fibres.  The 
upper  segment  comprises  the  motor  cortex  and  the  pryamidal  fibres;  and 
the  lower  segment  the  motor  cells  in  the  medulla  and  cord  and  the  nerve- 
fibres  arising  from  them,  forming  the  peripheral  nerves  distributed  to  the 
musck's,  which  may  themselves  be  considered  as  part  of  this  segment. 

The  nerve-cells  are  so  arranged  that  when  thrown  into  action,  by 
whatever  cause,  a  definite  movement  is  the  result,  and  the  same  combina- 
tion of  nerve-cells  always  causes  the  same  movement,  or,  in  other  words, 
every  movement  of  the  body  is  represented  in  the  nervous  centres  by  com- 
binations of  the  nerve-cells,  or,  as  we  say,  is  localized. 

Movements  are  localized  both  in  the  cells  of  the  lower  segment  and  in 
those  of  the  upper,  and  we  have  consequently  spinal  localization  and  cere- 
bral localization. 

Spinal  Localization. — In  the  lower  motor  segment  the  muscles  are 
rpjiresonted  in  their  simplest  movements,  and  different  sections  of  the  cord 
have  been  found  to  represent  the  movements  of  different  muscles.  Our 
knowledge  of  this  localization  is  by  no  means  complete,  but  enough  has 
been  learned  to  aid  us  materially  in  determining  the  site  of  a  spinal  le- 
sion. 

The  cells  of  the  lower  segment  are  found  in  the  motor  nuclei  of  the 
raodnlla,  and  in  the  anterior  gray  horns  of  the  spinal  cord.  They  are  con- 
nected with  the  muscles  by  the  axis  cylinder  processes,  the  anterior  nerve- 
roots  (roots  of  motor  cranial  nerves),  the  peripheral  nerves,  and  the  end 
organs  by  which  they  are  brought  into  intimate  relation  with  the  proto- 
plasm of  the  muscle  fibre  itself. 

The  following  table  prepared  by  Starr  gives  in  detail  our  knowledge 
on  this  subject ;  , 


[ 


ti' 


.«  ^ 
t 


>{ 


1'! 


Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord. 


Seiimknt. 

II  imd 

III  C. 


MUBCLBS. 


Stcmo-mustoid. 
Trapezius. 
Sciileni  and  neck. 
Diaphragm. 


Reflex. 


Ilypchondrium  (f). 

Sudden  inspiration  pro- 
duced by  sudden  press- 
ure beneath  the  lower 
border  of  ribs. 


Sensation. 


Back  of 

fex. 
Neck. 


head  to  ver- 


S2 


888 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Skiiment. 

MUKCLKB. 

REri.Bx. 

8BN8AT10.N. 

IV  c. 

Diaphragm.                         I'upil.     4th  to   7th  cer- 

Neck. 

Deltoid. 

vical. 

Upper  shoulder. 

Biceps. 

Dilatation   of    the   pupil 

Outer  arm. 

Coraco-braohiaiis. 

produced  by  irritation 

Supinator  loiigus. 

of  neck. 

Rhomboid. 

Supra  and  infra  spinatus. 

~V~C." 

Deltoid. 

Scapular. 

Back  of  shoiililcr  ami 

Hioeps. 

51  h  cervical  to  1st  dorsal. 

arm. 

Coraco-braehialis. 

Irritation  of  skin  over  the 

Outer    side    of    ann 

Braehialis  antieus. 

scapula   produces  con- 

and fori'iirm,  fnuii 

Supinator  longus. 

traction  of  the  scapular 

and  back. 

Supinator  brevis. 

muscles. 

Iliiomboid. 

Sui)inator  longus. 

Teres  niiiior. 

Tapping    its    tendon    in 

Pectoralis(claviculari)art).      wrist   produces  flexion 

Serratus  inagnus.                ;     of  forearm. 

VI  C. 

Biceps.                                  Triceps. 
Brachialis  anticus.               oth  to  Cth  cervical. 

Outer   side   of  forc- 

arni,     front     uiid 

l*ectoralis(cIavi(Mdar  part).  Tapping    elbow    tendon 

back. 

Serratus  magmis. 

produces   extension  of 

Outer  half  of  liaml. 

Triceps. 

forearm. 

Extensors   of   wrist    and 

Posterior  wrist. 

lingers. 

0th  to  8th  cervical. 

Pronators. 

Tapping   tendons  causes 

extension  of  hand. 

VII  C. 

Triceps  (long  head). 

Anterior  wrist. 

Inner  side  and  buck 

Extensors   of    wrist   and 

7th  to  8th  cervical. 

of  arm  and   fore- 

fingers. 

Tapping  anterior  tendons 

arm. 

Pronators  of  wrist. 

causes  flexion  of  wrist. 

Radial    half   ot   the 

• 

Flexors  of  wrist. 

Palmar.    7th  cervical  to 

hand. 

Subscapular. 

1st  dorsal. 

Pectoralis  (costal  part). 

Stroking     palm     causes 

Latisimus  dorsi.                       closure  of  fingers. 

Teres  major.                       | 

VIII  c. 

Flexors  of  wrist  and  fin- 

Forearm  and  Imnd, 

gers. 

inner  half. 

Intrinsic  muscles  of  hand. 

I  D. 

E.xtensors  of  thumb. 

Forearm,  iiuicr  half. 

Intrinsic  hand  muscles. 

Ulnar  dislrilmlimi  to 

Thenar   and    hypotlienar 

hand. 

eminences. 

II  to 

Muscles  of  back  and  abdo- 

Epigastric.    4th   to   7th 

Skin    of    ('host    and 

XII  D. 

men. 

dorsal. 

abdomen  in  ixuuls 

Erectores  spina). 

Tickling    mammary    re- 

running     iimiHid 

gions  causes  retraction 

and  downward, cor- 

of  epigastrium. 

respondiii;,'  to  sjii- 

Abdominal.    7th  to  11th 

nal  nerves. 

dorsal. 

Upper  gluteal  region. 

Stroking  side  of  abdomen 

causes     retraction     of 

belly. 

I  L. 

Ilio-psoas. 

Cremasteric.      1st   to  3d 

Skin  over  gruin  and 

Sartorius. 

lumbar. 

front  of  scrulura. 

Muscles  of  abdomen. 

Stroking      inner     thigh 
causes     retraction     of 
scrotum. 

AFFECTIONS  OP  THE  SUBSTANCE. 


889 


8l!(l>lKNT. 

11  L. 

Hi  L. 

Tv  L. 

V  u" 


MlTgri.KB. 


Ijio-psoas.    Sartoriiis. 
Flexors  of  knee  (Ueiimk). 
Quiidrieeps  femoris. 


Qiiiulriceps  femoris. 
Inner  rotators  of  thigh. 
Abiluctors  of  thigh. 

Abductors  of  thigh. 
Adductors  of  tiiigh. 
Flexors  of  knee  (Ferrier). 
I  Tibialis  antieua. 


Outward  rotators  of  t  high. 
Flexors  of  knee  (Ferrier). 
Flexors  of  anklo. 
Extensors  of  toes. 


ItoII 
S. 


Ill  to 

V  S. 


Flexors  of  ankle. 

Long  flexor  of  toes. 

Pcronn'i. 

Intrinsic  muscles  of  foot. 


Perineal  muscles. 


Keflex. 


Henhation. 


Patella  tendon. 

Stroking    tendon    cniises 
extension  of  leg. 


Outer  side  of  thigh. 


Front  and  inner  side 
of  tliigh. 


Gluteal.    4th  to  5ti»  hini-    Inner  side  of  thigh 
bar,  I       and  leg  to  ankle. 

Stroking  buttock   causes    Inner  side  of  foot, 
dimpling    in    fold    of  | 
buttock.  I 


j  Hack  of  thigh,  back 
of  leg.  and  outer 
I      part  of  foot. 


Plantar.  Hack  of  thigh. 

Tickling     sole    of     foot  Leg  and  foot,  outer 

causes   flexion   of    toes  side. 

and  retraction  of  leg.     I 


Foot      reflex.       Achilles    Skin  over  sacrum. 

tendon.  ,  Anus. 

Overextension     of     foot    Perina'um.    Genitals. 

causes    rapid    flexion ; 

ankle-clonus. 
Bhulder  and  rectal  centres. 


Cerebral  Motor  Localization. — In  tlie  motor  cortex  the  muscles  are 
ajjaiu  represented,  or,  as  llughliugs  Jackson  says,  re-represented  in  their 
tiller  movements. 

Motor  Centres. — The  experiments  of  Ilitzig  and  Pritsch  and  of  Fer- 
rier, together  with  the  previous  clinical  studies  of  lluglilings  Jackson, 
laid  the  foundation  of  our  present  knowledge  of  cerebral  localization. 

The  area  for  representation  of  the  movements  in  the  cerebral  cortex  is 
in  the  Ilolandic  region  and  comprises  the  ascending  parietal  and  ascending 
fioiitid  convolutions,  tlie  hinder  part  of  the  tliree  frontal  convolutions,  and 
the  ])arietal  lobule,  a  continuation  backward  of  the  ascending  parietal 
I'oiivohition  (Fig.  3,  motor  region).  This  entire  region  is  excitable,  and 
stimulation  by  weak  electrical  currents  produces  muscular  movements  in 
the  opposite  half  of  the  body.  The  centres  presiding  over  the  different, 
groups  of  muscles  may  be  thus  classified  : 

{(t)  Centres  for  the  trunk.  These  have  been  shown  by  Schiifer  to  be 
situated  in  the  marginal  gyrus,  just  within  the  longitudinal  fissure,  the 
region  sometimes  spoken  of  as  the  paracental  lobule. 

(h)  Centres  for  the  lower  limbs.  These  are  situated  at  the  upper  part 
of  the  Rolandic  region,  close  to  the  longitudinal  fissure.  As  indicated  in 
the  diagram,  the  representation  of  movements  of  the  different  portions  of 
tlie  lower  limb  in  this  region  is  as  follows  (Fig.  2) :  Most  anterior,  the 
hip ;  next  in  order,  the  knee  and  ankle ;  then  the  big  toe,  the  centre  for 


ip. 


i 


i! 


u 


11 


il 


■m 


■  m 


800 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


;fti 


the  movoimMit  of  wliicli  surrouiulH  the  upper  oiid  of  tlie  fissure  of  Itolimdn. 
Still  further  hack  are  the  centres  for  movetnent  of  the  snuill  toe.s. 

(<;)  Ceutrus  for  the  up])er  limbs.    This  urea  corresponds  to  iiljdiil  the 


r^ 


Fig.  2. — (After  Jfills).  This  diagram  approximately  indicates  the  views  now  luld  m a 
result  of  experiment  and  their  confirmation  or  modification  by  clinico-pathulogical 
observation.  It  represents  the  division  of  the  lateral  surface  of  the  cerebriiiu  int" 
higher  psychical,  motor,  sensory,  visual,  and  auditory  areas ;  also  the  subdivision  if 
the  motor  area  into  subareas  for  speech,  the  head  and  eyes,  the  fav3,  arm,  leg.  a"'' 
trunk.  Only  certain  main  points  have  been  indicated  by  lettering,  so  as  not  to 
confuse :  S,  fissure  of  Sylvius ;  E,  fissure  of  Rolando,  or  central  fissure ;  / ''.  pre- 
central  fissure;  Re,  retrocentral  fissure;  Fl,  F2,  superior  aiid  inferior  fidiitiil  fis- 
sure ;  Ip,  interparietal  fissure ;  Po,  i)arieto-occipital  fissure ;  Tl,  first  tiiiiiwral 
fissure. 


AFFECTIONS  OF  THE  smsTANCE. 


8^1 


nii<l(llo  two  fourths  of  tho  motor  area.  Tlio  curcfiil  wtudicH  of  IIorsK y 
iiiul  Heovor  have  shown  that  from  above  downward  tlu'  ditTi'ri'ut  noffnu'iitrt 
(if  the  litnhs  are  represciitcd  as  foHows :  Shoulder,  dhow,  wrist,  fiii^fcrs, 
tlic  iiidex-hngfr,  and,  lowost  of  all,  the  thiiriih. 

(d)  Till!  ct'iitrcs  for  the  faco,  tonf^'uc,  pharynx,  and  larynx  arc  situated 
ill  tho  lowest  i)ortion  of  the  l{olandic  area.  The  eentres  for  the  movement 
of  the  tongue  and  vocal  cords  are  in  tlie  lower  and  anterior  portion  of  the 
iisccnding  convolutioTi,  and  on  the  left  side  in  man  this  rc^Mon  ami  the 
pdsterior  part  of  the  third  left  frontal  convolution  constitute  the  speech 
ci'iitre  (Fig.  2),  destruction  of  which  is  followed  by  one  form  of  aphasia. 
Ill  front  of  tho  precentral  sulcus  are  centres  for  the  representsition  of 
movements  for  turning  the  head  and  eyes  to  the  opposite  side. 

The  determination  of  these  areas  was  worked  out  in  animals  and  has 
nctw  been  thoroughly  established  in  man,  both  by  clinical  observation  and 
by  the  application  of  the  electrodes  in  ditTerent  situations  during  opera- 
tidiis  for  the  removal  of  growths  in  the  brain  or  of  the  motor  centres  in 
ei)ile[)sy.  The  ditTerent  regions  must  not  be  regarded  as  sharply  8ei)arate(l 
fidiii,  but  as  blending  with  each  other. 

With  these  centres  for  voluntary  movements  are  associated  those  which 
preside  over  the  muscular  sense,  which  is  a  compound  of  sensory  im- 
piVf^sions,  of  pressure,  tension,  anc^  touch  derived  from  the  muscles  as  they 
iire  in  motion.  There  is  still  dispute  with  reference  to  the  localization  of 
tliis  sense,  but  the  general  opinion  is  that  lesions  of  the  motor  area  itself 
cause  slight  loss  both  of  muscular  and  tactile  sense.  Others  place  the  cen- 
tres for  general  sensation  in  the  situation  marked  in  Fig.  2. 

The  tibres  uniting  tiie  cortrrnil  motor  centres  and  the  spinal  centres 
liiive  a  long  course,  in  which  they  })robably  have  no  connection  with  any 
(itlier  nerve-cells.     They  arise  from  the  various  centres,  enter  the  white 
matter  of  the  hemisphere  (the  corona  rudiata),  and  gradually  converge  to 
what  is  called  the  internal  capsule,  which  lies  between  the  lenticular  nucleus 
ami  the  thalamus  and  the  caudate  nucleus  (Fig.  3).  The  position  of  the  fibres 
ill  the  internal  capsule  has  been  accurately  worked  out  by  several  observ- 
ers.   The  fibres  from  the  centres  cf  the  face,  tongue,  eyes,  and  head  occupy 
the  most  anterior  position.  Just  at  the  knee,  as  it  is  called,  of  the  internal 
capsule,  while  the  fibres  from  the  upper  extremities  are  just  behind  these, 
iiiul  those  from  the  lower  extremities  occupy  the  jiosition  in  the  middle 
third  of  the  posterior  part.     Leaving  the  internal  cajjsnle,  the  fibres  form- 
injr  the  motor  path  pass  from  the  brain  into  the  cms,  in  which  they  oc- 
cupy a  lower  and  medial  position.     Passing  through  the  pons,  covered  by 
the  superficial  layers  of  transverse  fibres,  they  enter  the  medulla,  of  which 
they  form  the  anterior  or  j)yramidal  traet.     At  the  lower  part  of  tho 
medulla  a  large  proportion  of  the  fibres  decussate  and  pass  into  the  ojipo- 
site  side  of  the  spinal  cord,  forming  tho  crossed  pyramidal  tract  of  the 
lateral  column,  while  a  smaller  number  of  the  fibres  descend  in  the  an- 
terior column  of  the  same  side,  forming  the  direct  pyramidal   tract,  or 


111 


V 


Iv 


d  '(. 


li» 


8^2 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Tiircik's  colunm.     Tlio  pymmidtil   tracts  diminish   in   sizo   from  above 
downward.     The  fibrea  enter  the  gray  mutter  between  the  anterior  and 


■Cmssii  Pymhw^l  FiBKtS 

'DlR£CT  PyIWMDAL  FlBRtS 

Fio.  3.— Motor  Tract  (after  Starr).  S,  Assure  of  Sylvius;  NL,  lenticular  nucleus; 
OT,  optic  thalumus ;  0,  olivary  body.  The  tracts  for  the  face,  arm,  and  log  galiiiT 
in  the  caj)sule  and  pass  together  to  the  lower  pons,  where  the  face-tibrcs  cross  to 
the  opposite  VII  nerve  nucleus,  while  the  others  pass  on  to  the  lower  incdiillii, 
wliere  they  partially  decussate  to  enter  the  lateral  columns  of  the  cord;  tln'  iiuii- 
decussating  fibres  pass  to  the  anterior  median  columns.  The  effect  of  a  k'sioii 
situated  at  three  points  in  the  tract  is  shown  on  the  loft  side  of  the  figure  at  A', 
Y,  Z,  At  Z  the  lesion  would  involve  the  left  facial  nerve  and  the  left  pynunidiil 
tract  above  the  decussation,  producing  facial  paralysis  on  the  left  side  and  paralysis 
of  the  arm  and  leg  on  the  opposite  side — crossed  paralysis. 

posterior  cornna,  pass  forward,  divide  and  subdivide,  and  finally  j<iin  the 
plexus  of  the  protoplasmic  processes,  and  are  in  this  way  connected  witli 
the  large  norve-cells  of  the  anterior  Jiorns. 

Lesions  of  the  Motor  System.— Each  of  the  segments  of  the  motor 
tract  is  to  be  considered  as  a  nutritional  unit,  depending  for  its  vitality 
u])on  the  integrity  of  its  ganglion  cells.  If  certain  cells  in  the  corti'X  are 
destroyed,  the  fibres  arising  from  them  will  degenerate  throughout  llicir 
length — that  is,  to  the  beginning  of  the  lower  motor  segment.  So  also  if 
the  motor  cells  in  the  medulla  or  cord  are  injured,  their  nerve-fibres  will 
degenerate,  and  the  muscles  to  which  they  are  distributed  will  also  be 
involved  in  the  process.  The  same  thing  occurs  if  the  nerve-fibres  Itcrome 
detached  from  their  ganglion  cells.     This  process  is  called  seioiulary 


■i\ 


mi   iibf)ve 
DtTior  mid 


ulav  nuelous; 
liiiiil  leg  gatluT 
llbres  cross  to 
sviT  incdiillii, 
unl;  till'  u.'ii- 
■ct  iif  a  1''^'"" 
,0  figiin'  nt  •\> 
letl  pyniiiiiili'l 
[>  ami  {lariilysis 

Mlly  join  the 
[uecti'tl  ^vitll 

the  motor 
it8  vitality 
le  corti'x  lire 
Lhout  llieir 
So  also  if 
l^e-tibres  will 
Lill  also  be 
lb  res  bi't'ome 
1\  secuiulary 


APFECTTONS  OP  TOE  SUBSTANCE. 


803 


(lpj.'t'ncration  or  Wullcrian  (U'^'eiieration,  after  tlic  ])liyHi('ian  who  first  tU^ 
s('ril)e(I  it.  Fi;,'.  4  iiliistnites  this  process  in  the  cortico-spimil  motor  seg- 
ment. 

'i'lio  U'sioiis  may  ho  groiiiuM'..  ;is  IIiighliii^H  Jackson  sti{i},'cstod,  into 
nofiativo  and  positive,  or,  as  tiicy  are  now  moro 
usually  termed,  destructive  and  irritative. 

Ne}!:ative  or  destructive  h'sions  an}  ivhere  in 
the  motor  jiath  have  as  a  result  the  aliolisliment 
of  I  lie  functions  of  these  parts — i,  c,  pamhjsis. 

I'ositivc  or  irritative  lesions  cause  a  perver- 
sion of  the  function — i.  o.,  abnormal  muscular 
contnirfioHs. 

Although  these  two  symptoms  (paralysis  and 
abnornuil  contractions)  oc(nir  whenever  the  mo- 
tor path  is  diseased,  cai-h  of  the  segments  im- 
parts to  them  peculiar  characteristics  which  en- 
uiilc  us  in  a  great  majority  of  cases  to  determine 
tliL'  site  of  a  lesion. 

These  characteristics  depend  upon,  first,  the 
special  symptoms  referable  to  the  secondary  de- 
generations in  tlie  two  segments ;  second,  upon 
tlii'ir  anatomical  relation. 

('/)  Lesions  of  the  Lower  or  Spino-muscular 
Segment.  J)entructivp  Le.nons. — The  destructive 
k'sions  cause  here,  as  everywhere  in  the  motor 
path,  ])aralysis.  AVe  have  seen  above  that  wlien 
the  nerve-fibres  are  cut  off  from  their  ganglion 
cells  in  the  anterior  liorns,  they  not  only  degen- 
erate themselves,  but  that  the  muscles  to  which 
tliey  are  distributed  degenerate.  'J'his  process  is 
made  evident  by  a  change  in  the  electrical  reac- 
tion of  the  nerve  and  muscle — the  reaction  of 
degeneration — and  the  muscle  becomes  evident- 


Fio.  4.  —  (After  Gowers.) 
I)ia;;raMi  showiiij^  cnurso 
luitl  (li'jjt'ncnitionof  pyr- 
anii<lal  tract  in  ri^'ht 
ht'inisphpro,  cms,  pons 
niodulia,  and  curd. 


ly  atrophied.  The  myotatic  irritability  or  mus- 
cle reflex,  which  depends  upon  the  integrity  of 
tlie  lower  motor  segment,  is  lost  in  destructive 

lesions.  This  gives  to  the  paralysis  certain  characteristics,  namely,  atro- 
phy of  the  muscles,  loss  of  its  reflex  excitability,  and  alteration  of  the 
electrical  reactions  of  the  nerve  and  muscle. 

'J'he  anatomical  relations  of  the  lower  motor  segment  also  give  'crtain 
peculiarities,  wliich  help  to  distinguish  its  lesions  from  those  of  the  upper 
segment,  on  the  one  hand,  and  of  the  different  jiarts  of  the  lower  segment 
i>n  the  other.  • 

In  general  the  different  units  which  make  up  the  lower  segment  are 
more  or  less  widely  separated  from  each  other.     An  extreme  example  of 


li 


m 


% 


m 


1^ 


.,4aSl 


894 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


IP 


I  si- 

f 


S.it' 


this  is  the  distance  between  the  nucleus  of  the  third  nerve  and  the  collec- 
tion of  motor  cells  in  the  lower  part  of  the  lumbar  enlargement.  V(\r  tliis 
reason  lesions  of  this  segment  are  more  apt  to  cause  paralysis  of  iiidividiial 
muscles  or  muscle  groups,  as  distinguished  from  the  more  wiuo-spR-iui 
paralysis  due  to  lesions  of  the  upper  segment. 

Iteference  to  Starr's  table  will  show  that  the  muscles  are  represented 
in  the  s])inal  cord  without  relati,>n  to  the  nerves  which  supply  them— that 
is  to  say,  muscles  that  are  supplied  by  a  certain  nerve  may  not  be  repre- 
sented close  together  in  the  anterior  horns;  for  instance,  in  the  fourtli 
cervical  segment,  movements  of  the  diapliragm,  deltoid,  biceps,  su|iiiiat()r 
longus,  rhomboid,  supra8])inatus,  and  infraspimitus  are  represented.  It  foj. 
lows  from  this  th;*t  the  distribution  of  a  paralysis  due  to  disease  of  the  hiwcr 
motor  segment  may  enable  us  to  distinguish  the  position  of  the  h'sion 
within  the  segment  itself.  We  are  often  helped  in  this  by  the  sensory 
symptoms,  which  may  accomjmny  the  paralysis.  Thus,  if  we  have  a  [>aral- 
ysis  with  the  characteristics  of  a  lesion  of  the  lower  motor  segment,  and 
if  the  paralyzed  muscles  are  all  supplied  by  one  nerve,  and  we  di.^covcr 
anaesthesia  in  the  skin  of  the  arm  supplied  by  that  nerve,  it  is  .'vidciit 
that  the  lesions  must  be  in  the  nerve  itself.  On  the  other  liand,  if  the 
muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but  are  represt'ntcd 
close  together  in  the  spinal  cord,  and  the  antesthesia  corresponds  to  tliat 
section  of  the  cord  (see  table),  it  is  equally  clear  that  the  lesion  must  be  of 
the  cord  itself  nr  of  its  nerve-roots. 

Irritative  Lexioiin  of  the  Lower  Motor  Segment. — We  know  of  no  lesion 
of  this  segment  which  has  as  its  result  abnormal  muscular  contraction 
unless  the  slow  atrophy  of  the  gan'glion  cells  occurring  in  progressive  mus- 
cular atrophy  be  considered  as  the  cause  of  the  fibrillary  contraction  so 
common  in  this  direction. 

(Certain  tonic  muscular  contractions  occurring  n  poisoning  by  strych- 
nine and  in  tetanus  are  thought  to  be  due  to  the  perverted  action  of  the 
lower  motor  centres,  and  llughlings  Jackson  believes  that  certain  convul- 
sive paroxysms — "  lowest  level  fits  " — are  due  to  discharging  lesions  >f  tlu'se 
centres,  and  di'ims  laryngismus  stridulus  in  this  category.) 

(/>)  Lesions  of  the  Upper,  Cerebrr^spinal  Motor  Segment.— A  ^/""/"'' 
lesions  cau.se,  as  in  the  lower  motor  segment,  ')aralysis,  and  here  a^'ain  the 
secondary  degeneration  »vhi(di  follows  th-  lesion  gives  to  the  paralysis  it< 
distinctive  clniracteristics.  In  this  case  I'm  paralysis  is  accompanied  liy  a 
spastic  condition,  shown  in  an  exaggeration  of  muscle  reflex  and  an  in- 
crease in  the  ♦^ension  of  the  muscle.  It  is  not  accurately  known  iiow  thr 
degeneration  of  the  pyramidal  fibres  causes  this  excet-s  of  the  niusclf 
reflex.  The  usual  explanation  is  that  under  normal  circumstaui  es  tlic 
upper  motor  centres  are  constantly  exerting  a  restrairing  inhiicnee  upon 
the  activity  of  the  lower  centres,  and  that  when  the  influence  ceases  to  ai  t, 
on  account  of  diseivse  of  the  pyramidal  fibres,  the  latcer  take  on  in.  icased 
activity,  which  is  mado  i.iunifest  by  au  exaggerutiou  of  the  uiuscle  rellex. 


t\;f'i 


AFP.OT,ONS  0.  THE  SfBST.XCR 


«  was  stated  above  tli„(  „„  i  *95 

*i.Ted  as  „  u„triti„„„,  Z^t°^^.  'I*"""'  »'  "«  motor  p„th  i,  .„  , 

,    ■I'i.e  upper  „,„  J  sCm    ;  r„rf ""  »'  "*-™ti '   '     ''"«™"''"™ 

f»r  tlu-s  reason  a  paral^rr  s„  li"T  '  "'"■•''  """'l'-'  """.  the  l„„.„r        , 
iiiaiiv  muscles     Ti,i   ■       "™">"g  from  a  l„sjo,,  :,,  ■,  .   ""■  """";  anrl 

'  'Je  motor  centres  of  tl 
°",'7'  """  »  «'-Ply  iocal,«lS^  r,r™  "'  '"''  '""""tol  from  eael, 

tn.  I  stimulation.  ^'"''^'^  ^'^^  «Iegenerutive  reaction  to  Tec 

'i'loli  lesions  is  confin^/f     I  ^'^'''*  ^^''^'''*  '^W/w^^;^/ -On,,  i        , 

'■"«y  Phenomena  an!;,,',',    „  ';;:;■-;;;•'>"  iV™""^-  a,::,  „      I'™ 

Sensory  Centres  and  Paths     T. 

1  osmon  of  the  sensory  tracts  is  by 


\i\ 


In 


I 


.ft 


lit 


) 


>'l 


!mm 


W 


n 


fc\.? 


If 


896 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


no  means  so  precise.  Some  importjint  fiu-ts  are,  however,  known.  Sensorv 
fibres  from  different  areas  of  the  skin  run  in  dose  connection  with  fibres 
of  tlie  lower  motor  sej^ment  in  the  mixed  nerves.  They  separate  fmin 
them  and  enter  tlie  spinal  cord  by  tlie  i>o«terior  r(K>ts.  1'he  regions  whieh 
the  different  jiosterior  roots  sup[)ly  is  given  in  Starr's  table  After  enter- 
ing the  spinal  (!ord  the  sensory  fil)res  cross  the  middle  line  at  once  and 
pass  lip  to  the  brain  in  the  opposite  half  of  the  cord.  Here  they  are  again 
in  close  contact  with  the  motor  path,  but  with  that  of  the  other  side  of  the 
body — i.  e.,  the  right  half  of  the  spinal  cord  contains  the  sensory  fibres  of 
the  left  side  of  the  body  and  mot<jr  fibres  of  the  right.  1'he  fibres  whicli 
conduct  the  imjyressions  for  the  muscular  sense  seem  to  be  an  exception 
and  do  not  decussate  in  the  cord.  The  exsu.'t  prjsition  of  the  sensory  paths 
in  the  cord  is  still  somewhat  uncertsiin,  nor  are  we  sure  of  their  course  in 
the  medulla,  pons,  and  peduncle.  All  the  sensiiry  fibres  of  the  opposite 
side  of  the  body  are  collected  in  the  posterior  third  of  the  posterior  limb 
of  the  internal  capsule,  just  behind  the  motor  fibres  of  the  upper  segment. 

Much  doubt  and  discussion  still  exist  as  to  the  areas  for  the  represen- 
tation of  sensory  impressions,  llorsley  has  suggested  that  the  muscular 
and  tactile  senses*  are  localized  in  the  motor  cortex,  and  that  two  of  the 
three  chief  layers  of  cells  in  this  region  subser^x*  their  functions.  Dana's 
study  shows  that  many  lesions  of  the  motor  area,  particularly  in  the  hinder 
part,  are  associated  with  anajsthesia.  On  the  other  hand,  Ferrier  regards 
the  hijjpocampal  convolution,  and  Schafer  the  gyrus  fonnicatus,  as  tlie 
centres  for  sensory  impressions. 

The  centres  for  sight,  hearing,  smell,  and  tiiste  have  been  referred  tti 
under  the  nerves  ministering  to  these  senses,  and  we  shall  consider  the 
speech  centres  in  the  next  section. 

In  the  centrum  ovale  the  fibres  of  the  motor  path  are  more  or  less 
closely  associated  with  other  systems  of  fibres;  those  connecting  the  cor- 
tex with  nervous  structures  lying  Iwlow  it,  projectifm  fibres;  the  fibres 
which  join  the  two  hemis])here8, commissural  fibres;  and  those  which  join 
different  parts  of  the  same  hemisphere,  aAsrK'iation  fibres.  Our  knowledire 
of  the  function  of  these  fibres  leaves  mu(!h  to  Ixj  desired.* 

The  following  is  a  brief  summary  of  the  effects  of  lesions  from  the 
cort«x  to  the  spinal  cord  : 

1.  The  Cerebral  Cortex. — {'i)  Destructive  lesions  cause  .»<;>««/(>■ />«n//'/ 
sis  in  tl»e  nuiscles  of  the  opjjosite  side  of  the  body.  The  extent  of  I  lie 
paralysis  depends  upon  that  of  the  lesion.  It  is  apt  to  be  limited  to  the 
muscles  of  an  extremity,  giving  rise  to  the  cerebral  monoplegias  (V\'i- 
3,  A').  A  lesion  may  involve  two  centres  lying  close  together,  thus  \)V"- 
(hieing  paralysis  of  the  face  and  arm,  or  of  the  arm  and  leg,  but  not  I'f 

•  The  student  will  find  in  Starr's  work,  Familiar  Forms  of  Nervous  Disease,  hh 
n<1mirable  presentation  of  this  subject. 


W  : 


;i()i\s  from  the 


PV0U8  Disease,  a" 


AFFECTIONS  OP  THE  SUBSTANCE. 


89; 


the  face  and  log  without  involvement  of  the  arm.  Very  rarely  the  wl»olc 
motor  cortex  is  involved,  causing  paralysis  of  one  side — cortical  hemi- 
plegia. 

Combined  with  the  muscular  weakness  there  is  usually  some  disturb- 
ance of  sensation,  particularly  tactile  impressions  and  those  of  the  mus- 
cular sense. 

(b)  Irritative  lesions  cause  localized  spasms  as  described  above.  These 
convulsions  are  usually  preceded  and  accompanied  by  sensory  impressions. 
Tingling  or  pain,  or  a  sense  of  motion  in  the  part,  is  often  the  siffiial 
Hijmptom  (Seguin),  and  is  of  great  importance  in  determining  the  seat  of 
the  lesion. 

Lesions  are  often  both  destructive  and  irritative,  and  we  have  combi- 
nations of  the  symptoms  produced  by  each.  For  instance,  certain  muscles 
may  be  paralyzed,  and  those  represented  near  them  in  the  cortex  may  be 
the  seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may  be  at 
times  subject  to  convulsive  spasms,  or  muscles  which  have  been  convulsed 
may  become  paralyzed.  In  this  manner  it  is  often  possible  to  trace  the 
progress  of  a  lesion  involving  the  motor  cortex. 

We  have  seen  in  a  previous  section  that  lesions  involving  tlio  centres 
for  the  special  senses  nuiy  give  rise  to  focal  symptoms,  aiul  shall  simply 
refer  to  them  here.  The  symptoms  caused  by  lesions  of  the  speech  centre 
will  be  described  under  aphasia,  and  it  is  only  necessary  to  note  the  near 
situation  of  the  motor  speech  area  (JJroca's  centre)  in  the  left  third 
frontal  convolution  to  the  centres  of  the  face  and  arm  on  that  side,  and  to 
sbite  that  motor  aphasia  is  often  associated  with  monoi)legia  of  the  right 
side  of  the  face  and  the  right  arm.  Accompanying  the  paralysis  follow- 
ing a  Jacksonian  fit  of  the  right  face  or  arm  there  is  often  a  transient 
motor  aphiisia. 

(2)  Centrum  Ovale. — Lesions  in  this  part  of  the  motor  path  cause 
paralysis,  which  has  the  distribution  of  a  cortical  palsy  when  the  lesion  is 
near  the  cortex,  and  of  that  due  to  a  lesion  of  the  internal  capsule  wlien 
it  is  near  that  region.  'J'hey  may  be  associated  with  symptoms  due  to  the 
interruption  of  the  other  system  of  fibres  running  in  the  centrum  ovale, 
and  there  may  be  seiisory  disturbances — hemiaiui^sthesia  and  hemianopisi — 
and  if  the  lesion  is  in  tlie  left  hemisphere  one  of  the  different  forms  of 
aphasia  may  accompany  tlic  paralysis. 

(3)  Internal  Capsule. — Here  all  the  fibres  of  the  upper  motor  scgnuMit 
are  gathered  together  in  a  compact  bundle,  aiul  a  lesion  in  this  region  is 
apt  to  cause  complete  hemiplegia  of  the  opposite  side,  and  if  the  lesion 
iiiv(»lves  the  hinder  third  of  the  posterior  limb  there  is  also  hemiana'sthe- 
sia,  including  even  the  special  senses(Fig.  ;},  }'). 

(4)  CrU8  Cerebri. — Here,  again,  all  the  motor  fibres  and  all  the  sen- 
sory fibres  of  the  opposite  side  are  collected  in  a  snuill  space,  and  a  lesion 
may  produce  hemiplegia  combined  with  sensory  disturbances.  On  ac- 
count of  its  anatomical  relation  the  third  cranial  nerve  is  often  involved 


{ lil 


}<>'■' 
P 


I 


f: 


898 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


m 


in  lesions  of  the  cms,  cmising  paralysis  of  the  muscles  of  the  eye  on  the 
same  side  us  the  lesion  combined  with  a  hemiplegia  of  tlie  opposite  sick'— 
i.  e.,  a  crossed  paralysis. 

(o)  Pons. — In  the  pons,  medulla,  and  cord  tiie  upper  and  lower  motor 
segments  are  both  represented,  the  first  by  the  pyramidal  fibres,  the  hiUvr 
by  the  motor  nuclei  and  the  nerve-fibres  arising  from  them.  Lesions  here 
often  alfect  both  motor  segments,  and  produce  combinations  of  paralysos 
having  the  characteristics  of  each.  Thus  a  lesion  in  the  lower  part  of  the 
pons  may  involve  the  pyramidal  tract  and  cause  a  spastic  paralysis  of  tlie 
opposite  arm  and  leg,  and  also  involve  the  nucleus  or  the  fibres  of  tlie 
facial  nerve,  and  so  produce  a  paralysis  of  the  same  side  of  the  face,  accom- 
panied by  loss  of  tiie  muscle  refiex,  atrophy,  and  the  reaction  of  degen- 
eration— crossed  paralysis  (Fig.  3,  Z).  The  abducens  and  hypoglossiis 
nerves  may  also  be  paralyzed  in  the  same  manner.  In  lesions  of  tlic 
pons  the  ])atient  often  has  a  tendency  to  fall  toward  the  side  on  whieli 
the  lesion  is,  due  probably  to  implication  of  the  middle  peduncle  of  the 
cerebellum. 

The  8ymi)tom8  produced  by  involvement  of  thedillcrent  cranial  nerves 
have  been  considered  in  detail  in  a  previous  section. 

(0)  Spinal  Cord. — Unilateral  lesions  cause,  first,  a  lower-segment  pa- 
ralysis, due  to  the  disease  of  the  centres  at  the  site  involved  ;  second,  a 
spastic  })araiysis  of  all  the  muscles  on  that  side  of  the  body  below  the 
lesion,  due  to  interruption  of  the  pyramidal  fibres ;  and,  third,  disturbanee 
of  sensation  in  the  opposite  side  of  the  body.  (See  under  Brown-Sequard's 
paralysis.) 

Transverse  lesions  of  the  cord  oause  paralysis  with  atrophy,  etc.,  at  the 
level  of  the  lesion,  spastic  paralysis  below  it,  combined  with  sensory  dis- 
turbance and  trouble  with  the  bladder  and  rectum. 

Affections  of  the  peripheral  nerves  luive  already  been  considered. 


II.  Aphasia. 

The  speech  mechanism  consists  of  receptive,  perceptive,  and  emissive 
centres  in  the  cortex  cerebri,  disturbances  of  which  cause  aphasia,  and 
centres  in  the  medulla  which  preside  over  the  muscles  of  articulation,  dis- 
turbance of  which  2)roduces  aitarfhria,  the  condition  of  gradual  loss  cf 
power  of  speech,  such  as  occurs  in  bulbar  paralysis. 

The  studies  of  Bastian,  Kiissmaul,  Wernicke,  Lichtheim,  and  othois 
have  widened  enormously  our  knowledge  of  speech  disorders.  Languaire 
is  gradually  acquired  by  imitation.  Thus,  in  teaching  a  child  to  say  bcH, 
the  sound  of  the  uttered  word  enters  the  afferent  j)ath  (auditory  nerve) 
and  reaches  the  auditory  perceptive  centre,  from  which  an  impulse  is  sent 
to  the  emissive  or  motor  centre  presiding  over  the  nuclei  in  the  medulla, 
through  which  the  muscles  of  articulation  are  set  in  action.  The  ai'' 
in  Lichtheim's  schema  (Fig.  5)  is  a  A,  Mm.     The  child  gradually  ui  - 


i!i 


cranial  nerves 


AFFECTIONS  OF  THE  SUBSTANCE. 


899 


n 

-Lichtheim's  schema. 


quires  in  this  way  word  memories,  which  are  stored  at  the  centre  A,  and 
motor  memories — the  memories  of  the  co-ordinated  muscuhir  movements 
necessary  to  utter  words — whicli  are  stored  at  the  centre  M.  In  u  similar 
manner,  when  shown  the  bell,  the  child  acquires  visual  memories^  wliich 
arc  conveyed  through  the  optic 
nerve  to  the  visual  perceptive 
centres,  o  O.  So  also  the  memo- 
ries of  the  sound  of  the  bell 
when  struck.  The  memory  pict- 
ure of  tlie  shape  of  tlie  bell,  the 
memory  of  the  appearance  of  the 
word  bell  as  written,  and  the 
motor  memories  of  the  muscuhir 
movements  required  to  write  the 
word  are  distinct  from  each 
other;  yet  they  are  intimately 
connected,  and  form  together 
what  is  termed  the  word-iniac/f. 
In  addition  to  all  liiis  the  child 

gradually  acquires  in  his  education  idetw  as  to  tl;e  use  of  the  bell — 
intellectual  concepts — the  centre  for  wliich  is  represented  at  1  in  the 
(Hagram  In  volitional  or  intellectual  speech,  as  in  uttering  the  word 
bell,  the  path  would  be  I,  M  m,  and  in  writing  the  word,  I,  M,  W,  h. 
These  various  "memories"  are  as  a  rule  stored  or  centred  in  the  left 
hemisphere. 

The  relations  of  written  and  spoken  language  arc  then  with  (a)  sen- 
sory perceptive  centres  (hearing  and  sight  and,  in  the  blind,  touch) ;  (A) 
emissive  or  motor  centres  for  speech  and  writing ;  and  (r)  psychical  cen- 
tres, through  which  we  obtain  an  intellectual  conception  of  what  is 
s:iid  or  written,  and  by  which  we  express  voluntarily  our  ideas  in  lan- 
guage. 

There  are  two  chief  forms  of  aphasia — sensnrtf  and  motor. 

(1)  Sensory  Aphasia;  Apraxia;  Word-blindness;  Word-deafness.— Hy 
apraxia  is  understood  a  condition  in  which  there  is  loss  or  impairment  of 
the  power  to  recognize  the  miture  and  iduvracteristics  of  objects.  Persons  so 
iitTccted  act  "  as  if  they  no  longer  possessed  siu-h  ol)je(;t  nuMnories,  for  they 
fail  to  recognize  things  fdrmerly  familiar.  A  fork,  a  cane,  a  pin,  may  bo 
taken  up  and  looked  at  by  such  a  person,  ami  yet  held  or  used  in  a  numner 
wliich  clearly  shows  that  it  awakens  no  idea  of  its  use.  And  this  symp- 
t(»ni,  for  which  at  lirst  the  term  blindness  of  mind  was  used,  is  found  to 
txtend  to  other  senses  than  that  of  sight.  Thus  the  tick  of  a  watch,  the 
t'onml  of  a  bell,  a  melody  of  music,  may  fail  to  arouse  the  idea  which  it 
furmerly  awakened,  and  the  patient  has  then  deafness  of  mind,  or  an 
odor  or  taste  no  longer  calls  up  the  notion  of  the  thing  smelled  or 
tasted  ;  and  thus  it  is  found  that  each  or  all  of  the  sensory  organs,  when 
67 


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1^ 


1 


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,  I 


ri 


V' 


I' 


w 


I  i: 


yoo 


DISEASES  OF  THE  NERVOUS  SYSTESI. 


!l; 


:|: 


called  into  play,  may  fitil  to  arouse  an  intolli<ront  pt'ivopli(,ii  df  the 
object  ox('itin<;  tlicni.  For  the  i^eiieral  symptoms  of  inability  to  mwr. 
nize  the  use  or  import  of  an  object  the  term  apvaxiu  is  now  employed." 
(Starr.) 

Apraxiu  may  occur  alone,  but  moro  commonly  is  ussociuted  with  vaiii'- 
tics  of  sensory  ami  motor  a()hasia.  The  patient  may  be  able  to  rea'l,  Init 
the  words  arouse  no  iiitellii,'ent  impression  in  his  mind.  While  lilind  to 
memory-pictures  aroused  throujj;b  sight,  the  perceptions  may  be  siiimi- 
luted  by  touch ;  thus  there  are  instances  on  record  of  apnixic  jjaticuts  un- 
able to  read  by  sight,  who  could  on  tracing  the  letti'rs  by  touch  \va\w. 
them  correctly.  Of  the  forms  of  apraxia,  miml-blindness  aud  iiiiml- 
deafiu'ss  are  the  most  important. 

The  cases  of  ii)iiid-b/iii((iirss  collected  by  Starr  indicate  that  the  Wuiu 
exists  in  the  leit  hemisphere  in  right-handed  persons,  and  in  the  riirlit 
hemisphere  in  hd't-handcd  persons.  The  disease  nsually  iuvolvcs  tin? 
angular  and  supramarginal  gyri  or  the  tracts  proceeding  from  tlieiii. 
Windness  of  the  "  mind's  eye  "  nuiy  at  times  be  functional  and  traii>it(iry, 
a!id  is  associated  with  many  forms  of  mental  disturbance,  lu  a  reiiiark- 
able  case  reported  by  !Macewen,  the  patient,  after  an  injury  to  the  hciul, 
had  sullered  witli  lunulaehe  and  melancholia,  but  there  was  no  j)ara!ysi,s. 
He  was  psychically  bliiul  and  though  he  could  see  everythiug  perfectly 
well  ami  could  read  letters,  objects  conveyed  no  intelligent  impression. 
A  man  before  his  eyes  was  recognized  as  some  object,  but  not  as  a  man 
until  the  sounds  of  the  voice  led  to  the  recognition  through  the  auditory 
centres.  The  skull  was  trephined  over  the  angular  gyrus  ami  the  inner 
table  was  found  to  be  depressed  aiu4  a  ]iortion  had  been  driven  info  the 
brain  in  this  region.  The  patient  recovered.  Mind-blindness  is  the  e<|niva- 
lent  of  visual  amnesia. 

Word-blindness  may  occur  alone  or  Avith  motor  aphasia.  Tu  un- 
complicated cuses  the  patient  is  no  longer  able  to  recall  the  appeai- 
ajices  of  words,  and  does  not  recognize  them  on  a  printed  or  written 
page.  The  j>atient  nuiy  be  able  to  pronounce  the  letters  aud  can 
often  write  correctly,  but  he  cannot  read  understandiugly  what  he  Inus 
written.  It  is  rare,  however,  for  the  patient  to  be  able  to  write  with 
any  degree  of  facility.  There  are  instjinces  in  which  the  ])aticnt,  un- 
able to  read,  has  yet  been  able  to  do  mathematical  ])roblems  and  to 
recognize  play  cards,  'I'he  lesion  in  cases  of  word-blindness  is,  in  ii 
majority  of  cases,  in  the  angular  and  supramarginal  gyri  on  the  left  .^ide. 
It  is  commonly  associated  with  hemianopia,  and  not  infreriucntly  with 
mind-blindness. 

Afiiul-dodfneftii  is  a  condition  in  wliich  sound.s,  though  heard  and  pir- 
ceived  as  siu-h,  awaken  no  intelligent  conceptions.  A  person  who  knows 
nothing  of  French  has  mind-deafness  so  far  as  the  French  languap'  i- 
concertied,  and  though  he  recognizes  the  words  as  words  when  s])oken, 
aud  can  repeat  them,  they  awaken  no  auditory  memories.     The  mu.-ical 


AFB^ECTIONS  OF  THE  SUltSTANCK. 


Wl 


hi  i' IT! 


faculties  may  bo  lost  in  aphasics,  who  may  bo(>ome  notc-doaf  and  unable 
til  apprcciati!  mclodios  or  to  road  music.  This  inay  oi-cur  without  tlio 
oxistoiice  of  motor  apluisia,  and  on  the  otiicr  hand  tiicro  aro  casi-s  on 
record  in  wliich  with  motor  apliasia  for  ordinary  spooch  the  pationt  could 
siuj^j  and  follow  tunes  correctly.  Mind-deafness  is  also  known  as  auditory 
iiiiiiicsia.  Word-deafness  is  a  condition  in  whi<'h  the  patient  no  lonjror 
understands  spoken  languai^e.  'i'he  memory  of  the  sound  of  the  word 
is  lost,  and  can  neither  be  recalled  nor  recognized  when  heard.  It  is  usu- 
ally associated  with  other  varieties  of  aphasia,  though  there  are  cases  in 
which  the  patient  has  been  able  to  read  and  write  and  speak.  The  lesion 
ill  word-deafness  has  been  accurately  defined  in  a  number  of  cases  to  be  in 
the  posterior  portion  of  the  first  and  second  temporal  convolutions  on  the 
left  side  (Fig.  2). 

Other  nninifestations  of  mind-blindness  are  mot  with ;  thus  a  young 
man  with  scseondary  syphilis  had  several  convulsive  seizures,  aftt'r  one  of 
which  he  remained  unconscious  for  some  titne.  On  awakening,  the  mem- 
ory-pictures of  faces  and  places  were  a  blank,  and  he  neither  kiu'W  his 
jiai'ents  nor  brothers,  nor  the  streets  of  the  town  in  which  he  lived.  He 
had  no  ai^hasia  proper,  and  no  paralysis. 

(v)  Motor  or  ataxic  aphasia  is  a  condition  in  which  the  memory  of 
the  ellorts  necessary  to  pronounce  words  is  lost,  owing  to  disturbance 
in  the  emissive  centres.  This  is  the  variety  long  ago  recognized  by 
Hroca,  the  lesion  of  which  was  localized  by  him  in  the  third  left  frontal 
(•(involution.  In  pure  eases  the  jmtieiit  is  able  to  read  (not  aloud)  and 
understands  perfectly  what  is  said,  lie  may  not  be  able  to  utter  a 
single  word ;  more  commonly  he  can  say  one  or  two  words,  such  as 
"no,"  "yes,"  and  he  not  infrequently  is  able  to  repeat  words.  When 
shown  an  object,  though  not  able  to  name  it,  ho  may  evidently  recog- 
nize what  it  is.  If  told  the  name,  he  may  be  able  to  repeat  it.  A  man 
knowing  the  French  ami  (Jernum  languages  may  lose  the  power  of  ex- 
pressing his  thoughts  in  them,  while  retaining  his  nu)ther-tongue ;  or, 
if  completely  aphasic,  may  recover  one  before  the  other.  As  the  tbii'd 
lift  frontal  convolnti<m  is  in  close  contact  with  the  centres  for  the  fac(^ 
and  arm,  these  are  not  uncommonly  involved,  with  the  production  of  a 
partial  or,  in  some  instances,  a  comi)lete  right-sided  hemiplegia.  Alcria^ 
or  inability  to  read,  occurs  with  motor  aphasia  aiul  also  with  word- 
blindness. 

As  a  rule,  in  motor  aphasia  there  is  also  innbility  to  write  — 
i'!irti)i/iia.  When  there  is  right  brachial  monoplegia  it  is  dillicult  to 
test  the  capability,  but  there  are  instances  of  motor  aphasia  without 
paralysis,  in  which  the  power  of  voluntary  writing  is  lost.  The  con- 
dition varies  very  much;  thus  a  patient  nuiy  not  be  able  to  write 
vi  1  mtarily  or  from  dictation,  and  yet  may  copy  perfectly.  It  is  still 
a  ([uestion  whether  there  is  a  sj)ecial  writing  cc^ntre.  It  has  been  placed 
liy  some  writers  at  the  base  of  the  second  frontal  convolution,  but  in  a 


I ' 


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ii 


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1 

'  ^■'ki 

', 

%' 

tl^l 

i  ':\ 

.M 

902 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


recent  study  Dejerine  concludes  that  it  is  not  separate  from  tlio  spooch 
(jontre. 

There  is  a  form  known  as  mixed  aphasia,  or  ])arapfiasia,  in  wliicli 
the  patient  understands  what  is  said,  and  speaks  even  loii<f  sciitciices 
correctly,  but  lio  constantly  tends  to  misplace  words,  and  does  not 
express  his  ideas  in  the  proper  words.  All  grades  of  this  may  ho  met 
with,  from  a  stjite  in  which  oidy  a  word  or  two  is  misi)lac(>d  to  an 
extreme  condition  in  which  the  patient  talks  jargon.  In  these  ciiscs 
the  association  tract  is  interrupted  between  the  auditory  pcrccptivi; 
and  the  emissive  centres,  hence  it  is  sometimes  known  as  Wcrnicko's 
aphasia  of  conduction.  The  lesion  is  usually  in  the  insula  and  in  tiio 
convoluticms  which  unite  the  frontal  and  temporal  lobes.  Lichtluiin's 
schema  will  assist  the  student  in  obtaining  a  rational  idea  of  the  varietius 
of  aphasia : 

1.  In  the  condition  of  apraxia  or  mind-blindness  the  ideation  centres, 
I,  are  involved,  often  with  the  auditory  and  visual  perceptive  centres,  A 
and  0. 

2.  A  lesion  at  A,  the  centre  for  the  auditory  memories  of  words  (first 
left  temporal  gyrus),  is  associated  with  word-deafness. 

3.  A  lesion  at  O,  the  i-i'ntre  for  visual  memories  (angular  and  suiini- 
marginal  gyri),  causes  word-blindness. 

4.  Interruption  of  the  tracts  uniting  A  M  and  0  M  causes  the  conduc- 
tion aphasia  of  Wernicke — parajihn.sin. 

5.  Destruction  of  the  centre  M  (Broca's  convolution)  causes  i)iin( 
motor  aphasia,  in  which  the  patient  cannot  express  thoughts  in 
speech. 

A  lesion  at  M  usually  destroys  also  the  power  of  writing,  hut,  ;us 
stated,  it  is  believed  by  many  that  the  centre  for  writing,  W,  is  distinct 
from  that  of  speech.  In  this  case  a  lesion  at  M,  which  would  destroy 
the  power  of  voluntary  speech,  might  leave  open  the  connections  be- 
tween 0  W  and  A  W,  by  which  the  patient  could  copy  or  write  from 
dictation. 

The  problems  of  aphasia  are  in  reality  excessively  complicated,  and 
the  student  must  not  for  a  moment  suppose  that  cases  are  as  sirniilc 
as  diagrams  indicate.  A  majority  of  them  are  very  complex,  but  with 
patience  the  diagnosis  of  the  different  varieties  can  often  bo  worked 
out. 

The  following  tests  should  be  applied  in  each  case  of  aphasia;  (1)  The 
power  of  recognizing  the  nature,  uses,  and  relations  of  objects-  i.  c, 
whether  apraxia  is  present  or  not ;  (2)  the  power  to  recall  the  niune  of 
familiar  objects  seen,  smelled,  or  tasted,  or  of  a  sound  when  heard,  or 
of  an  object  touched;  (3)  the  power  to  understand  spoken  words;  (4) 
the  capability  of  understanding  printed  or  written  language;  (">)  the 
power  of  appreciating  and  understandhig  musical  tunes;  (0)  the  power  of 
voluntary  speech — in  this  it  is  to  be  noted  particularly  whether  he  mis- 


AKFKCTIONS  OF  THE  SUBSTANCE 


903 


10  spooch 

in  wliicli 

sciitonces 

does   not 

ly  1)0  iiiol 

(■('(1  to  an 

Ih'80     CJISCS 

piTi-'cptivn 
^Vcrnifko's 
lud  in  tlu! 
iiclitlu'iin's 
de  viirietics 

ion  centres, 
)  centres,  A 

words  (first 

aud  siipra- 

thc  cundiic- 

ciiusos  \nm 
louglits    in 

inp,  l"it,  ii-'^ 
is  distinct 
)uld  destroy 
nections  be- 
write  from 

iciited,  and 
•c  as  sinipli! 
(X,  but  witli 

bo  worked 

m:  (l)Tl>e 
)jects— i.  f'l 
be  iiiune  of 
n  heard,  or 
I  words;  (^) 
Ire;  (r>)  tlin 
[be  powiT  of 
Jier  \w  ii>'^- 


jiliicea  words  or  not;  (7)  the  power  of  roiiding  idoud  and  of  underKtundiTig 
wliiit  lie  reads;  (8)  the  i)ower  to  write  voUmtiirily  and  of  reading  what  he 
hius  written ;  (9)  the  power  to  copy;  (10)  the  power  U)  write  at  dictation  ; 
uiid  (11)  the  power  of  repeating  words. 

Prognosis  and  Treatment. — In  young  persons  the  outlook  is  good, 
and  the  power  of  speech  is  gradually  restored  ai)parently  by  the  education 
(if  tlie  centres  on  the  opposite  side  of  the  brain.  In  adults  the  (condition 
in  less  hopeful,  particularly  in  the  cases  of  complete  motor  apluusia  with 
right  hemiplegia.  The  patient  may  remain  sj)eeehless,  though  caimblo 
of  understanding  everything,  and  attempts  at  re-education  may  lie  futile. 
I'lirtial  recovery  may  occur,  and  the  patient  may  be  able  to  talk,  but  mis- 
places words.  In  sensory  aphasia  the  condition  may  be  only  transient,  and 
the  ditferent  forms  rarely  persist  alone  without  im])airment  of  the  powers 
of  expression. 

The  education  of  an  aphasic  person  requires  the  greatest  care  and 
patience,  j)articularly  if,  tis  so  often  happens,  he  is  emotional  and  irritable. 
It  is  best  to  begin  by  tho  use  of  detached  letters,  and  advance,  not  too 
rapidly,  to  words  of  only  one  8yllal)le.  Children  often  make  rapid  ])rogross, 
but  in  adults  failure  is  only  two  frequent,  oven  after  the  most  jjaiiis-taking 
elTorts.  In  the  cases  of  right  hemiplegia  with  aphasia  tho  patient  may  be 
tiujght  to  write  with  tho  left  hand. 


III.  Inflammation  of  the  Bkain 

{Suppxirative  Encephalitis ;  Abscesn). 

etiology. — Suppuration  of  the  brain  substance  is  rarely  if  ever  pri- 
mary, but  results,  as  a  rule,  from  extension  of  inflammation  from  neigh- 
boring parts  or  infection  from  a  disUmce  through  the  blood.  The  question 
of  idiopathic  brain  abscess  need  scarcely  be  considered,  though  occasion- 
ally instances  occur  in  which  it  is  extremely  difhcult  to  assign  a  cause. 
There  are  three  important  etiological  factors: 

(1)  Trauma.  Falls  upon  tho  head  or  blows,  with  or  without  abra- 
bIou  of  the  skin,  ilore  commonly  it  follows  fracture  or  j)unctur(d 
Wounds.  In  this  group  meningitis  is  frequently  associated  with  the 
abscess. 

(a)  Extension  of  the  inflammation  from  the  neigliboring  parts,  more 
particularly  in  caries  of  the  petrous  portion  of  tho  tem]>oral  bone,  loss 
fre([ucntly  necrosis  of  tho  other  bones,  or  extension  of  disease  from  the 
orl)it.  In  this  group  otitis  is  the  most  important  fa(!tor.  There  may 
be  extension  through  the  bono  and  involvement  of  tho  lateral  sinus 
as  already  mentioned ;  but  in  other  instances  no  direct  connection  can 
be  traced  and  the  infection  is  i)robably  carried  through  tho  lympli 
channels. 

(3)  In  septic  processes.  Abscess  of  tho  brain  is  not  often  found  in 
pyiemia.     In  ulcerative  endocarditis  multiple  foci  of  suppuration  are 


'>•    "!] 


mi 


m 


■•1    i 


'H 


■-  \  K-l 


004 


DISEASES  OP  TUE  NEUVOUS  SYSTEM. 


CDintiion.  Loouli/cMl  bone-disousc,  suppuration  in  tlio  livor,  l>iil,  above 
ull,  certain  iiillaMnnutious  in  Uk?  liiii^s  (partifuhirly  {^anj:;rciK',  brdiiihi- 
t'cttisiH,  and  IVtid  hrDiichitis),  arc  lial)l('  to  Ix;  followed  1)}'  abscess.  It  is 
un  (KHUsioniil  coinplication  of  cnipycnui.  Alwccss  of  tlio  brain  niay  follnw 
the  s|tccilie  fevers,  liri.stowo  liaa  called  attention  to  its  occurrence  as  a 
sc(piel  of  influenza.  The  larj^cst  luinihcr  of  ca.ses  occur  between  the  twen- 
tieth and  fortieth  years,  and  the  eonilition  is  more  freipieiit  in  men  than 
in  women. 

Morbid  Anatomy. — The  abscess  nuiy  be  solitary  (»r  multiple,  dif- 
fuse (»r  circumscrilicd.  In  the  a<'ute,  rapidly  fatal  ea.ses  followinjr  injury 
the  suppuration  is  not  limited  ;  Init  in  lon<:j-s(.aiulinf^  oases  tlu!  abscc.vs  is 
enclosed  in  a  delinitc  capside,  which  nuiy  have  a  thickness  of  from  two  to 
five  millimetres.  The  pus  varies  mucli  in  appearance,  depending'  upun 
the  age  of  the  abscess.  In  early  cases  it  may  be  mixed  with  nd  iisli 
(U'hriH  and  softened  brain  matter,  but  in  the  solitary  encai)sulated  ahscoss 
the  pus  is  distinctive,  havin;^  a-  j^'reenish  tint,  an  acid  reaction,  and  a  jic- 
euliar  odor,  sonu>times  like  sulj)huretted  hydrogen.  The  brain  sulistancc 
Hurrounding  the  abscess  is  usually  (r'dematous  ami  infiltrated.  Tlic  size 
varies  from  that  of  a  walnut  to  that  of  a  largo  orange.  There  are  case.". 
on  record  in  which  the  cavity  has  occuj  1  the  greater  jmrtion  of  a  luini- 
Hpliere.  Multiple  aI)S(es.ses  are  usually  snuill.  In  four  fifths  of  all  rases 
the  abscess  is  solitary.  Supj)uration  occurs  moat  frequently  in  the  circ. 
brum,  and  the  temj)oro-splienoidal  l(»be  is  more  often  involved  than  utlur 
parts.  The  cerebellum  is  the  next  most  common  seat,  particularly  in  coi.- 
ncction  with  ear-disease. 

Symptoms. — Following  injury  .or  operation  the  disease  may  run  an 
nrnlc  course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The 
symptoms  are  those  of  an  acute  meningo-encephalitis,  and  it  may  be  verv 
difllcult  to  determine,  unless  there  are  localizing  symptoms,  whether  there  is 
really  suppuration  in  the  brain  substance.  In  the  cases  following  ear  dis- 
ease the  symptoms  may  at  fir.st  be  those  of  meningeal  irritation.  There 
may  be  irritability,  restlessness,  severe  beadache,  and  aggravati-d  (<ara('ho. 
Other  striking  sym|)toms,  particularly  in  the  more  prolonged  cases,  aro 
drowsiness,  slow  cerebration,  vomiting,  and  optic  neuriti.s.  In  the  chnuiic 
form  of  brain  abscess  which  may  follow  injury,  otorrlura,  or  local  lunj,' 
trouble,  there  may  bo  a  latent  period  ranging  from  one  or  two  weeks  to 
several  months,  or  even  a  year  or  mo'ro.  In  the  "  silent "  regions,  when 
the  abscess  becomes  encapsulated  there  may  be  no  symptoms  wliatcver 
during  the  latent  period.  During  all  this  time  the  patient  may  l)e  niitltr 
careful  observation  and  no  suspicion  be  aroused  of  the  existence  ot"  sii])- 
puration.  Then  severe  headache,  vomiting,  fever,  set  in,  perhajis  with 
a  chill.  An  Arab  was  admitted  to  my  wards  at  the  University  Hos- 
pital in  a  condition  of  profound  anaemia,  having  been  picked  up  hy  the 
police  in  the  street,  covered  with  blood.  There  was  a  small  localize  I  area 
of  dulness  in  the  tliird  and  fourth  interspaces  on  the  right  side  close  to  the 


^ 


AFFIX  TIONS  OF  THE  SUIJ.STAXCK. 


UU5 


liplc,  (lit- 
iijr  injury 
iilisi'if-^  is 
»m  iwo  to 

h   rci!  lisli 

Lt'll  llllSCOSS 

aiid  11  ]!('- 

sulisliinci' 
'riu'  si/r 
i>  a  IT  I'usc'i 
of  a  liiiiii- 
jf  all  i'usi's 
II  the  i'«'iv. 

than  other 
arly  in  <ni.- 

i\ay  run  an 
(f(irs.    'Hii' 
jiay  be  wry 
her  tlicrc  is 
11!^  oar  (li>- 
i(,n.    'riit-'i'<' 
(1  carat'lu'. 
cases,  art' 
theclironic 
local  lunj; 

()   AVl'l'l<S  to 

ions,  vlicn 
s  whatever 
y  be  under 

ce  of  sup- 

ivhaps  with 

rsity  ll"'^- 

up  iiy  the 

.aliziMl  area 

lose  to  till' 


Ktcrnnm,  iiml  altliuni^h  no  tubercle  ba<illi  were  found,  it  was  thought  to 
Ic  |)rol);il)Iy  !i  localizcil  tubiMculosis.  He  recovered  rapidly  from  the  aiiiu- 
niia,  and  williiii  three  moutlus  was  strouf,'  and  well.  A  few  days  before 
his  intended  dischurgo  ho  began  to  complain  <d'  headuclie,  whieh  became 
airgruvuted.  He  hud  vomiting,  fever,  and  gradually  increasing  eonui.  A 
large,  8olita"V  encapsul.  ted  abscess  was  found  in  the  parieto-or.  ipital  region 
of  tlu'  left  In  Miisphcre,  and  in  the  ndddle  lobe  of  the  right  lung  ii  eireum- 
Kcribed  i-avity,  probably  bronchieetuti*',  surrounded  by  libroid  tissue  und 
eoutaining  a  very  otfensive  pus.  So,  too,  after  a  blow  u}>on  the  head  or  a 
fracture  the  symptom,-;  of  the  lesion  may  be  transient,  and  months  after- 
ward (;erel)ral  symptoms  of  the  most  aggravated  character  may  ilevclop. 

'i'lie  locali/alion  of  the  lesion  is  often  dillicult.  In  or  near  the  motor 
region  there  nuiy  hv  convul.-iona  or  paralysis,  und  it  is  to  bo  renieniberetl 
that  an  abscess  in  the  teinporo-sphenoidal  lobe  may  compress  the  lower 
motor  centres  and  produi'c  piaralysis  of  the  arm  and  face  and  on  the  left  side 
cause  aphasia.  A  large  absce  ;s  may  exist  in  the  frontal  lobe  without  caus- 
ing paralysis,  but  in  these  (;ases  there  is  almost  always  some  mental  duliuws. 
In  the  temporo-sphenoidal  lobe,  the  common  seat,  there  may  be  no  fcealiz- 
ing  symptoms.  So  also  in  the  parieto-oocii)ital  region;  though  here  early 
examination  nuiy  lead  t<-  the  detection  of  hennaiujpia.  In  abscess  of  the 
cerebellum  vomiting  is  comnutn.  If  the  middle  lobe  it;  utrected  there  may 
he  staggering — cereljellar  iiu'oordi nation.  Localizing  symptoms  in  the 
pons  and  other  })arts  are  still  more  uncertain. 

Diagnosis. —  In  tlu;  acute  cases  tlx're  is  rarely  any  doubt.  The  his- 
tory of  injury  followed  by  fever,  nuirked  cerebral  symptoms,  the  develop- 
ment of  optic  neuritis  und  rigors,  delirium,  ami  pt'rha|)s  paralysis,  make 
the  diagnosis  certain.  In  chronic  eur-diseuse,  such  cerebrul  symptoms  as 
(h'owsiiu'ss  and  torpor,  with  irregulur  fever,  supervening  upon  tho  cessation 
of  a  discharge  sli(nd<l  excite  the  susiiicion  of  abrccss.  It  is  particularly 
in  the  chronic  cases  that  dilli(;ulties  arise.  The  symptoms  rescnd>le  those 
of  tumor  of  the  brain;  indeed,  the.v  arc  those  of  tunior  plus  fever.  In  a 
[lalient  with  a  history  of  truuma  or  with  localized  lung  or  pleural  trouble,, 
who  for  weeks  or  months  has  had  slight  headache  or  ilizziness,  tho  imset  of 
a  rapid  fever,  intense  headache,  and  vomiting  point  strongly  to  absi-ess. 

It  is  not  always  easy  to  determine  whether  the  meninges  arc  itivolved 
with  tlie  abscess.  Often  in  ear-disease  the  condition  is  that  of  meningo- 
i'iui'|)halitis.  I  have  already  referred  to  a  condition  sometimes  associated 
with  ear-disease,  which  nuiy  simulate  ch)sely  cerebral  meningitis  or  even 
ahscess.  Indeed,  (lowers  states  that  not  only  nuiy  these  general  symptoms 
he  produced  by  ear-disease,  but  even  distiiu't  optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in 
ilealiug  with  those  cases,  owing  to  tho  impunity  with  which  the  brain  can 
be  explored.  In  oar-disease  free  discharge  of  tho  inftanimatory  products 
should  be  promoted  and  careful  disinfection  prac^tiseil.  Tho  treatment  of 
injuries  and  fractures  comes  within  the  scope  osf  the.surgpou.     The  acute 


ll 


<in 


t  ' 


'  y 


DISEASES  OF  THE  NEIIVOUS  SYSTEM. 

symptoms,  Rtich  iis  fovor,  licadiu-lio,  uikI  di'liritun,  mtiHt  ho  troatcd  by  rest 
an  i(!e-cap,  mid,  if  necchisary,  local  depletion.  In  all  oasew,  when  a  icasnn- 
ablc  Hus[)icioii  I'xist.s  of  tlio  cK-currtMiee  of  abscess,  the  trephine  sliouid  be 
ftpi»licd  and  tho  brain  explored,  'i'he  cases  following  ear-disease,  in  wlii,)) 
the  suppuration  is  in  the  teniporo-sphenoidal  lobo  or  in  the  cerebcjlmii 
olTor  the  most  favorable  chances  of  recovery.  Tho  localization  can  rarclv 
bo  made  accurately  in  these  cases,  and  the  operator  must  be  ;j:iiidcd  mon. 
by  general  aiuitomical  and  jiathological  knowledge.  In  cases  of  iiijmv  tlu^ 
trophitie  should  be  applied  over  the  seat  of  tho  l)low  or  the  fracture.  In 
oar-dii?ease  the  sup[)uration  is  most  frcrpient  in  tho  temporo-spbenoidal  or 
in  tho  cerelxlluin,  and  the  operation  should  bo  porforined  at,  the  points 
most  accessible  to  these  regions. 


IV.    HEMIPLEGIA  AND   DIPLEGIA   IN   CHILDREN. 

It  is  as  yet  hard  to  say,  without  fuller  knowledge  of  tho  etioloiry  of 
these  common  conditions,  where  they  should  bo  (rlassitiod.  In  a  majority 
of  the  cases,  whatever  tho  nature  of  the  primary  pathological  cliange,  tho 
final  state  is  one  of  a  chronic  encephalitis,  often  with  great  atrophy  of  the 
convolutions  or  tho  formation  of  largo  cyst-like  spaces — porence])haliis. 


1.  IIemipleoia. 

Etiology. — Of  135  case?,  comprising  those  from  tl>e  Infirmary  for 
Diseases  of  the  Nervous  System,  Philadelphia,  from  tho  Elwyn  Institution 
for  Feeble-minded  Children,  under  Kerlin,and  from  my  clinic  at  tho  Johns 
Hopkins  Hospital,  (iO  were  in  boys  and  75  in  girls.  IJight  bciniplcgiii 
occurred  in  TO,  left  in  50.  In  15  cases  tho  condition  v.;!s  said  to  bo  con- 
genital. 

In  a  great  majority  tho  disease  sets  in  during  tho  first  or  second  year; 
thus  of  tho  total  number  of  cases,  95  wore  under  two.  Cases  above  the 
fifth  year  are  rare,  only  10  in  my  series.  Neither  alcoholism  nor  syphilis 
in  the  parents  appears  to  play  an  important  role  in  this  affection.  Diffi- 
cult or  abnormal  labor  is  responsible  for  certain  of  the  cases,  particularly 
injury  with  the  forcrps:  Trauma,  such  as  falls  or  puncturing  wouiuU,  is 
more  rare.  Tho  condition  followed  ligation  of  the  common  carotid  in  one 
case. 

Infectious  diseases.  All  the  authors  lay  special  stress  ujion  this  furtor. 
In  19  cases  in  my  series  the  disease  came  on  during  or  just  after  om 
of  the  specific  fevers.  I  saw  one  case  in  which  during  the  height  of 
vaccination  convulsions  developed,  followed  by  hemiplegia.  In  a  sroat 
majority  of  the  cases  tho  disease  sets  in  with  a  convulsion,  in  which  tlii' 
child  may  remain  for  several  hours  or  longer,  and  after  recovery  the  j)anily- 
sis  is  noticed. 


IIKMIPLKOIA   AND   DIPLEGIA   IN  CIIILDIIKN. 


007 


Morbid  Anatomy.—  In  an  analysis  which  I  have  maih^  of  00  an- 
topsic's  reportod  in  tlio  litoruturo,  ti»e  losioiis  may  he  grouiKil  untkr  three 
headings: 

(it)  Kniholisin,  throinhosis,  and  liiPinorrhago,  ('(iriijivising  Ki  cases, 
in  7  of  wliich  there  was  hlockiiig  (^f  a  Sylvian  artery,  and  in  !)  ha'mor- 
rha;;o.  A  Htriking  fealnre  in  tliis  group  is  the  advamcd  ugc  of  onset. 
Tt'ii  of  the  oases  oeeurred  in  eliihlren  over  six  years  ohi. 

(/>)  Atrophy  and  seh-rosis,  comprising  r)0  eases.  Tlie  wasting  is  either 
of  groups  of  eonvohitions,  an  entire  h)he,  or  the  wliok;  lieniisphere.  The 
nioriinges  are  usually  (closely  adherent  over  the  alTecled  region,  though 
Honietinies  they  look  normal.  The  convolutions  are  atrophied,  llrni,  and 
hard,  contrasting  8trr)ngly  with  tho  normal  gyri.  The  sclerosis  may  he 
dilTuao  and  wide-si)read  over  a  hemisphere,  or  there  may  he  nodular  pro- 
jections— the  hypertro])hic  sclerosis.  Some  of  the  cases  show  renuirkahle 
unilateral  atrophy  of  the  hemisph(>ro.  In  one  of  my  car.cs  the  atrojdiicd 
lipiiiisphere  weighed  KJ'J  grammes  and  the  normal  (!.*);]  grtimmes.  The 
brain  tissue  may  ho  a  more  sliell  over  a  dilated  ventricle. 

(c)  l'oren(!e])halus,  which  was  present  in  21  of  the  !)()  autopsies.  Thia 
term  was  applied  hy  Ilcschcl  to  a  loss  of  .substance  in  th((  form  of  cavi- 
ties and  cysts  at  the  surface  of  the  brain,  either  opening  into  and  hounded 
by  the  arachnoid,  and  even  passiiig  det^ply  into  the  hemisphere,  or  reach- 
ing to  the  vcntriide.  In  the  study  by  Audrey  of  103  cases  of  ])orencepha- 
liis,  hemiplegia  was  mentioned  in  68  ca.ses. 

Practically,  then,  in  infantile  licmiplegiii  cortical  sclerosis  and  prrcn- 
ceplialus  are  tho  important  anatomical  oondition.s.  The  ])rinuiry  change 
in  the  majority  of  these  cases  is  still  unknown.  Porencephalia  may  n^sult 
from  a  defect  in  development  or  from  hivmorrhage  at  birth.  'IMie  etiology 
is  dear  in  the  limited  ninnher  of  cases  of  luDmorrhage,  em])olism,  and 
tliroml)osis,  but  there  renuiins  the  largo  group  in  which  the  final  change 
is  sclerosis  and  atrophy.  What  is  the  primary  lesion  in  the.so  instances? 
The  clinical  history  shows  that  in  nearly  all  these  cases  tho  onset  is  sud- 
den, with  convulsions — often  with  slight  fever.  Striimpell  believes  that 
this  con<litio)i  is  duo  to  an  infUunmation  of  the  gray  matter — jiolio-cn- 
cepiialitia — a  view  which  has  not  been  very  widely  acce|>t('d,  as  the  ana- 
tomical proofs  are  wanting,  (lowers  suggests  that  thrombosis  nuiy  be 
present  in  some  instances.  This  might  i)robably  account  for  tho  final 
condition  of  sclerosis,  but  clinically  thrombosis  of  tln'  veins  rarely  occnirs 
in  iiealtliy  children,  which  appear  to  bo  those  most  fre(|ucntly  attacked 
by  infantile  hemiplegia,  and  post-mortem  proof  is  yet  wanting  of  the 
association  of  thrombosis  with  the  disease. 

Symptoms. — (n)  The  onset.  Tho  disease  may  set  in  snddnnly 
witliout  spasms  or  loss  of  consciouisncss.  In  more  than  half  the  cases  '.lie 
diild  ia  attacked  with  partial  or  general  convulsions  aud  loss  of  conscious- 
ness, which  may  last  from  a  few  hours  to  many  day.'.  This  is  one  of  tho 
most  striking  features  in  the  disea.se.     Fever  is  i.saally  present.     Tho 


4    !) 


■-    I. 


I 


1 

■L-'3 

m 

^i;\n 

f 

*;|| 

1  'i 

mu)k 

908 


DISKASES  OF  THE  NERVOUS  SYSTEM. 


Of 


Ki 


I'll 


n 


heiiiiplcjria,  n()tic(>(l  as  tin*  cliild  rocovors  cnnsciousnoss,  is  iroTicmllv  coni- 
pIi'U'.  Sumt'tiini's  i\w  ])iiral_v.sis  is  iii)t  conqdi'to  ut  first,  hut  lU'Vilop-  ;if(,.r 
Kul)S('(|iient  convulsions.  Tiie  right  side  is  more  frt-qucntly  aHV(,if,l  ihaii 
the  left,     'i'ho  face  is  conuiionly  net  involved. 

(A)  Hesidual  symptoms.  In  some  cases  the  ]iaralysis  fjraduallv  disnii- 
jjcars  and  leaves  scarcely  a  tr.ce  as  tlie  child  <,n'o\vs  up.  The  \v<j,  as  n 
rule,  recovers  more  rapidly  itnd  nu>r?  fidly  than  the  arui,  mul  tlic 
paralysis  may  he  ccarcely  notici- ;l)lc.  In  a  nuijority  of  cases,  li(;\vover, 
there  is  a  characteristic  hemiplegic  fjait.  The  paralysis  is  most  marked 
in  the  arm,  which  is  usually  wasted  ;  the  forearm  is  tlexed  at  I'iirlit  anjrlc.s. 
the  hand  is  Hexed,  and  the  tin;j[ers  are  contracted.  Motion  mav  he  aliiidst 
completely  lost;  in  other  instances  the  arm  can  he  lifted  ahove  the  head, 
liate  rigidity,  whii'h  almost  always  develojjs,  is  i\w.  syjn])toni  which 
suggested  the  name  hriitipJi'ijid  sptislira  rcnf/ralis  to  Jleine,  the  urtlin- 
pa'dic  surgeon  who  first  accurately  described  llu-se  cases,  jt  is,  huwcvcr, 
not  constant.  Tiu'  limits  may  hi'  tjuite  ndaxeil  even  years  after  the  nnsct. 
'I'he  reflexes  are  usually  increased.  In  several  instances,  however,  1  have 
known  tlu>m  to  he  absent.     Sensation  is,  as  a  rule,  not  disturhcd. 

Ajili(isi<i  is  a  not  uncommon  synij)tom,  aud  occurred  in  K'  cases  of  my 
series — a  smaller  nundicr  tlian  given  in  the  series  of  Wallenherg, 'iaudard, 
and  Sa(dis. 

Menial  Drfrrh. — One  of  the  nu»st  serious  consef|uences  of  infautilo 
hemiplegia  is  the  failure  of  nu-ntal  develojtmcnt.  A  considerahle  mnnl" . 
(>!'  these  cases  drift  into  the  institutions  for  feehle-mindi'd  children.  'I  lirce 
grades  may  he  distinguished — idiocy,  which  is  most  common  when  the 
lu'nu|>legia  has  existc(l  from  l)irlh  ;  iuibecility,  which  oftcji  increases  with 
the  development  of  epilepsy;  and  feeble-minded ness,  a  retarded  rather 
than  an  arrested  dcvi'lopnu-nt. 

Iy)ili-/)si/.^i)i  tlii^  cases  in  my  series,  41  were  subjects  of  coiivnlsivc 
seizures,  which  is  one  of  the  most  distressing  stMpu'Uces  of  tin  disease. 
The  seizures  nniy  be  either  transient  attacks  of  pcfit  mitl,  true  .lackso'daii 
fits,  beginiung  in  and  confined  to  the  alTected  side,  en*  general  convulsiuii.-. 

Piist-hcDiipli'ijic  Mni't'iiwuh. — It  was  in  cases  of  this  sort  that  Weir 
!Mit(diell  first  ilescribed  the  post-hemiplegic  movements.  They  .uv  ex- 
tremely common,  and  were  present  in  34  id'  my  series.  There  may  Im 
either  slight  tremor  in  the  alTected  muscles,  or  incoiirdimite  ( horeil'diiii 
movements — the  so-called  post-hemiplegic  chorea — or,  lastly, 

Alhciosis. — In  this  coiulition,  described  by  irannuond,  there  .ire  re- 
markable spasms  of  the  paralyzed  extremities,  (diitdly  of  the  lingers  and 
toes,  and  in  rare  instances  of  the  muscles  of  the  mouth.  The  moveiiH  tits 
are  invohnitary  and  somewhat  rhythmical ;  in  the  hand,  nioveiuents  of 
adduction  or  abduction  and  of  supination  and  pronation  follow  oacli 
otlur  in  ordcrl\  se(iuence.  Theri'  may  be  hyperextension  uf  the  lingiTs. 
during  which  they  are  spread  wide  apart.  This  condition  is  nuidi  iiiore 
frequent  in  children   ihan  in  adults.     In  the  latter  it  may  he  coiubinoii 


HEMIPLEGIA  AND  DIPLEGIA   IN   C'llILDIlKN. 


9U9 


ly  com- 

i\r.  iift«T 
.uil  lliim 

[y  ilis;iii- 
li'^',  as  ft 
im4  tlu' 
iK.wcvcr. 
iiiarki'il 

it  aiijrlt'S, 
lie  aliiKist 
thr  head, 
iin  wliii'h 
lie  nrthd- 
,  lluWt'Vt'I', 

tlic  (iiisct. 
iv\\  1  have 
1. 

■asts  of  my 
f,  Jiaudavd. 

if  infantilis 
l)le  imiiil" . 
'I  linr 
wlnii  tlu' 
■usi'S  with 
,m1  rallicr 


vn. 


!•( 


(•(iiiviilsivc 
In  (list'asc. 
,larlxS"'iiaii 

()iiviil>-i""- 
tliat  Wi'ii 

IfV    .'IT    I". 


■re  Hiav 


1. 


lion 


iforiii 


ivw  .U'L'  1'"- 
liin^'fi's  ami 

nt!»  of 
pacli 


,iut)Vr 
Ivcnii' 


itW 


lie 


fin^vrs 


huu'ii 


inoH' 
bint'ii 


with  homiiiiia?stlu't<ia,  aiul  the  lesion  i.-i  not  cortical,  but  liasic  in  the  nci^rh- 
JMii'hood  of  the  thalanius.  The  niuvonients  are  tiouieiinies  increased  by 
emotion.     They  usually  persist  during  sleei). 

II.  Spastic  Dii'liujia — Hiunr  Pai.siks, 

In  this  condition  there  is  a  ])ariilysis  with  spasm  of  all  extremities, 
dating  from  or  shortly  succeeding  birth,  more  rarely  f(dlo\ving  the  fevers 
or  an  attack  of  convulsions.  The  legs  are  usually  moic  involved  than  the 
arms;  there  is  no  wasting,  no  <listiiri)ance  of  sensation.  The  rellexes  are 
increasetl.  The  mental  coiulition  is  profoundly  disturbed.  The  patients 
arc  nsually  iiid)eciles  or  idiots,  helple.ss  u.  mind  and  body.  Ataxic  and 
atlietoid  movements  of  the  most  exaggerated  kind  may  occur. 

While  a,  limited  number  only  of  cases  of  infantile  hemi]>legia  are 
I'niiL't'iiital,  on  the  ()ther  hand,  in  spastic  diplegia  a  largi^  jtroportion  of 
the  eases  results  from  injury  at  birth.  Practically  the  spastic  j)araplegia  of 
I  liildren  should  be  considered  with  this  condition,  as  its  eti(dogy  is  essen- 
tially the  8anu\  The  arjus,  too,  may  be  so  slightly  alTeitcd  as  to  make  it 
(lillicult  to  determine  whether  it  is  a  ( .ise  of  iliplcgia  or  paraplegia.  The 
cases  iisually  date  from  birth,  and  a  majority  are  born  in  tirst  labors  or 
are  forceps  cases.  Iioss  suggests  that  in  feet  presentation  there  nuiy  be 
hiceration  or  tearing  of  the  cerebro-spinal  mendiranes. 

Morbid  Anatomy. — The  birth  palsies  which  ultimately  induce  the 
silastic  diplegias  or  paraplegias  are  most  fre.|nently  the  resnltof  meningi-al 
lia'Miorrhage.  Thr  iini)ortancc  of  this  condition  has  been  sh.own  bv  tin; 
.<tii(lics  of  fjitzmann  and  Sarah  .'.  McNutt.  The  bleeding  nuiy  come 
from  the  \t'ins,  or,  in  one  case  which  1  .saw  with  Hirst,  from  the  longi- 
tudinal sinus.  The  bleeding  has  in  nniiiy  ca.ses  been  thickest  over  the 
motor  areas,  and  it  seems  probable  that  the  sclerosis  found  in  lhes(>  cases 
may  result  frotn  the  coni|)ression  of  the  blood-cdot.  In  other  instances 
the  condition  may  be  due  to  a  fecial  meningo-encephalitis.  in  sixteen 
autopsies  collected  in  the  literature,  in  which  the  jiaticnts  died  at  ag(>a 
uiiying  from  two  to  thirty,  the  anatcmical  condition  was  cither  a  ditTnse 
atrii|iliy,  which  was  most  common,  or  porenccphaliis. 

Symptoms. —At  lirst  nothing  abnormal  maybe  noticecl  about  the 
iiiild.  In  some  instances  there  have  be(Mi  early  and  frcipient  convnl- 
sioiis;  t!\en  at  the  age  when  the  child  should  begin  to  walk  it  is  jiotic(-d 
that  the  limbs  are  not  u.se<l  readily,  and  on  examination  a  stilTncss  of  tlu! 
Il'^'s  and  arms  is  found.  Even  at  the  age  of  two  the  child  may  iu)t  be 
able  to  pit  up,  and  often  the  head  is  not  well  supported  by  the  neitk  mus- 
ili's.  The  rigitlity,  as  a  rule,  is  more  marked  in  the  legs,  and  there  is  ad- 
ihutor  spasm.  When  supported  on  the  feet,  the  child  eitbt>r  rests  on  its 
tiit.i  and  the  inner  surface  of  the  feet,  with  the  ktu'cs  clo.se  together,  or  the 
le^'s  may  be  cnissed.  The  stiffness  of  the  upper  lind).s  varies.  It  nuiy  be 
i(^^arcely  noticeable  or  the  rigidity  muy  be  as  nuirked  as  in  the  legs.     Cou- 


■■  $    \ 


910 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


^^7,  ■ 
1 V  -tt  M 


->i' 


"5',' 


Btant  irropfuliir  movements  of  the  arms  are  not  uncommon.  The  rhii,] 
has  great  'Urticulty  in  fira.sping  an  object.  The  spasm  and  weakness  mav  Ik 
more  evident  on  one  side  than  the  other.  The  mental  condition  is,  as  u 
rule,  defective  and  convulsive  seizures  are  common. 

Associated  with  the  spastic  paraplegia  are  two  allied  conditions  of  vi.w 
siderable  interest,  characterized  by  sjiasm  and  disordered  m.ivements.  A 
child  with  spjustic  diplegia  may  present,  in  an  unusual  degree,  irrcguhir 
movements  of  the  muscles.  In  attcjnpting  to  gra.sp  an  object  the  finders 
may  be  thrown  out  in  a  stilT,  spasmodic,  irregular  manner,  or  there  niav  \)v 
constant  irregular  movements  of  tiie  shoulders,  arms,  and  hands,  wiili 
slight  incoordination  of  the  head.  Cases  of  this  description  have  been  dc- 
scribed  as  chorea  spastica,  and  they  may  be  diflicult  to  separate  from  nm'- 
tiple  sclerosis  and  from  Friedreich's  ataxia. 

A  still  more  remarkal)le  condition  is  that  of  btlafcral  alhchisis,  in 
which  there  is  a  combination  of  spasm  more  or  less  marked  with  the  most 
extraordinary  bizarre  movements  of  the  musc^les.  The  condition,  as  a 
rule,  dates  from  infancy.  The  patient  may  not  Ix- able  to  walk.  'J'ho  head 
is  turned  from  side  to  side;  there  are  continual  irregular  movements  (if 
the  face  muscles,  and  the  mouth  is  drawn  and  greatly  distorted.  Tlif 
extremitiea  arc  more  or  less  rigid,  particularly  in  extension.  On  makin-: 
the  sli'jfhtest  attempt  to  move,  often  spontiineously,  there  are  extraonlinarv 
movements  of  the  arms  and  legs,  ])articularly  of  th«-  arms,  somewhat  like 
though  much  more  exaggerated  than  athetosis.  'I'he  patients  are  oftin 
unable  to  help  themselves  on  jiceount  of  these  movements.  The  relloxos 
are  increased.  The  mental  condition  is  variable.  The  patient  may  lie 
idiotic,  but  in  two  of  the  four  cases 'which  I  liave  seen  the  patiiiits  wiic 
intelligent.  Massalongo,*  who  has  carefully  Ktudie<l  this  condition,  (iesciil»(H 
three  cases  in  one  family.  I  have  collected  fifty-three  cases  from  tlie 
literature,  thirty-three  of  which  occurred  in  males  and  twenty  in  fomales. 
There  have  lu-en  three  auto])sies.  In  Kurella'a  case  there  was  pachv- 
meniiigitis  and  bilat(  ral  lesions  of  the  motor  convolutions.  DejeriiuV  |ia- 
tient  had  afiuphy  of  tlie  convolutions  on  both  sides,  while  in  my  case  llic 
brain  macroscopicuUy  presented  I'o  ciuingcd. 


III.  Spastic  Pauapleoia. 


f  f  • 


This  conditicm,  which  is  more  fully  described  under  the  section  upim 
the  spinal  cord,  is  in  reality  a  cerebral  aflfection,  and  may  be  due  to  condi- 
tions similar  to  those  found  in  spastic;  diplegia.  Indeed,  it  may  at  iirst  be 
diilicult  to  determine  wlutiicr  the  arms  are  involved  or  not.  The  evi- 
dence of  the  cerebral  origit.  of  tlie  affection  is  ba.sed  upcm  the  frequent  co- 
existence of  idiocy,  imbecility,  and  nystagmus,  and  the  occurrence  of  cas<>S(if 
spastic  diplegia,  in  which  the  paraplegic  symptoms  are  identical  AH 
grades  are  met  with,  from  pure  spastic  paraplogiu  witli  perfect  use  of  the 


Doir  Atctosi  Uoppiu,  Culleziono  Itttliana  Ji  Lctturc  suUa  Medicina,  Scries  V,  N.) 


SCLEROSIS  OP  THE  BRAIN. 


Oil 


arms  to  the  most  extrenio  biliitLTiil  spasm.  Thnre  liavo  boon,  so  far  lus  I 
kiKJW,  only  two  autopsies  in  this  diseaso  :  tho  wiso  of  Fcirstor,  in  whicli 
there  was  a  moderate  grade  of  genoral  cortical  sclerosis  with  slight  dilata- 
tion of  the  ventricles,  and  the  recent  case  of  Sachs,  in  which  there  was  a 
nieningo-ence})halitis  with  atrophy  and  descending  degeneration  of  both 
lateral  columns. 

Treatment. — The  possibility  of  injury  to  the  brain  in  protracted 
liilior  and  in  forceps  cases  should  be  l)orne  in  mind  by  the  practitioner. 
The  former  entails  the  greatest  risk.  In  infantile  hemiplegia  the  physi- 
cian at  the  outset  sees  a  case  of  ordinary  convulsions,  perhaps  more  pro- 
tracted and  severe  than  usual.  These  should  be  checked  as  rapidly  as 
possible  i)y  the  use  of  the  bromides,  the  a]>plication  of  cold  or  heat,  and  a 
hrisk  purge.  Duriiig  oonvuhsicms  chloroform  may  be  administered  with 
Hifety  even  to  the  youngest  children.  When  the  paralysis  is  established 
lint  much  can  lu*  Imped  from  medicines.  In  only  rare  instances  docs  the 
jiaralysis  entirely  disai)pear.  The  indications  are  to  favor  the  natural 
tendency  to  improve  by  maintaining  the  general  nutrition  of  the  child,  to 
lessen  the  rigidity  and  cfjiitractures  by  massage  and  jiassive  motion,  and 
if  necessary  to  corr(!ct  deformities  by  niccluuiical  or  surgical  measures. 
.Much  may  be  done  by  careful  iiianijndation  and  rubbing  and  the  ajiplica- 
tioii  of  a  proper  apparatus.  In  children  tho  aphasia  usually  disa{t{)ear8. 
The  epilepsy  is  a  distressing  and  obstinate  symptom,  feu*  which  a  euro 
can  rarely  be  antiiMpated.  Prolonged  ])erio(ls  of  cjuiescenee  are,  h()We\er, 
not  uncommon.  In  the  Jacksonian  fits  the  bromides  rarely  do  good,  un- 
less there  is  much  irritability  and  excitement.  Operative  measures, 
wliieh  have  been  carried  out  in  several  cases,  have  not  been  successful. 
Tho  liability  to  feeble-mindedness  is  the  mo.st  serious  outlook  in  the  in- 
faiitilc  cerel)ral  palsies.  In  many  cases  the  damage  is  irreparable,  and 
iiliocy  and  imbecility  result.  With  patient  training  and  with  care  many 
ui  the  children  reach  a  fair  measure  of  intelligence  and  self-reliance. 


m-i  ' 


■Ui^ 


?'-i 


f'-3 


V.    SCLEROSIS  OF  THE   BRAIN. 


General  Remarks. — The  connective  tissue  of  the  central  nervoiM 
Rvstcm  is  of  two  kinds — one,  the  neuroglia,  s])ecial  and  })eculiar,  deriwsi 
f'om  the  ectoderm,  with  distinct  morphological  and  chemical  «-haract«'r8; 
the  other,  deriveil  from  the  n'.esoderm,  identi,';il  with  the  ordinary  (rol- 
liii.'eii()us  fibrous  tissue  of  tnv  body.  Hoth  plav  important  parts  in  indura- 
tive processes  iu  tho  brain  and  cord.  A  <'onveiiient  division  of  thocerebro- 
fpiiial  sclero.s«  is  into  degenerative,  inflammatory,  and  developmental 
forii\s. 

The  flefjenrr.it ive  scleroses  comprise  t\w  largest  and  most  important 
^iihdivision,  in  which  provisionally  the  fcdlowing  groups  may  be  made: 
(rt)  Tho  commoD  r:  eondary  degeneration  whicii  follows  when  uerve-librea 


r 


912 


niSKASRS  OF  THE  NERVOUS  SYSTEM. 


arc  cut  (tfT  from  tlicir  tropliic  ccutros;  (h)  toxic  forms,  nmonji;  which  mav 
bo  placed  the  sch>roscs  from  h'lul  iiiid  cr^'ot,  uiul,  most  im]iort!iiit  nf  all,  the 
sckTosi.H  of  tiio  posterior  cohimn,  due  in  such  a  large  proportion  of  cuscs  to 
the  virus  of  syphilis.  Other  unknown  toxic  agents  may  possihty  iudiin. 
degeneration  of  the  nerve-lihres  in  certain  tracts.  Tiie  systemic  jialhs  in 
the  coril  dilTer  apparently  in  their  susceptil)ility  and  the  posterior  cdliniins 
appear  niost  prone  to  undergo  this  idiange;  (c)  the  sclerosis  assiiciatid 
with  change  in  the  smaller  arteries  and  ca[)illaries,  'Ahich  is  nu't  with  as  a 
senile  process  in  the  convolutions.  In  all  prohahility  some  of  the  foriiis  of 
insular  sclerosis  are  due  to  j)rimary  alterations  in  the  hlood-vessels;  hut 
it  is  not  yet  settled  whether  the  lesion  in  these  cases  is  a  jjriinarv  degen- 
eration of  the  nerve  cells  and  fibres  to  which  the  sclerosis  is  sccoudarv,  or 
whether  the  essential  factor  is  an  alteration  in  nutrition  caused  by  lesions 
of  the  capillaries  and  smaller  arteries. 

The  iiijUniuiuiltini  srir roses  cxwhriu'v  a  less  important  and  less  extensive 
group,  comprising  secondary  fi)rms  which  develop  in  conseciuence  of  irri- 
tative inflammation  about  tumors, foreign  bodies,  lui>morrh»ges, and  absciss. 
Histologically  these  are  chiefly  me.sodermic  (vascular)  scleroses,  which  arise 
from  the  connectiv-'  tissue  aliout  tlu'  blood-vessels.  I'ossibly  a  similar 
I'bange  nniy  follow  the  primary,  acute  encephalitis,  whi(di  Striimpell  Imlds 
is  the  initial  lesion  in  the  cortical  s(derosis  whicdi  is  so  commonly  foniul 
post  mortem  in  infantile  hemi|>legia. 

I'ho  i/nr/(ipnini/i(/  f<ch'rof<fs  are  believed  to  bo  of  a  ])uroly  ncurogliur 
character,  and  end)rac(>  the  new  growth  about  the  central  canal  in 
syringomyelia  and,  according  to  recent  Krencli  writers,  the  sclerosis  of 
tho  ])osteri()r  colunuis  in  l-'riedreich  o  ataxia.  It  is  statcnl  that  histo- 
logically thi.s  form  is  different  from  the  onlinary  variety.  It  may  he, 
too,  that  the  diffuse  cortical  sclerosis  met  with  as  a  congenital  ciiinli- 
tion  witiiout  thickening  of  the  meninges  belongs  to  this  type.  It  is 
not  improbable  that  many  forms  of  sclerosis  are  of  a  mixed  charadi  r, 
in  which  both  the  ec'odermic  and  mcsodermic  connective  tissues  are  in- 
volved. 

■\natomically  we  meet  with  the  following  varieties: 

(1)  Miliary  sclerosis  is  a  term  which  lias  bei-n  a|>plied  to  several  dif- 
ferent  conditions,  (lowers  mentions  u  ca.se  in  which  there  were  grayisli- 
red  spots  at  the  junction  of  the  white  and  gray  matters,  an<l  in  which  llir 
neuroglia  was  increased,  'i'here  is  also  a  condition  in  which,  on  th''  •sur- 
face of  the  convolntions,  there  are  simill  nodulur  projections,  varying  Mdi" 
a  half  to  five  or  iinire  tuillimelres  in  diumeter.  Single  nodules  of  thi-  sort 
are  luit  uncommon ;  sometinu's  thoy  are  abundant.  So  far  as  is  known  ii'> 
Hymptoms  are  prodiued  by  them. 

(•.')  Diffuse  sclerosis,  which  may  involve  an  entire  hemisphere,  <>]■  n 
Kingle  lol)e,  in  which  case  the  term  sr/rrasr  hilxtirc  has  been  applied  I"  ii 
liy  tho  Frenidi.  It  is  not  an  important  c(»ndilion  in  general  in^dicd 
practice,  but  occurs  most  frecpiently  in  idiots  and  imbeciles.    In  exten-'ivc 


\-i. 


ell  may 

all,  thV 

(•il>('S  to 
i'  iiulurc 

[liillis  ill 
(■(iliiiuiis 
v<(M'iatiil 
,vilh  ii!i  a 
forms  of 
■!ols;  Itiit 
y  (Ic^ri'U- 
mlarv,  or 
ly  li'.-ioiis 

oxtt'iisivc 
CO  of  irri- 
i(l  al'si'css. 
Iiich  arise 
a  Kiiiiilar 
]i('ll  liolds 
lily  fouiiil 

ncnrojiliar 
canal  in 
Icrosis  of 
lat  liisto- 
\\  may  ln', 
Ital  comli- 
ic.  It  is 
iliaractrr, 
ics  arc  in- 


I'vcral  ilif- 
j-c  <.n-ayi.-li- 
Iwliicli  till' 
111  til''  >iii- 
Iviii}.'  froMi 
If  tlii>  ^"Vt 
Ikiiown  no 

iicrc,  oi"  I' 
i.lic.l  ti.  it 
|l    itir,li(;il 
e\tcn<ivc 


SCLEROSIS  OF  TIIK  KRAIN. 


(•13 


cortioal  sclerosis  of  one  licmisidHM'o  the  vciitricU  is  itsiially  dilatod.*  The 
(iviiiptoms  of  this  condition  (1c|k'1u1  upon  the  rcixion  attcctcd.  'I'hcro  niav 
tic  a  coiisid('riil)lo  extent  of  sclerosis  without  sytnptonis  or  wiMioiit  much 
mental  iinpairnieiit.  In  ii  nnijority  of  cases  there  is  liemipleiiia  or  dii»lc<;ia 
with  iinl)ccility  or  idiocy. 

(:!)  Tuberous  Sclerosis. — In  this  remarkahlc  form,  wlii<h  is  also  known 
;i,s  hypertrophic,  there  are  on  the  convojutiims  areas  [)rojectinL(  beyond 
tlie  surface  of  an  opa(pie  white  color  and  exeeediniifly  lirm.  'I'he  sck-rosis 
may  not  disliirh  the  syniinetry  of  the  convolution,  luit  simply  cause  a /.n-cat 
('iilar<feinent,  increase  ia  the  di'iisity,  and  a  clian^'e  in  the  color. 

These  three  forms  are  not  of  niucli  |»ractical  interest  except  in  asylum 
;i  id  institution  work.  The  last  variety  forms  a  well-characterized  disease 
of  eo^isiderahle  importance,  namely: 

(t)   Insilak  S('i,i:i{Osis  (Sclerose  en  phtqucs). 

Definition. — A  chronic  alfection  of  the  brain  and  cord,  characterized 
liv  localized  areas  in  which  the  nerve  elements  are  inore  or  less  replaced  by 
■oimcctivo  tissue.  This  may  occur  in  the  liraiii  or  cord  alone,  more 
roiiimonly  in  both. 

Etiology. — 'I'iiis  is  obscure.  Kahler,  Marie,  and  othens  assij^Mi  jrreat 
iiii|iortance  io  the  infectious  diseases,  luirticularly  scarlet  fever.  It  is 
foinul  most  commonly  in  middlc-ajred  persons,  but  cases  are  not  uncom- 
mon in  children,  in  whom  l'rilehar«l  states  that  more  than  tifty  cases  have 
liii'ii  reported.! 

Morbid  Anatomy.— -Tlie  sclerotic  areas  are  widely  ilistributed 
!lir"ii.i,di  the  brain  and  cord.  Cases  limited  to  the  cord  art'  almost  nn- 
kiit.wn.  On  section  of  the  brain,  f,'rayisli-reil  an>as  are  seen  .scattered 
tliiouj;h  the  wliiti'  matter.  The  cortex  is  not  ofti-n  involved.  The  patches 
MH' sometimes  abundant  in  the  iieiLrbboriiood  of  the  ventricles,  and  in  the 
|ioiis,  cerebellum,  basal  ijan^dia,  and  the  medulla.  The  cord  may  be  only 
>li;:litly  involved  or  there  may  be  irrcirular  areas  in  dilTcrcnt  r«\t,Mons, 
ilistolo^ically  in  the  sclerosed  jiatchcs  there  is  j^reat  increase  in  the  con- 
iieetivo  tissue,  the  lii)reH  of  which  ari'  denser  and  lirmer.  The  jfradnal 
L'li'Wtli  destroys  the  medulla  of  the  nerves,  but  the  axis  cylinders  persist 
11  a      .iarkable  way. 

Symptoms. — Tlie  onset  is  slow  and  the  disease  is  chronic.  Kcelilc- 
iii  i>r  ''.e  le;;s  with  irregular  pains  and  stitTness  are  anion;.,' the  early 
•  ..!)t<  ...s.  Indeed,  the  clinical  picture  may  be  that  of  spastic  paraplei^ia 
^villi  j^reat  increase  in  the  rellexes.  '{"he  rollowinj,'  ai'e  the  most  important 
f"iiiMres : 

('      VuUiiunnl  Tremor. — There  is  no  paralysis  of  the  arms,  luit  on  at- 


*  In  my  iiioiioijraiih  on  ('crcbnil  Pnlsifs  of  Cliildrfii  T   Imve  jjivcn  a  (li-cription  of 
'ii'iii-iiiliiiliiiii  of  ili('seli'rii>i,s  in  t<'ii  •^pt'i'iinciis  in  tlic  imi.st'Uinal  llii'  Klwyii  lii^lilulion. 


il 


MM  ■ 

f ' 

m 

1 

'  •  1 

1 

.,.^ 

■f! 

i) 

i:|l 


I 


?ii 


t  <'ycl()|U'iliii  of  lli((  IHst'ttaes  of  Cliildreu,  vol.  iv. 


> 


9U 


D1SEASI5S  OF  THE  NERVOUS  SYSTEM. 


^k 


tomptinp:  to  ]ni:k  up  an  ol)jcct  there  is  trembling  or  rapid  oscillation.  .\ 
patient  may  bo  unable  to  lift  oven  a  glass  of  water  to  the  luoiiih.  'J'ho 
tremor  may  be  marked  in  the  logs  and  in  the  head,  \vlii(!h  .sluikcs  as 
he  walks.  When  the  patient  is  reeumbont  the  muscles  nia\  he  per- 
fectly quiet.  Onattem[)tingt()raise  the  head  from  the  pillow,  treniblint; at, 
once  comes  on.  (/;)  ScanniiKj  Speech. — The  words  are  j)ronounee(l  slowly 
and  sejiaratcly,  or  the  individual  syllables  nuiy  be  acccutiuitcd.  This 
staccato  or  syllabic  utterance  is  a  ccmimon  feature.  {<•)  Nyslagnuis,  a 
rapid  oscillatory  movement  of  both  eyes,  constitutes  an  important  synijiioin. 

Sensation  is  uimlTe(;ted  in  a  nuijority  of  the  cases.  Optic  atrojiliy  .sotno- 
times  oc(;urs,  but  not  so  frequently  as  in  tabes.  The  sphincters,  as  a  rule, 
are  unalTectcd  until  the  last  stages.  Mental  debility  is  not  uncotniuon. 
Remarkable  remissions  occur  in  the  course  of  the  disease,  in  which  for  u 
time  all  the  symptoms  nuiy  improve.  Vertigo  is  common,  and  there  may 
be  sudden  attacks  of  conui,  such  as  occur  in  general  paresis. 

The  (lia(jnt)sis  in  well-marked  cases  io  easy.  Volitioiuil  tremor,  scan- 
ning speech,  and  nystagmus  form  a  characteristic  symptom-group.  Willi 
this  there  is  usually  more  or  less  spastic  weakness  of  the  legs.  Paralvsis 
agitans,  certain  cases  of  gi-neral  paresis,  aiul  occasionally  hysteria  may 
simulate  the  diseasj  very  closely.  If  the  case  is  not  seen  until  near  t lie 
end  the  diagiu)sis  may  be  impossible.  IJuzzaril  holds  that  of  all  organic 
diseases  of  the  nervous  system  disseminated  sclerosis  in  its  early  stages  is 
that  which  is  most  commonly  mistaken  for  hysteria. 

]\[uch  more  })uzzling,  however,  are  the  instances  of  psrHflo-srlcrase  en 
plaques,  which  have  been  described  by  Weslphal.  The  volitional  tremor, 
the  scanning  speech,  and  the  spastic  condition  are  present,  but  no  lesions 
have  been  found  }>ost  mortem.  The  movements  in  this  form  are  more 
violent,  but  nystagmus  does  not  occur.  Some  of  the  cases  may  possibly  be 
examples  of  general  paresis.  In  children  the  condition  may  with  dilliculty 
be  se])aratcd  from  Friedreich's  ataxia. 

The  prof/uosis  is  unfavorable.  Ultimately,  the  patient,  if  not  carried 
off  by  some  intercurrent  affection,  becomes  bedridden. 

Treatment. — No  known  treatment  has  any  intluence  on  the  prog- 
ress of  sclerosis  of  the  brain.  Neither  the  iodides  nor  mercury  have  tlio 
slightest  cllect,  but  a  prolonged  course  of  nitrate  of  silver  nuiy  be  tried. 


VI.  CHRONIC  DIFFUSE  MENINGO-ENCEPHALITIS 

(Dementia  Paralytica ;  General  /Viresis), 

Definition. — A  chnnnc,  progressive  meningo-iiicephalitis  assoeiutfd 
with  psychical  and  motor  disturbances,  finally  loading  to  denuntia  and 
|>aralyHi-!. 

Etiology.  Males  are  allccled  much  more  fr"quently  tliau  fun  iK'- 
It  occur*  chiully  botweuu  the  ages  of  thirty  and  lifty-livc.     iieredit\  i?  »j 


fa- tor  in  only  a  fo,v  ,,,,,,.     An  ovrul    .    • 

•-•-■^1  J).o,,lo.    Statistic.  s).,nv  tha       ;  ::"'^  "'"•«--'^>-  "^  tl.o  oase«  aro  in 

•'^pcctjifion  "  (Mi,.j.i,,^      ,p,         ,    "^'*^'<N '!»'l<'mM|  ]„„„,,  .,,,,1    f 
'>!isin(\s.s  nion  in  ,,.,,.  i  •  .    '""''^  <>'   'i'<'  .so  Jn'</ii,.i,ilv   .         •  "f» 

•Kiorbid  Anatomv     n. 

''™; '-'-^ -  H„,« .Z;- L  i ';:;■;;';'  i"«'..i:«i,,„ ,., ,,„, „  ,„„ „^ 

'■^'^  (-"l.fcrati,,,,,  ,,r„f,„„„|  ,„,,,'     '!  "'-  "■•  "'^  »i,l,  ,.v,,.,,i,„  ,    _ 

■■'■■■;:;.;■■».". ..,.,,! i„ ,„„ .•.,„„::,;" "'—.lar ..„„„„„,, „„j ,„  ;;■ 

i)  A  8taj;,!  „f  j,,,,„.,„|  in,   ,1    .  "■"'  I   II  .'V  ar,.  ,l,,„„l.,|. 

"7;;";,,,        """■' "«'"-^ '- ■'■"«■■.»  i.:...';::;' ;:,:;";;: 

'' *".-«,;"!:.' I  fr';;;;;^rt;':,'™'""'-'  '■■  '■■-■«•  i..  .i , n-™ 

I ::;,;;;;  ,.7 ^'-"^  ".^  .;;:..ii;  r  r;i::t; "  "-^ '"-  '■"'--  ■ 


^^i! 


ii 


910 


DISEASES  OF  THE  NEIIVOUS  SYSTEM. 


1 1 


may  astonisli  the  friends  and  relatives  may  be  the  first  iiidicatioib.  in. 
Ktead  of  apathy  or  iiidilTereiice  there  may  he  an  extraonlinarv  tlc'rn  of 
j)hysi('al  and  mental  restlessness.  Tiie  patient  is  eonliniiaily  planning'  uml 
Ki'iieminjjc,  or  may  launeh  into  extravaj^anees  and  speenlation  of  tiie  wiliji^t 
eharaeter.  A  common  featnre  at  thi8  period  is  the  display  of  mi  nn- 
honndefl  eji^oism.  lie  hoasts  of  his  personal  attainments,  his  proptru,  his 
position  in  life,  or  of  his  wife  and  children.  Fullowini;  these  features  arc 
important  in(li<ations  of  moral  perversion,  manifested  in  <itU"nces  a^'ainst 
(locoiiey  or  the  law,  many  of  whiuli  ucts  have  about  tiiem  a  siispicjiuis 
elTrontery.  Korgetfulness  i.s  (!on\mon,  and  maybe  shown  in  inattention  to 
business  details  aiul  in  the  minor  courtesies  of  life.  At  this  period  ila  iv 
miiy  be  no  motor  ]ihenoinena.  The  on.set  of  the  disease  is  usually  iiiMilj- 
(»UH,  althou|,fh  cases  are  reported  in  which  epileptifoim  or  apopicrlil'oiiii 
seizures  were  the  first  symptoms.  Amonj^  the  early  motor  features  are 
tremor  of  the  ton;^ue  and  lips  in  speakinj^,  slowness  of  s[)eeeh  and  hesi- 
tancy, and  inecpiality  of  the  pajjils. 

(//)  Second  Staijc. — Tliis  is  characterized  in  brief  by  mental  exaltation 
or  excitement  and  a  prctgress  in  the  motor  symptoms.  "The  intensity  of 
the  excitement  is  often  extreme,  acute  maniacal  states  are  frci|Ui'iii ;  in- 
cessant restlessness,  obstinate  sleeplessiu'ss,  noisy,  boisterous  exciteiiiciit, 
a!i(l  blind,  uncalcidatinj^  violem-e  especially  ciuiractcrize  such  states" 
(licwis).  It  is  at  this  sta^e  that  the  delusion  of  f,n-aiuleur  beconus  marked 
amd  the  patient  believes  himself  to  be  pos.sesscd  of  countless  millions  or  td 
have  reached  the  most  exalted  sphere  possible  in  profession  or  oecnipatioii. 
This  expansive  delirium,  as  it  is  called,  is,  however,  not  characlerislie.  ms 
M'as  fortnerly  supposed,  of  paralytic  dcinu'utia.  IJesides,  it  docs  not  always 
oeeur,  hut  in  its  stead  there  may  be  marked  melancholia  or  hypodioii- 
driasis,  or,  iu  other  instances,  ulternatc  attacks  of  delirium  and  (lepns- 
sion. 

The  faci(>s  has  a  peculiar  stolidity,  and  in  speakinej  then?  is  inaikcil 
trenndousm'ss  of  the  li|)s  and  facial  muscles.  Tlu!  ton<,nie  is  also  tremu- 
lous, and  may  be  protruded  with  ditlicidty.  Tlu;  speech  is  slow,  inter- 
rupted, and  blurred.  Writinff  becomes  diHi(Milt  on  acciount  of  unsteadi- 
ness of  the  haiul.  The  sid)jcct  matter  of  the  patient's  letters  <rive  valu- 
able! indications  of  the  mental  condition.  In  many  instances  the  pupils 
are  une(pud,  irrej^idar,  sluefjijish,  soiuetimes  larf^e.  lmi)ortant  syiuptoms 
in  this  stape  are  apoplectiform  seizures  and  paralysis.  Ther<!  imiy  K' 
sliffht  .syiu'opal  attacks  in  which  tlu;  patient  ttirn.s  pale  and  nuiy  fall. 
Some  of  these,  an;  petit  nutl.  In  the  true  apoplectiform  seizure  the  pa- 
rent falls  suddenly,  becomes  unconscious,  tin?  limbs  are  relaxed,  tin'  l':i"' 
is  flu.shcd,  the  breathinj;  stertorou.H,  the  tempcrtdun*  increased,  and  death 
may  occur.  The  epileptic  seizures  are  nn)re  (;ommon  than  the  apnpleeii- 
form  and  may  occur  early  in  the  disease.  A  delliutc  aura  is  not  imhciii- 
nu)n.  Tlu'  attack  usually  begins  on  (uie  sidc^  and  nuiy  not  spread.  Then 
may  be  twitchings  either  in  the  facial  or  brachial  muscles.     Typical  -laek- 


"■■^^i:."- 


CIIUON'IC   IHFITSK  MKNlXdO-KNCKIMIALITlS. 


M7 


sdiiiiin  epilepsy  may  oeeur.  In  a  ease  wliieli  died  recently  under  my  care, 
tiicse  Keizures  were  amon"^  the  early  sym|i((imH  and  the  disease  was  re- 
jriirded  aH  eerebral  syphilis.  Paralysis,  either  nidnnplejfie  or  heiniplejjic, 
may  follow  tlieso  epileptic  seizures,  or  may  eomo  on  with  great  suddenness 
and  In*  transient.  In  this  stajre  the  gait  heeomes  impaired,  the  patient 
tiips  readily,  has  diniculty  in  going  up  or  (hnvn  stairs,  and  the  walk  may 
lie  spastic  or  occasionally  tabetic.  This  paresis  may  be  progressive.  The 
kiii'e-jerk  is  usually  increa.sed.  HIadder  or  rectal  symptoms  gradually 
develop.  The  patient  beeoini'S  luditless,  bedridden,  and  compU'tely  di-- 
nifiitcd,  and  uide.ss  care  is  taken  nuiy  sulTer  from  bed.sores.  J)cath  occurs 
from  exhaustion  or  from  some  intercurrent  alTeetion. 

Diagnosis. — The  recognition  of  the  diseavse  in  the  earliest  stage  is  ex- 
tremely dirticult,  lus  it  is  (»ften  impossible  to  decide  that  the  slight  altcra- 
tidU  in  conduct  is  anything  more  than  one  of  the  moods  or  pha cs  to 
which  most  men  are  at  tinu-s  subject.  The  following  description  by  l-'ol- 
SDtii  is  an  admirable  presentation  of  the  diagnostic  characters  of  the  early 


Ht 


)f  th 


"It  should 


if,  f( 


^t4 


4i 


ouso  Huspici 

Healthy  man,  in  or  near  the  prime  of  life,  distinctly  not  of  the  '  nervous,' 
neurotic,  or  neurastlu'nic  type,  shows  some  loss  of  iutcri'st  in  his  affairs  or 
iiii|iaired  faculty  of  attending  to  them;  if  he  becoiues  \Mr\ingly  aliscnt- 
iniiided,  heedless,  indilTerent,  negligent,  apathetic,  inconsiderate,  and.  al- 
though able  to  follow  his  routine  duties,  his  ability  to  take  up  new  work 
is,  no  nuitter  how  little,  diminished  ;  if  he  can  less  well  command  mental 
attention  and  concentrati(»n,  conception,  perception,  rellection,  judgment  ; 
if  tiiere  is  an  unwoiiteil  lack  of  initiative,  and  if  exertion  causes  unwonted 
mental  an<l  physical  fatigue  ;  if  the  emotions  arc  inliiiisided  and  easily 
eliaiige,  or  are  excited  readily  from  trilling  causes;  if  the  sexiuil  instinct 
is  not  reasonably  controlled  ;  if  the  liner  feelings  are  even  slightly  bluntcil ;  if 
the  person  in  (piestion  regarils  with  a  jdacid  apathy  his  (»wn  acts  of  indilfer- 
I'liee  ami  irritability  and  their  consefpu^nces,  and  es))eeially  if  at  times  ho 
sees  himself  in  his  true  light  and  siuldenly  fails  again  to  do  so;  if  any 
symptoms  of  cerebral  vaso-motor  disturbances  are  notii'ed,  however  vague 
or  \ariable." 

There  are  cases  of  eerebral  syphilis  which  closely  simulate  dementia  para- 
Uti'u.     The  mode  of  onset  is  inii)ortnnt,  iiartieularly  since  paralytic  symp- 


toms are  usmdly  early  in  syphilis.  The  alTcction  of  the  speech  and  tonguo 
is  not  present.  Epileptic  si'izures  are  more  common  and  more  liable  to 
lie  cortical  or  .lacksonian  in  cduiraclcr.  The  expansive  delirium  is  rare. 
\\  Idle  synn)tom8  of  general  i)aresis  are  not  conjinon  in  connection  with 
tl'.e  development  of  gummata  (U- delinite  gummatous  mi-ningitis,  there  are, 
en  the  other  hand,  instances  of  paresis  which  follow  syphilitic  iiifce(i<(ii 
sii  rlosi'Iy  that  an  etiological  connection  lu'twecn  the  two  must  beaeknowl- 
•'•lired.  IVist  mortem  in  smd»  cases  tliere  nuiy  be  nothing  more  than  u 
prieial  arteri(»-sclerosis  and  ditTuse  meningo-encephalitis,  which  may  pre- 
sent nothing  distinctive,  but  the  lesions,  nevertheless,  nmy  be  causcil  by 


:f  I 


I 


I 


■ii  k   k 


4  ! 


DISKASKS  OF  TFIK  NKUVOUS  SYSTEM. 


tlu*  sypliilitio  virus.  Thoro  aro  certain  forms  of  loail  onccplmlopatliv  whidi 
rcsoiiihlc  f?(MUM'al  paresis,  and,  considering;  tlio  as.Hociation  of  jdinnhism  wiih 
artcri()-s(dcrosis,  it  is  not  uidikdy  that  the  anatomical  siihstratuin  <if  ilu- 
disease  may  result  from  tliis  poison. 

Prognosis. — The  disease  rarely  ends  in  recovery.  As  a  rule  th  pm;,'. 
ress  is  slowly  downward  and  the  case  terminates  in  a  few  years,  althdiii'li 
it  is  occasionally  prolonj^ed  ten  oi'  fifteen  years. 

Treatment. — 'I'he  only  hope  of  permanent  relief  is  h\  the  cases  follow- 
ins?  syj)hilis,  which  should  he  placed  upon  la rj^e  doses  of  iodide  nt|i(ita- 
Biiim.  Careful  nursiiiff  and  the  orderly  life  of  un  asylum  are  the  mily 
rm'asures  necessary  in  a  great  majority  of  the  cases.  For  sleeplessness  uiiil 
the  epileptic  seizures  hromides  may  he  used.  l'rolonf,'cd  remissions,  wliiili 
are  not  uneonwnon,  aro  often  erroneously  attrihuted  to  the  adioii  if 
remedies. 

VII.    TUMORS  OF  THE    BRAIN. 


The  following  uro  the  most  common  varieties  of  new  growths  will, in 
the  cranium  : 

{(i)  Tulicrcle^  which  may  form  snuill  or  larg(!  growths,  usually  imilti|il(. 
'J'hey  are  most  freciucnt  early  in  life.  Three  fourths  of  the  cases  (iccur 
undi-r  twenty,  and  one  half  of  the  patients  are  under  ten  years  of  ii;:c 
((Jowers).  Of  'Z\)\)  cases  of  tumor  in  ])ersons  uiuler  nineteen  collccUil 
from  various  sources  by  Starr,  152  were  tubercle.  They  are  most  niiiiicr 
ous  in  the  c(>relH'llum  and  about  the  base. 

(b)  Syphiloma  m  most  commoidy  found  in  the  hemispheres  or  alKUit 
the  pons.  The  tumors  are  superficial,  atta<died  to  the  arteries  or  the  im  - 
ninges,  and  rarely  grow  to  a  large  size.     1'hey  may  bo  nuiltii)le. 

(f)  Glioma  and  Neuro;;liomn. — These  vary  greatly  in  aj)poarance.  'I'lioy 
may  be  firm  aiul  hard,  almost  like  an  area  of  sclerosis,  or  soft  and  vi  ly 
vascular.  They  persist  remarkably  for  many  years.  Klebs  has  ralKd 
attention  to  tlui  oc(!urr(Mice  of  elements  in  them  not  unlike  gaiijjjlioii-cclls. 
Tumors  of  this  (dutrac^ter  contain  "  the  spinnen  "  or  spider  cells ;  eiioniinii-; 
Bpindlo-shaped  cells  with  single  largo  nuclei ;  cells  like  the  ganglii'ii-irll. 
of  nerve-centres  with  nucdei  and  one  or  more  j)rocesses ;  and  tiaiisluciit, 
band-like  fibres,  tapering  at  each  end^  which  result  from  a  vitreous  or  lua- 
line  transformation  of  the  large  si)indle-cells. 

{(I)  Sarcoma  occurs  most  commonly  in  the  memhranes  oT  tlio  Imiiii 
and  in  tlie  i)ons.  It  forms  some  of  Uie  largest  and  most  dilTuscly  intil- 
trating  of  intracranial  growths. 

(r)  Carcinoma  not  infre(|uently  is  secondary  to  cancer  in  otlur  |iai'ts. 
It  is  seldom  primary.  Occasionally  cancerous  tumors  have  been  fonnil  in 
symnu'trical  parts  of  the  brain. 

(/)  Other  varieties  occur,  such  as  fibroid  growths,  whi(di  ii~;ially 
develop  from  tho  membrane.;;  bony  tumors,  which  grow  soi  otime.-  fii  m 


l\y  wlilcli 
)ism  with 
m  (if  Iho 

til"  pro};. 

Ultlli)ll},'ll 

SI'S  fdlllAV- 
•  of  jtOtil- 

•I'  llu'  only 

ssiii'ss  iiiid 

oiis,  wliicli 

ui'li»'ii  cf 


ivlhs  w  hi. ill 

lly  imiltipli. 

cases  (ici  ur 

yc'iirs  of  iip 

i'll     ciillrrtHl 

lost  iiuini'r 

•S  OV  illiiUlt 

or  till'  1111- 

L'. 

■lUK'C.     'I'lll^ 

)ft  lUiil  vn;. 
has  oulKil 
imlion-i'i'll- 

,;   oll'irill'ilU' 
lllirlidll-i'l'll' 

tnui>l'-"'>'"'' 
c'oiis  or  liy;i- 

^r  tho  hiiiiii 
tTiisi'ly  iiitil- 

othiT  iiarls. 
[jeti  full  ml  i'.i 

lucli    usually 
lotiiiu-  fv  m 


TUMORS  OF  TIIK   lUiAlN. 


919 


tho  falx,  and  psnmmnnm  nnd  cliolcstciitnnm.     Kutty  tumors  are  ocniKion 
ally  fouixl  on  tiic  corpus  ciillosuin. 

(.'/)  ^'.'Z*'^*'  '"''■'"'  '"'^"''''"  ''"'  nK'nihrniics  iin<l  tlic  hniiii,  tlic  rt-Hult  of 
liaiiiorrhagc  or  of  softciiiii;;.  I'orcnccplialiis  is  a  sc(|ut'iiii'  of  coiifjctiitul 
fttroiiliy  or  of  ha'nu)rrliii;;c,  or  may  be  due  to  a  developmental  defect. 
Hydatid  cysts  will  be  referred  to  in  the  wection  on  parasites. 

Symptoms. -(I)  General.— The  following' are  the  m(»st  important: 
Ilnn/di/ir,  v'lihvr  dull,  achin<r,  and  continuous,  or  sharp,  stabi(in<.',  and  par- 
oxysmal, it  may  be  dilTused  o\er  the  entire  head  or  limited  to  the  hack 
(ir  front  In  the  former  case  it  may  extend  down  the  nock,  and  in  tho 
latter  be  accompanied  with  ncuraljri*'  pains  in  the  face.  Occasionally  tlie 
liiiiii  may  be  very  localized  and  associnted  with  tendernesK  (tu  pressure. 

()/)fif  .\ciirifis. — This  occurs  in  four  fifths  of  all  the  i-ases  ((lowers). 
It  is  usually  double,  but  occasionally  is  found  in  only  one  eye.  A  j^rowth 
may  develop  slowly  and  attain  considerable  size  without  produciiif?  o[ttic 
neuritis.  On  the  other  liaml,  it  may  occur  with  u  very  small  tumor,  more 
(•(iiiimotily  in  a  f^rowth  at  the  base. 

I'dinifiii;/ — 'I'his  is  a  common  feature,  and  with  headache  and  optic 
neuritis  maki-s  up  the  characteristic  symptom  group  of  cerebral  tumor. 
All  important  ])oint  is  the  absence  of  deiinitc  relation  to  the  meals.  It 
Miiiy  be  very  obstinate,  iiarticiilarly  in  ;.frowtlis  of  the  cerebellum  and  the 

|III|1S. 

(I'ith/iiu'ss. — This  is  often  an  early  symptom.  The  patient  com[dainH 
(if  vertij^o  on  risiu}^  suddenly  or  on  turnin((  ipiickly.  Mental  Dixhirbancc. 
Tlie  patient  may  act  in  an  odd,  unnatural  manner,  or  there  may  be  stupor 
and  heaviness,  'i'hc  patient  may  become  emotional  or  silly,  or  synqitoms 
i(-einblin<;  hysteria  may  develop.  CDiiriilsions,  either  jfcneral  aiul  resem- 
iiliiij;  true  epilepsy  or  localized  (.lacksonian)  in  character. 

(;i)  Localizing  Symptoms.— (^0  ('oi/ntl  .lAVwr  . I /w.— The  symptoms 
are  either  irritative  or  destnictive  in  character.  Irritation  in  the  lower 
third  may  produce  spasm  in  the  muscles  of  tlu'  face,  in  the  angle  of  the 
nimith,  or  in  the  tongue.  The  spasm  with  tingling  may  be  strictly  lim- 
iteil  to  one  muscle  group  liet'ore  ext.'iiding  to  others,  and  Ibis  Segiiin 
terms  the  xiijiutl  si/iiip/(iiii.  The  middle  third  of  the  motor  area  contains 
the  centres  controlling  the  Mrni,  and  here,  too,  the  spasm  may  begin  in 
the  lingers,  iji  the  tliuini),  in  the  muscles  of  the  wrist,  («r  in  the  shoulder. 
In  the  ui)per  third  of  the  motor  areas  tlu;  irritation  may  iirodiiee  sjiasm 
liegiiining  in  the  I' c  in  the  ankles,  or  in  the  muscles  of  tlu^  leg.  In 
niaiiy  instances  he  j'uient  can  determine  accurately  the  point  of  origin 
(if  the  spasm,  and  then  are  imjxirtant  sensory  disturbances,  such  as  niimb- 
iiess  and  tingling,  ;>  l.icli  may  be  felt  first  at  the  region  alVected. 

In  all  cases  it  is  important  to  determine,  first,  tho  j)oint  of  origin,  the 
■"iijiHil  .■<i/iiiji/oni  ;  .second,  the  order  or  march  of  the  spasm  ;  and  third, 
tile  subse(iuent  condition  of  the  parts  first  affected,  wlielher  it  is  a  stiite  of 
paresis  or  aniesthesia. 


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DISEASES  OP  THE  NERVOUS  SYSTEM. 


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imf. 


Destructive  lesions  in  the  motor  zone  cause  paralysis,  which  is  Dftoii 
preceded  by  local  convulsive  seizures;  there  may  be  a  monoplegia,  u.s  of 
the  leg,  and  convulsive  seizures  in  tlie  arm,  often  due  to  irritation  in 
these  centres.  Tumors  in  the  neighborhood  of  the  motor  area  may  caiiso 
localized  spasms  and  subsequently,  as  the  centres  are  invaded  by  the 
growtii,  iiaralysis  occurs.  On  the  left  side,  growths  in  the  tliird  frontal 
or  Broca's  convolution  may  cause  motor  aphasia. 

(/y)  Prefrontal  Reyion. — Neither  motor  nor  sensory  disturl)un(.'e  may 
he  present.  The  general  syTni)toms  are  often  well  marked.  'J'lie  most 
striking  feature  of  growths  in  this  region  is  mental  torpor  and  gruduai 
imbecility.  In  its  extension  downward  the  tumor  may  involve  on  ttie  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progres.i 
backward  cause  irritative  or  destructive  lesions  of  the  motor  area. 

{(•)  Tumors  in  the  pnrielo-ovcipifal  lobe  may  grow  to  large  size  without 
causing  any  symptoms.  There  may  be  word-blindness  and  mind-bliudiioss 
when  tlie  angular  gyrus  is  involved,  and  paraphasia. 

(d)  'J'umors  of  the  occipital  lobe  produce  hemianopia,  and  a  ])ihit(!ral 
lesion  may  produce  blindness.  Tumors  in  this  region  on  the  left  heiui- 
sphere  may  be  associated  with  word-blindness  and  mind-blindness. 

(c)  Tumors  in  the  temporal  lobe  may  attain  a  large  size  without  pro- 
ducing symptoms.  In  their  growth  they  involve  the  lower  motor  centres. 
On  the  left  side  involvement  of  the  first  and  second  gyri  maybe  associated 
with  word-deafness. 

(/)  Tunu>rs  growing  in  the  neighborhood  of  the  haml  ganglia  produce 
herii'i)legia  from  involvement  of  the  internal  capsule.  Limited  growtlis  in 
either  nucleus  of  the  corpus  striatum  d«i  not  necessarily  cause  paralysis. 
Tumors  in  the  thalamus  opticus  may  also,  when  small,  cause  no  symjitonis, 
but  increasing  they  may  involve  the  fibres  of  the  optic  radiation,  produc- 
ing hemianopia  and  sometimes  hemiana?sthesia.  Growths  in  this  situation 
are  apt  to  cause  early  optic  neuritis  and,  growing  into  the  third  ventri(!le, 
may  cause  a  distention  of  the  lateral  ventricles.  In  fact,  pressure  symp- 
toms from  this  cause  and  paralysis  due  to  involvement  of  the  internal 
capsule  are  the  chief  symptoms  of  tumor  in  and  about  these  ganglia. 

Growths  in  the  corpora  qtiadrir/emina  are  rarely  limited,  but  most  com- 
monly involve  the  crura  cerebri  as  well.  Ocular  symptoms  are  nnu'ked. 
The  puj)il  refiex  is  lost  and  there  is  nystagmus.  In  the  gradual  growth 
the  third  nerve  is  involved  as  it  passes  through  the  crus,  in  Avhich  case  there 
will  be  motor  oculi  paralysis  on  one  side  and  hemiplegia  on  the  other,  a 
combination  almost  characteristic  of  unilateral  crus  disease. 

(g)  Tumors  of  the  poiis  and  medulla.  The  symptoms  are  chiefly  tlioso 
of  pressure  upon  the  nerves  emerging  in  this  region.  In  disease  of  tlie 
pons  the  nerves  may  be  involved  alone  or  with  the  tract.  Of  b'i  cases 
analyzed  by  Mary  Putnam  Jacobi,  there  were  13  in  which  the  cranial 
nerves  were  involved  alone,  13  in  which  the  limbs  were  affected,  and  v(!  in 
which  there  was  hemiplegia  and  involvement  of  the  nerves.     Twenty- two 


TUMORS  OP  THE  BRAIN. 


921 


of  the  latter  had  what  is  known  a:5  alternate  paralysis — i.  c,  involvement 
oL'  the  nerves  on  one  side  and  the  limbs  on  the  opposite  side.  In  four 
cases  there  wore  no  motor  symptoms.  A  tumor  growing  in  the  lower  part 
of  the  pons  usually  involves  the  sixth  nerve,  ])rodueing  internal  strabis- 
mus ;  the  seventh  nerve,  producing  facial  paralysis ;  aiul  tlie  auditory  nerve, 
ciiusing  deafness.  Conjugate  deviation  of  tlie  eyes  to  tlie  side  opposite 
that  on  wliich  there  is  facial  })aralysis  also  oc;eurs. 

Tumors  of  the  medulla  nuiy  involve  the  cranial  nerves  alone  or  cause 
in  some  instances  a  coml)ination  of  hemijilegia  with  paralysis  of  the  nerves. 
Signs  of  irritation  in  tlio  ninth,  tenth,  and  eleventh  ]ierves  are  usually 
present,  and  produce  difliculty  in  swallowing,  irregular  action  of  tlie  iu'art, 
irregular  respiration,  vomiting,  aiul  sometinujs  retraction  of  the  head  and 
nt!ck.  The  gait  may  be  unsteady  or,  if  there  is  pressure  on  the  cerebellum, 
at:ixic.  Occasionally  there  are  sensory  symptoms,  numbness,  and  tingling. 
Toward  the  eiul  convulsions  may  occur, 

(//)  'J'umors  of  the  cerebellum  constitute  by  far  the  most  important 
alTection  of  this  part.  There  may  be  no  symptoms  whatever  if  the  tumor 
is  confined  to  one  hemisphere  and  does  not  involve  the  middle  lobe.  When 
this  portion  is  affected  the  symptoms  are  very  characteristic,  consisting  of  : 

Vcrli(/o,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  'J'his  may  be  due,  some  believe,  to  the  central  rela- 
tions of  the  semicircular  canals  Avith  the  cerebellum.  The  giddiness  may 
be  of  the  most  distressing  nature. 

IlcaihtcJie. — In  the  analysis  by  Mary  Putiuim  Jacol)i  of  symptoms  in 
tumors  in  various  parts  of  the  brain  headache  was  relatively  much  more 
frecpient  in  tumors  of  the  cere])ellum  than  in  any  other  region. 

Cerebellar  Ataxia. — The  gait  is  irregular  and  staggering.  In  attemi)t- 
iug  to  walk  the  patient  reels  to  and  fro  like  a  drunken  man.  Then!  may 
be  a  tendency  to  fall  to  one  side,  backward,  or,  less  commonly,  forward. 

Other  less  constant  but  suggestive  symptoms  are  the  optic  neuritis; 
nystagmus ;  neuralgic  pains  in  the  region  of  the  neck  and  occiput ;  press- 
ure symptoms  on  the  medulla,  causing  vomiting;  distention  of  the  lateral 
ventricles,  causing  in  children  hydrocephalus;  and,  lastly,  bilateral  rigidity 
from  pressure  on  the  nu)tor  paths  (Sharkey). 

Diagnosis. — From  the  general  symptoms  alone  the  existence  of 
tumor  nuiy  be  determined,  for  tlu;  combination  of  headache,  optic  neuri- 
tis, and  vomiting  is  distinctive.  The  localization  must  be  gathered  from 
tlie  consideration  of  the  symptoms  above  detailed.  Mistakes  are  most 
likely  to  occur  in  connection  with  uraunia,  hysteria,  and  general  paralysis; 
but  careful  consideration  of  all  the  circumstances  of  the  case  usually  en- 
ables the  practitioner  to  avoid  error. 

Prognosis. — Syphilitic  tumors  alone  are  amenable  to  treatment. 
Tuberculous  growths  oocasiomilly  cease  i.o  grow  and  become  calcified. 
The  gliomata  and  fibromata,  particularly  when  the  latter  grow  from  the 
membranes,  may  last  for  years.     I  have  described  a  case  of  small,  hard 


•■Hi 


1i 


,m& 


922 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


glioma,  in  which  the  Jaoksonian  epilepsy  persisted  for  fourtoon  voars. 
Ilughlings  Jackson  lias  reported  cases  of  glioma  in  which  the  syiti|)t(itns 
lasted  for  over  ten  years.  The  more  rapidly  growing  sarcomata  usuallv 
prove  fatal  in  from  six  to  eighteen  months.  Death  may  he  sudden,  |m,- 
ticularly  in  growths  near  the  medulla  ;  more  commonly  it  is  due  to  ccniu 
in  consecjuoiu-e  of  gradual  increase  in  the  intracranial  pressure. 

Treatment.  —  (n)  Medical. — If  there  is  a  suspicion  of  syphilis  the 
iodide  of  potassium  and  mercury  should  he  given.  Nowhere  do  we  see  inoro 
brilliant  therapeutical  effects  than  in  certain  cases  of  cerebral  guiuinata. 
The  iodide  should  be  given  in  increasing  doses.  In  tuberculous  tumors  the 
ontlook  is  less  favorable,  though  instances  of  cure  are  reported,  and  there 
is  post-mortem  evidence  to  show  that  tli';  solitary  tuberculous  tunu)r.s  may 
undergo  changes  and  become  obsolete.  A  general  tonic  treatment  is  indi- 
cated in  these  cases.  The  headache  usually  demands  prompt  treatment. 
The  iodide  of  potassium  in  full  doses  sometimes  gives  marked  relief.  An 
ice-cap  for  the  head  or,  in  the  occipital  headache,  the  application  of  iho 
Paquelin  cautery  may  be  tried.  The  bromides  are  not  of  much  use  iii  the 
headache  from  this  cause,  and,  as  the  last  resort,  morphia  must  be  given. 
For  the  convulsions  bromide  of  potassium  is  of  little  service. 

(/;)  Surgical. — Tumors  of  the  braiti  have  been  successfully  removed  liy 
Macewen,  Ilorsley,  Keen,  and  others.  The  number  of  cases  for  operatien, 
however,  is  small.  Four  fifths  at  least  of  all  the  cases  are  probably  un- 
successful, or  of  such  a  nature  as  to  render  an  operation  fatal.  The  most 
advantageous  cases  are  the  localized  fibromata  growing  from  the  dura  and 
only  compressing  the  brain  substance,  as  in  Keen's  remarkable  case.  The 
safety  with  which  the  exploratory  operation  can  be  made  warrants  it  in 
all  doubtful  cases. 


VIM.  CHRONIC  HYDROCEPHALUS. 

Definition. — -V  condition,  congenital  or  acquired,  in  Avhich  there  is 
a  great  accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  term  hydrocephalus  has  also  been  apjdied  to  the  collection  of  fluid 
between  the  cortex  of  the  brain  and  the  skidl,  known  in  this  situation  as 
h.  crtcrntt.s'  or  //.  e.v  vacuo,  a  condition  common  in  cases  of  atrophy  of  tlw 
brain  Sul>stince,  and  perhaps  caused  also  by  meningeal  cysts.  A  t;ue 
droi)sy,  however,  of  the  arachnoid  siic  probably  does  not  occur. 

The  cases  may  1)e  divided  into  two  groups,  congenital  or  infantile,  and 
secondary  or  ac([uired. 

(1)  Congenital  Hydrocephalus. — The  eidarged  head  may  obstruct 
labor;  more  frequently  the  condition  is  noticed  some  time  after  birth. 
T'he  cause  is  unknown.  It  has  occurred  in  several  members  of  the  sa:ne 
family. 

The. anatomical  condition  in  these  cases  oilers  no  clew  to  the  nature  of 


CHRONIC  IIYDROCEPHALUS. 


923 


tlio  trouble.  The  lateral  ventricles  are  enormously  distended,  but  the 
epcndyma  is  usually  clear,  sometimes  a  little  tbiokeiied  and  granular,  and 
the  veins  largo.  Tlie  choroid  plexuses  are  vascular,  sometimes  sclerotic,  but 
ot'tru  natural-looking.  The  third  ventricle  is  enlarged,  the  atjueduet  of 
Sylvius  dilated,  and  the  fourth  ventricle  may  be  distended.  The  quantity 
of  lluid  nmy  reach  several  litres.  It  is  limitid  and  contains  a  trace  of 
albumen  and  salts.  The  changes  in  consequence  of  this  enormous  ven- 
tiicular  distention  are  remarkable.  The  cerebral  cortex  is  greatly  stretched, 
and  over  the  nnildle  region  the  tlr.ckness  nuiy  amount  to  no  more  than  a 
few  millimetres  without  a  trace  of  the  suIcm  or  convolutions.  Tlie  basal 
ganglia  are  flattened.  The  skull  enlarges,  and  the  circumference  of  the 
head  of  a  child  of  three  or  "  ,r  years  may  reach  twenty-five  or  even  thirty 
inches.  The  sutures  widen,  Wormian  bones  develop  in  them,  and  the 
l)ones  of  the  cranium  become  exceedingly  thin.  'J'he  veins  are  marked  be- 
neath the  skin.  A  fluctuatioi  wave  may  sometimes  be  obtained,  and 
Fisher's  brain  murmur  may  be  heard.  Tlie  orl)ital  plates  of  the  frontal 
bone  are  depressed,  causing  exophthalmos,  so  that  the  eyeballs  cannot  be 
covered  by  the  eyelids. 

Convulsions  may  occur.  The  reflexes  are  increased,  the  child  learns 
to  walk  late,  and  ultimately  in  severe  cases  the  legs  becone  fi'cljlc  and 
sometimes  spastic.  I'he  mental  condition  is  variable;  the  child  may  be 
bright,  but,  as  a  rule,  there  is  some  grade  of  imbecility.  The  congenital 
cases  usually  die  within  the  first  four  or  five  years.  The  jirocess  may  be 
an-osted  and  the  patient  may  reach  adult  life.  Cases  of  this  sort  are  not 
very  uncommon.  Even  when  extreme,  the  mental  facndties  nuiy  be 
retained,  as  in  liright's  celebrated  patient,  Cardinal,  who  lived  to  the  age 
of  twenty-nine,  and  whose  head  was  translucen'  when  the  sun  Avas  shin- 
ing behind  him.  Care  must  be  taken  not  to  mistake  the  ra(;hitic  head  for 
liydrocephalus. 

(2)  Acquired  Chronic  Hydrocephalus.— This  is  stated  to  be  occasionally 
primary  (idio])athic) — that  is  to  say,  it  comes  on  spontaneously  in  the 
adult  without  observable  le;iion.  Dean  Swift  is  said  to  have  died  of  hydro- 
cephalus, but  this  seems  very  unlikely.  Jt  is  based  upon  the  statement 
that  "he  (Mr.  AVhiteway)  opened  the  skull  and  found  much  water  in  the 
brain,"  a  condition  no  doubt  of  //.  ex  varuo,  due  to  the  wasting  associated 
with  his  prolonged  illness  and  paralysis.  In  nearly  all  cases  there  is  either 
a  tumor  at  the  base  of  the  brain  or  in  the  third  ventricle,  which  compresses 
tlu;  vena3  Caleni.  The  i)assnge  from  the  third  to  the  foui  th  ventricle  may 
be  closed,  either  by  a  tumor  or  by  parasites.  More  rarely  the  foi'amen  of 
Magendie,  through  which  the  ventricles  communicate  with  the  cerebro- 
spinal meninges,  becomes  closed  by  meningitis.  These  conditions,  occur- 
ring in  adults,  may  produce  t!ie  most  extreme  hydrocephalus  without  any 
enlargement  of  the  iiead.  Even  when  the  tum(jr  begins  early  in  life  there 
may  be  no  expansion  of  the  skull.  In  the  case  of  a  girl  aged  sixteen,  blind 
from  her  third  year,  the  head  was  not  unusually  large,  the  ventricles  were 


^, 


I' 


¥ 

Wi^ 

j^fi 

Hii 


IMS 


92-t 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


enormously  distended,  and  in  the  Kolandic  region  the  brain  substanc^o  was 
only  five  iiiillinietres  in  thickness.  A  tumor  occupied  the  third  ventricle. 
In  a  case  of  cholesteatoma  of  the  floor  of  the  third  ventricle,  in  w  hich  tiio 
symptoms  persisted  at  intervals  for  eight  or  nine  years,  the  ventricles  wore 
enormously  distended  Avithout  enlargement  of  the  skull.  In  other  in- 
stances the  sutures  separate  and  the  head  gradually  enlarge;!. 

The  sym^jtoms  of  hydrocephalus  in  the  adult  are  curious>y  varialdo. 
In  the  c;iso  first  mei\tioned  there  were  early  headaches  and  gradiiiil  liHiid- 
ness ;  then  a  prolonged  period  in  which  she  was  able  to  atteiul  to  Iut 
studies.  Headaches  again  supervened,  the  gait  became  irregular  uiid 
somewhat  ataxic.  Death  occurred  suddenly.  In  the  other  case  tlicru 
were  prolonged  attacks  of  coma  Avith  a  slow  pulse,  and  on  one  occasion  the 
patient  renuuned  unconsc.'ious  for  more  than  three  months.  (Jraduahv 
progressing  optic  neuritis  without  focalizing  symptoms,  lieadachc.  and 
attacks  of  somnolence  or  coma  are  suggestive  symptoms.  Cases  are  rare 
as  a  result  of  meningitis.  The  only  instances  I  have  seen  Averc  two  wliicli 
corrosponded  to  the  posterior  meningitis  of  CJee  and  Barlow,  in  wliieh, 
with  the  distention,  there  was  extensive  chronic  purulent  ejtcndyniiiis. 

Treatment. — Very  little  can  be  done  to  relieve  hydrocephalus. 
Medicines  are  powerless  to  cause  the  absorption  of  the  fluid.  More 
rational  is  the  system  of  gradual  compression,  with  or  Avithout  the  Avitii- 
drawal  of  small  quantities  of  the  fluid.  The  compression  may  bo  made 
by  means  of  broad  ])lasters,  so  applied  as  to  cross  each  other  on  the  vortex, 
and  another  may  be  jilaced  round  the  circumference. 

Of  lato  years  puncture  of  the  ventricles,  an  operation  which  had  been 
abandoned,  has  been  revived,  particularly  by  Keen,  and  in  a  few  cases 
is  justifiable.  When  pressure  sym])toms  are  marked  it  nuiy  be  emjjloyed 
Avith  great  relief  to  the  lieadache  and  remoA'al  of  the  silastic  state  df  the 
legs.  Quincke  recommends,  and  has  practised  in  these  cases,  as  io!l  as 
in  acute  hydrocephalus,  puncture  of  the  .subarachnoid  sac  between  the 
third  and  the  fourth  lumbar  vertehne.  At  this  point  the  spituil  cord  can- 
not be  touched.  The  advantage  is  a  sloAver  removal  of  fluid  and  less 
danger  of  collapse. 


IV.  GENERAL  AND  FITXCTIONAL  DISEASES. 
I.    ACUTE   DELIRIUM  {BelVs Mania). 

Definition. — Acute  delirium  running  a  rapidly  fatal  courso,  with 
slight  fever,  and  in  Avhich  post  mortem  no  lesions  arc  found  suflicient  to 
account  for  the  disease. 

Cases  arc  reported  by  many  old  AVriters  under  the  term  brain  fever  or 
phrenitis.     Bell,  at  the  time  Superintendent  of  the  McLean  Asylum,  do- 


n(;e  was 
I'lUride. 
Iiich  the 
■Ics  wore 
ithcr  iu- 

variul)lc. 
Ill  blind- 
,d  to  lior 
iilar  iiiiti 
asc  tlioro 
■asion  the 
.Jnviluiilly 
aclio,  iuitl 
'S  i\\\'  nu'o 
;avo  wliii'li 
in  which, 
ytnitis. 
occphalus. 
id.     More 
,  tlie  with- 
r  be  inailc 
;lio  vertex, 

liaii  been 
few  cases 
om])loy(Hl 

Itiite  of  tlie 
us  >''i'll  »s 

Itwoou  tlic 
oonl  ean- 
d  and  less 


lurso,  with 
iflicient  to 

[\  fever  or 
Isvluni,  de- 


ACUTfi  DELIRIUM. 


925 


scribed  it*  accurately  under  the  designation,  "  a  form  of  disease  resembling 
some  advaTieed  stages  of  mania  and  fever." 

The  disease  may  set  in  abruptly  or  be  preeedod  by  a  period  of  irrita- 
l)ility,  restlessness,  and  insomnia.  The  mental  symptoms  develop  with 
rai)idity  and  may  quickly  reach  a  grade  of  the  most  intense  frenzy.  There 
arc  the  wildest  hallucinations  and  outbretvks  of  great  violence.  The  pa- 
tient talks  incessantly,  but  incoherently  and  unintelligibly.  Xo  sleep  is 
obtained,  and  at  last,  worn  out  with  the  intensity  of  the  muscular  move- 
ments, tha  patient  becomes  utterly  prostrated  and  assumes  the  sitting  or 
rcc. unbent  jiosture.  There  may  sometimes  bo  definite  salaam  movements, 
and  in  a  case  whicdi  I  saw  at  AVestphal's  clinic  the  patient  incessantly 
made  motions  as  if  working  a  pump  handle.  After  a  period  of  intense 
bodily  excitement,  lasting  for  from  twenty-four  to  thirty-six  hours  or 
longer,  the  patient  can  be  examined,  and  presents  the  conditions  which 
Bell  described  as  typho-mania.  The  temperature  ranges  from  10Ji°  to 
104°,  or  even  higher.  The  tongue  is  dry,  the  pulse  ra])id  and  feeble, 
and  sometimes  there  are  seen  on  the  skin  bullae  and  pustules,  and  fre- 
quently sor  s  from  abrasion  and  self-inflicted  injuries.  Toward  the  close 
or,  accordin<4  ^o  Spitzka,  even  during  the  development  of  the  disease  there 
maybe  lucid  i  tervals.  There  may  be  jietechiic  on  the  skin,  and  often 
there  is  marked  congf\stion  of  the  face  and  extremities.  Tlie  duration  of 
the  disease  is  variable.  Very  acute  cases  may  terminate  within  a  week ; 
others  persist  for  two  or  even  three  weeks.  The  course  of  the  disease  is 
almost  uniformly  fatal.  The  anatomical  condition  is  practically  nega- 
tive, or  at  any  rate  presents  nothing  distinc'tive.  There  is  great  venous 
cniiorgement  of  the  vessels  of  the  meninges  and  of  the  gray  cortex.  In 
two  cases  in  which  T  made  a  careful  microscopic  examination  of  the  gray 
matter  there  Avere  perivascular  exudation  and  leucocytes  in  the  lymi)h 
slieaths  and  porigangliar  spaces.  In  the  inspection  of  fatal  cases  of  acute 
ilelirium  careful  examination  should  be  made  of  the  lungs  and  ileum.  It 
should  be  borne  in  mind  that  in  a  majority  of  the  cases  dying  in  this 
manner,  there  is  engorgement  of  the  bases  of  the  lungs  or  even  deglutition 
pneumonia. 

The  nature  of  the  disease  is  quite  unknown.  Some  of  the  cases  sug- 
gest acute  infection.  Spitzka  thinks  that  it  u  due  to  an  autochthonous 
nerve  poison. 

Diagnosis. — There  are  several  diseases  which  may  present  identical 
:yinptoms.  As  Bell  remarks  in  his  paper,  the  first  glance  in  many  cases 
suggests  typhoid  fever,  particularly  when  the  patient  is  seen  after  the  vio- 
lence of  the  mania  subsides.  lie  gives  two  instances  of  this  which  were  ad- 
mitted from  a  general  hospital.  Enlargement  of  the  spleen,  the  occur- 
rence of  spots,  and  the  history  give  clews  for  the  separation  of  the  cases ; 
but  there  are  instances  in  which  it  is  at  first  impossible  to  decide.     More- 

*  American  Jouraal  of  Insanity,  1849. 


k  i: 


926 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


m 


*!  ,V  -I 


over,  typhoid  fever  may  set  in  with  the  most  intense  delirium.  TLo  oxist- 
eno((  of  fever  is  the  most  deceptive  symptom,  and  its  coml)iniitii»u  with 
delirium  and  dry  tonguu  so  eonimoiily  means  typhoid  fever  that  it  is  viiv 
ditheult  to  avoid  error. 

Acute  pneumonia  may  come  on  with  violent  maniacal  delirium  aiul  tlie 
pulmonary  symptoms  may  be  entirely  nuisked. 

Occasionally  acute  nra'iuia  sets  in  suddenly  with  intense  ni;mia,  aiid 
finally  subsides  into  a  fatal  coma.  'I'he  condition  of  the  urine  and  Ihe  ab- 
sence of  fever  would  be  important  diagnostic  features. 

The  character  of  the  delirium  is  quite  different  from  that  of  nuuiia  h 
potn.  It  may  be  extremely  difhcult  to  differentiate  act  te  delirium  from 
certain  cases  of  cortical  meningitis,  which,  liowever,  is  usually  a  secoiulary 
affection,  occurring  in  connection  with  pneumonia  or  ulcerative  endo- 
carditis, or  is  due  to  extension  from  disease  of  the  car.  This  sets  in  iiu^ro 
frequently  with  a  chill,  and  there  may  be  convulsions. 

Treatment. — Even  though  bodily  prostration  is  apt  to  come  on 
early  and  be  profound,  I  would  not  hesitate  to  advise,  in  the  case  of  ii 
robust  man,  free  venesection.  It  is  not  at  all  improbable  that  some  of  the 
many  cases  of  mania  in  Avhich  Benjamin  Rush  let  blood  with  sucli  benefit 
belonged  to  this  class  of  affections.  Considering  its  remarkable  calm ini,' 
influence  in  febrile  delirium,  the  cold  bath  or  the  cold  pack  should  l)o  em- 
ployed. Morphia  and  chloroform  may  be  administered,  and  hyoscino  and 
tUe  bromides  may  be  tried.  Krafft-Ebing  states  tha/  Solivetti  lias  ol)- 
tained  good  results  by  the  use  of  ergotin.  Unfortunately,  as  asylum  re- 
ports show,  the  disease  is  almost  uniformly  fatal. 


II.  PARALYSIS  AGITANS 

(Parkinson's  Disease  ;  Shaking  Pahy), 

Doflnition. — A  chronic  affection  of  the  nervouc  system;  characterized 
by  muscular  weakness,  tremors,  and  rigidity. 

Etiology. — ^len  are  more  frequently  afPected  than  women.  If  rarely 
occurs  under  forty,  but  instances  have  been  reported  in  which  the  disease 
began  about  the  twentieth  year.  It  is  by  no  means  an  uncomuion  alloe- 
tion.  Direct  heredity  is  rare,  but  the  patients  often  belong  to  families  in 
which  there  are  other  nervous  affections.  Among  exciting  causes  inay  be 
mentioned  exposure  to  cold  and  wet,  and  business  W'orries  and  an:;ieties. 
In  some  instances  the  disease  has  followed  directly  upon  severe  mental 
shock  or  trauma.  Cases  have  been  described  after  the  specific  fevers. 
Malaria  is  believed  by  some  to  be  an  important  factor,  but  of  this  there  is 
no  satisfactory  evidence. 

Morbid  Anatomy. — No  constant  lesions  have  been  found.  The 
similarity  between  certain  of  the  features  of  Parkinson's  disease  and  those 
of  old  age  suggest  that  the  affection  may  depend  upon  a  premature  senil- 


w 


>o  exist- 
on  with 
t  is  very 

anil  the 

niii,  mill 
1  the  iib- 

UKtllill  (I 

un>  from 
iGCouthiry 
vc  cn(h)- 

s  in  more 

come  on 
case  of  a 
me  of  the 
ch  benefit 
e  calmiii;^ 
ihl  he  em- 
aseine  and 
ti  lias  oh- 
lavlum  re- 


racterized 

It  rarely 

Ihe  (lisea^o 

liion  all'oc- 

lanuHes  in 

|es  may  he 

anxieties. 

Ii'e  mental 

i\c  fevers. 

lis  there  is 

ino.  Tlio 
laud  tlioso 
lure  ^^enil- 


PARALYSIS  AGITANS. 


927 


ity  of  certiiin  rorrions  of  the  brain.  Our  orj^fans  do  not  npfo  imifornily,  lint 
in  some,  o\vin<i;  to  lieroditury  (li.spo.sition,  thu  process  may  bo  more  rapid 
than  in  others.  "  Parkinson's  disease  has  no  characteristic  lesions,  but  on 
tlie  other  hand  it  is  not  a  neurosi,^.  It  has  for  an  anatomical  basis  the 
lesions  of  (,'erebro-spinal  senility,  and  whic'  only  dilT(>r  from  those  of  true 
senility  in  their  early  onset  and  greater  intensity."  (I)ubicf.)  1'lie  ini- 
portant  changes  are  doubtless  in  the  cerebral  cortex. 

Symptoms. — The  disea.se  begins  gradually,  usually  in  one  or  other 
hand,  and  the  tremor  may  be  either  constant  or  intermittent.  With  this 
may  be  as.iociated  weakness  or  stiffness.  At  first  the.se  symptoms  may  be 
present  only  after  exertion.  Although  the  on.set  is  slow  and  gradual  in 
nearly  all  ca.ses,  there  arc  instances  in  which  it  sets  in  abruptly  after  fright 
or  trauma.  When  well  established  the  disease  is  very  characteristic,  and 
the  diagnosis  caii  be  made  at  a  glance.  The  four  prominent  symptoms 
arc  tremor,  weakness,  rigidity,  and  the  attitude. 

Tremor. — This  may  be  in  the  four  extremities  or  confined  to  hands  or 
feet ;  the  head  is  not  so  commonly  affected.  The  tremor  is  usually  marked 
in  tlie  hands,  and  the  thumb  and  forefinger  display  the  motion  made  in  the 
act  of  rolling  a  pill.  At  the  wrist  there  are  movements  of  pronation  and 
supination,  and  less  marked  of  flexion  and  extension.  The  u])per-arm 
inn.sclcs  are  rarely  involved.  In  the  legs  the  movement  is  most  evident  at 
the  ankle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the 
head  is  less  frequent,  but  does  occur,  and  is  usually  vertical,  not  rotatory. 
The  rate  of  oscillation  is  al)out  five  per  second.  Any  emotion  exaggerates 
the  movement.  The  attempt  at  a  voluntary  movement  may  check  the 
tremor  (the  patient  may  be  able  to  thread  a  needle),  but  it  returns  with 
increased  intensity.  The  tremors  cease,  as  a  rule,  during  sleep,  but  persist 
wlien  the  muscles  are  at  repose.  The  writing  of  the  patient  is  tremulous 
and  zigzag. 

Weakness. — Loss  of  jiowcr  is  present  in  all  cases,  and  may  occur  even 
before  the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer, 
until  the  late  stages.  The  weakness  is  greatest  where  the  tremor  is  most 
developed.  The  movements,  too,  are  remarkably  slow.  There  is  rarely 
complete  loss  of  power. 

Ri(jiiUty  may  early  be  expressed  in  a  slowness  and  stiffness  in  the  vol- 
untary movements,  which  are  performed  with  some  effort  and  difficulty, 
and  all  tlie  act.ons  of  the  patient  are  deliberate.  This  rigidity  is  in  all  the 
mu.scles,  and  leads  ultimately  to  the  characteristic 

Attitude  and  Gait. — The  head  is  bent  forward,  the  back  is  bowed,  and 
the  arms  are  held  away  from  the  body  and  are  somewhat  flexed  at  the 
elbow-joints.  The  face  is  expressionless,  and  the  movements  of  the  lips 
are  slow.  The  eyebrows  are  elevated,  and  the  whole  exprcsion  is  immobile 
or  mask -like,  the  so-called  Parkinson's  mask.  The  voice,  as  pointed  out 
by  Buzzard,  is  apt  to  be  shrill  and  piping,  and  there  is  often  a  hesitancy  in 
beginning  a  sentence ;  then  the  words  are  uttered  with  rapidity,  as  if  the 


!!: 


rW 


W' 


928 


DISEASKS  OF  THK   NERVOUS  SYSTEM. 


1  ."  J  '-J 


patient  Was  in  a  liurry.  This  is  soniotiuiea  in  stril<in_c;  oontruat  to  tlio  scmh- 
iiiiij,'  H|K'C(;h  of  insular  sclerosis.  The  fin<j;ers  arc  Hexed  and  in  tlu;  ])osiii(,n 
assumed  when  the  hand  is  at  rest;  in  the  lato  stages  they  canixit  he  cx- 
tende(l.  Oeeasionally  there  is  overextension  of  tlie  tcrtriiiial  iiliahui'rcs. 
'I'he  hand  is  usually  turned  toward  the  idnar  side,  and  Lho  attitudi-  suiiic- 
what  rcsonil)les  that  of  advanced  cases  of  rlieuniatoid  arthritis,  in  the 
late  sta<fes  there  are  contractures  at  the  elbows,  knees,  and  anl<Us.  'i'lic 
movements  of  the  patient  are  characterized  by  great  deliberation.  He 
rises  from  the  chair  slowly  in  the  stooping  attitude,  witli  the  head  inojeci. 
ing  forward.  In  attempting  to  walk  the  steps  are  short  and  hurried,  ami, 
as  'IVousseau  remarks,  lie  a])pears  to  be  running  after  liis  centre  of  ^iruvitv. 
This  is  termed  festination  or  propulsion,  in  contraili.stinclion  to  a  peculiar 
gait  observed  when  the  juitient  is  pulled  backward,  when  he  nudves  u  num- 
ber of  steps  and  would  fall  over  if  not  prevented — retropulsion. 

The  reflexes'  are  normal  in  most  eases,  but  in  a  few  they  are  cxaij- 
ge rated. 

Of  sensory  disturbances  Charcot  lias  noted  abnormal  alterations  in  the 
temperature  sense.  The  patietit  may  complain  of  subjective  sensations  of 
lieat,  either  general  or  local — a  ])henomcnon  Avliieh  may  be  present  on  one 
side  only  and  associated  with  an  actual  increase  of  the  surface  tempera- 
ture, as  much  as  G°  F.  ((lowers).  In  other  instances,  patients  complain 
of  cold.  Localized  sweating  may  be  present.  The  mental  condition  rarely 
shows  any  change. 

iotis  in  the  Sj/mpioms. — The  tremor  may  be  absent,  hut  the 
rigi'  oakness,  and  attitude  are  suflicient  to  make  the  diagnosis.    Tlio 

disease  may  be  hemiplegic  in  character,  involving  oidy  one  side  or  even 
one  limb.     Usually  these  are  but  stages  of  the  disease. 

Diagnosis. — In  well-developed  cases  the  disease  is  recognized  at  a 
glan(!e.  'JMie  attitude,  gait,  stiffness,  and  mask-like  expression  are  points 
of  as  nnuih  im})ortance  as  the  oscillations,  and  usually  serve  to  separate 
the  cases  from  senile  and  other  forms  of  tremor.  Disseminated  sclerosis 
develops  earlier,  and  is  characterized  by  the  nystagmus,  and  the  scanning 
speech,  and  does  not  present  the  attitude  so  constant  in  paralysis  agitiuis. 
The  hemiplegic  form  might  be  confounded  with  post-homiplegic  tremor, 
but  the  history,  the  mode  of  onset,  and  the  greatly  increased  reflexes  would 
be  suflicient  to  distinguish  the  two.  The  Parkinsonian  face  is  of  great 
importance  in  the  diagnosis  of  the  obscure  and  anomalous  forms. 

T'he  disease  is  incurable.  Periods  of  imiirovement.  may  occur,  but  tlio 
tendency  is  for  the  affection  to  proceed  progressively  downward.  It  is  a 
slow,  degenerative  process  and  the  cases  last  for  years. 

Treatment. — There  is  no  method  which  can  be  recommended  as 
satisfactory  in  any  respect.  Arsenic,  opium,  and  hyoscyamia  may  lie  tried, 
but  the  friends  of  the  patient  should  be  told  frankly  that  the  disease  is 
incurable,  and  that  nothing  can  be  done  except  to  attend  to  the  pliysieal 
comforts  of  the  patient. 


J 


ACUTF-:  CIIOUKA. 


929 


Othicu  Forms  ok  'I'uiimou. 

(a)  Simple  7'iriiinr. — Tim  is  occiisioimlly  foil  ml  in  porsons  in  whom  it 
is  itiipossiblc  to  assign  any  caiisc.  It  may  Ik'  traiisiiMit  or  persist  for  an 
iiidi'tiiiito  time.  It  is  often  extremely  slight,  and  is  aggravutod  by  all  causes 
which  lower  tho  vitality. 

{/))  Iferedi/itrj/  Tremor. — C.  ]j.  Dana  has  reported  remarkahle  rases  of 
hort'ditary  tremor.  It  oeeiirred  in  all  the  members  of  one  family,  and 
beginning  in  infancy  it  continued  wilhoiit  producing  any  serious  clianges. 

(r)  Senile  Tremur. — With  advancing  ago  tronudousness  during  mus- 
cular movements  is  extremely  common,  but  is  rarely  seen  under  seventy. 
It  is  always  a  fine  tremor,  which  begins  in  the  hands  and  often  extends  to 
the  muscles  of  the  nei'k,  causing  slight  movement  of  tlu^  head. 

{(I)  Toxic  tremor  is  seen  chictly  as  an  elTect  of  tobacco,  alcohol,  lead,  or 
mercury:  more  rarely  in  arsenical  or  opium  poisoning.  In  elderly  nu'ii 
who  smoke  much  it  may  be  entirely  due  to  the  tobacco.  One  of  tho  com- 
monest forms  of  this  is  tho  ah^oholic  tremor,  which  occurs  only  on  move- 
ment and  has  consideralde  range.  Lead  tn^mor  will  be;  I'oiisidered  in 
speaking  of  lead  poisoning,  of  which  it  constitutes  u  very  importiint 
symptom. 

((!)  IIijKterical  tremor.,  which  usually  occurs  under  circumstances  wliich 
make  the  diagnosis  easy,  will  be  considered  in  tho  section  on  hysteria. 


■!   'i 


<li 


If') 
ft. 


agitiins. 
tremor, 
,\s  would 
of  great 

but  tho 
It  is  a 


1)0  tried, 

disease  is 

plivsieal 


III.    ACUTE  CHOREA 

(Sydenham's  Chorea ;  St.  Vitus's  Dance). 

Deflllition. — A  disease  chiefly  alfecting  children,  characterized  by 
irregular,  involuntary  contraction  of  the  muscles,  a  variable  amount  of 
psychical  disturbance,  and  a  remarkable  liability  to  acute  endocarditis. 

We  shall  speak  here  only  of  Sydenham's  chorea.  Senile  chorea,  chronic 
chorea,  the  prehemiplegic  and  post-hemiplegie  forms,  and  rhythmic  chorea 
are  totally  different  affections. 

Etiology. — Sex. — Of  oo-t  cases  Avhich  I  have  analyzed  from  the 
Philadelphia  Infirmary  for  Diseases  of  the  Xervous  System,  seventy-one 
per  cent  were  in  females  and  twenty-nine  per  cent  in  males.  After  pu- 
herty  the  percentage  in  females  increases. 

Ar/e. — The  age  incidence  in  ii'22  cases  was  as  follows:  In  the  first 
decade,  201 ;  in  the  second  decade,  'US;  in  the  third  decade,  10;  in  the 
fourth  decade,  1 ;  above  the  fourth  decade,  2.  In  the  cases  under  twenty 
years  the  following  is  the  age  incidence  in  the  hemidecades :  In  the  first 
heniidecade,  33 ;  in  tho  second  hemidec!^  le,  1G8  ;  in  the  third  liemi- 
deeade,  212 ;  in  the  fourth  heniidecade,  52. 

Station. — AVhile  the  disease  affects  children  of  all  grades  of  society,  it 
is  more  common  among  the  lower  classes. 


:  '    H 


,m. 


I 


03) 


DISKASKS  OF  THE  NERVOUS  SYSTEM. 


'3'i    - 


luirr.  —  AA  shown  by  iiU|iiirios  iiistituti'd  hy  Weir  Mitclicll  s(»inc  vian 
!i>,'i),  clHircii  is  niro  in  tho  iu';,'r(>.  So  iic^n-i)  cliiltl  of  full  liiitli  luis  Ihch 
uiidor  tri'iitTiK'nt  attlio  Pliiladclitliiii  Inlinnary.  From  iiuniiriis  tiiiiic 
iiiiioiijjf  tlu)  int'dicul  nion  who  priictisc  in  tho  Indian  'IV'rritorics  niiil  in  ih,. 
Indian  schools  in  this  counlry,  I  find  that  the  disi-asc  is  uidxnown  in  tlu' 
nativi^  raci's 

Si'dsoiidl  /ir!(i/ii))is. — Morris. I.  Lewis  lias  analyzed  437  separate  attm  ks 
with  rci'criiice  to  this  i)oint.  T'.iroii<;hont  Docendier,  Januar\',  aiid  IVh- 
riiary  the  cases  inereas.t  Thorp  is  a  fall  in  Ai)ril,  a  rise  tlirou;,di  Miiy  iiini 
.July,  and  then  a  steady  fall  until  OctoiuT.  The  cases  ar(>  most  nuiuenms 
when  the  mean  relative  humidity  and  barometric  pressure  are  low. 

Itlu'umatixm. — A  causal  relationshii)  between  rheunuitisni  and  chorea 
has  been  elai»ned  by  numy  since  the  time  of  ]?ri^dit.  The  Kn^disli  juid 
Freiudi  writers  maintain  the  closi'uess  of  this  connection,  and  Ijoi^cr  "uva 
so  far  as  to  re;far(l  thi'  disease  in  all  cases  as  a  manifestation  of  rheuniiitisrii. 
On  the  other  hand,  (Ji-rman  authors,  as  a  rule,  rejrard  the  connection  us  liv 
no  means  very  close.  Discrepancy  sucli  as  exists  between  the  tij^nircs  df 
Steiner,  who  fouiul  only  4  cases  of  acute  rheumatism  in  'i.'yl  cii.-^fs  nf 
chorea,  and  Knirlish  writers,  s.ic'-  as  Dickenson,  Harlow,  and  others,  who 
place  the  percenta,.5e  at  from  iiliV  lo  seventy  of  the  eases,  can  oiilv  i)e  ex- 
j)laincd  on  the  supposition  tha .  the  oonnoetion  varies  greatly  in  dilTeroiit 
localities.  Of  bbi  cases  which  1  have  analyzed,  in  15-")  per  cent  there  wii.-, 
a  history  of  rheumatism  in  the  family.  In  SS  cases,  l.">•^!  per  cent,  there 
was  a  history  oi;  a/tieular  swelliuijf,  acute  or  sul)acute.  Jn  ;3I5  cases  there 
were  pains,  sojnetimes  descril)ecl  as  rheumatic,  in  various  parts,  but  not 
associated  with  joint  trouble.  If  wo  reganl  all  such  cases  as  rheuinutic 
and  add  them  to  those  with  manifest  articular  trouble,  tho  percentage  is 
raised  to  nearly  twenty-one. 

We  find  two  groups  of  cases  in  which  acute  arthritis  is  jjreseiit  in 
chorea.  In  one,  the  arthritis  antedates  by  some  months  or  years  the  onset 
of  the  chorea,  and  does  not  recur  befoi'o  or  during  tho  attack.  In  tho 
other  group,  tho  chorea  sots  in  with  or  follows  immediately  u|ioii  the 
acute  arthritis.  In  some  instances  it  is  impossible  to  decide  whether 
the  joint  trouble  or  tho  movements  come  first.  It  is  diHicult  to  dillVren- 
tiate  the  cases  of  irregular  pains  without  definite  joint  alTeetioii.  It  is 
probable  that  many  of  theni  are  rheumatic,  and  yet  I  think  it  would 
1)0  a  mistake  to  regard  as  such  all  cases  in  children  in  which  there  are 
complaints  of  vague  pains  in  the  bones  or  muscles — so-called  growing 
pains.  It  should  never  bo  forgotten,  hoAvevor,  that  a  slight  articular  swell- 
ing may  be  the  sole  manifestation  of  rheumatism  in  a  child — so  slight  in- 
deed, that  the  disease  may  bo  entirely  overlooked.  The  statistics  of  tho 
Colle(!ti\e  Investigation  Comniittoo  of  the  British  Medical  Assoriation, 
based  u})on  439  cases,  give  twenty-six  per  cent  of  antecedent  joint  aiTec- 
tion,  and  if  the  cases  of  vague  pains  believed  to  be  rheumatic  are  added,, 
the  i^erceutage  is  raised  to  thirty-two.     In  this  country  rheumatinn  is  uot^ 


S  I  I' 

•"■;■ 

in()> 

(■;l.-,' 

inlla 

thi'Si 

thcv 

and 

iia\t' 


wniwiiiii'' 


ACUTE  CIIORKA. 


931 


rsciit  in 
lu'  (inset 
In  the 
|i(tn  the 
whflhor 
(lilTtTon- 
n.    It  is 
it  would 
licvc  live 
(.■rtiwins,' 
ar  swcll- 
iiiiil  in- 
is  (if  the 
lociation, 
il  alTec- 
■  adili'il, : 
m  in  not 


8,1  common  in  chiUlivn  l.^  in  Kn,!.':liui(l.  Of  tlio  last  144  nisos  of  tlio  Iiifirni- 
arv  aurios,  almost  cvciy  ono  of  \vlii<'ii  1  saw  iK-rsDnally,  and  in  wiiidi  tlio 
nio-it  mitiuto  inquiries  witc  made  about  rhoumutism,  tlicro  were  only  Si5 
cases  with  articular  ]tains  or  swtllin^',  and  in  only  0  had  tiioro  boon  ucuto 
inll.mimatoi'y  rlioumatisin.  Tlio  (juoslion  may  reasonably  bo  askod,  Do 
tlu'so  articular  aH'ootions  of  chorea  belong  to  triio  rlioumatisin?  Aro 
tlioy  not  analogous  to  tho  joint  troubU's  of  scarlet  fovor,  puorpei'al  fovor, 
and  j^onorrluta,  which  no  (jiio  now  ro;^ard.s  as  truly  rheumatic?  They 
have  boon  sj)okon  of  by  French  writers  as  choreic  arthropathies. 

Ilcarl-discase. — Jhidocarditis  is  believed  by  some  writers  to  bo  tho 
ciuiso  of  the  disease.  Tho  jiarticles  of  libriii  and  vegetations  from  tho 
valves  puss  as  emboli  to  tho  cerebral  vessels.  On  this  view,  which  wo  shall 
discuss  later,  chorea  is  the  result  of  an  embolic  {trocess  occurring  in  tho 
eonrso  of  a  rlioiunatic  endocarditis. 

hifir/ioiis  /}isp(tw.'<. — Scarlet  fever  with  arthritic  manit  tations  may 
be  a  direct  antecedent.  It  may  be  mentioned  that  a  history  <>i  this  disoa.so 
(iceiirrod  in  141  cases,  or  about  twenty-fivo  per  cent.  Sturges  states  that  u 
history  of  previous  whooping-cough  occurs  more  fre(p,  .'I'tly  in  choreic  than 
ill  i;tlier  children,  but  I  (ind  no  evidence  of  this  in  the  Intirmary  records. 
With  tho  v\  c"  ti)n  of  rheumatic  fever,  there  is  no  intimate  relationship 
between  chorea  and  the  acute  diseases  incident  to  childhood.  It  may  bo 
noted  ill  contra.st  to  this  that  the  so-called  canine  chorea  is  a  common 
seiiuel  of  distemper.  Chorea  has  been  known  to  develop  in  the  course  of 
an  atuitc  pyaemia,  and  to  follow  gonorrluea  and  puerperal  fovor. 

Kiunicutt  and  others  have  reported  cases  of  chorea  in  malarial  fevers, 
but  the  association  was  probably  accidental,  not  causal.  Aiuomia  is  less 
often  an  antecedent  than  a  sequence  of  chorea,  and  though  cases  develop 
ill  children  who  are  ana'mic  and  in  poor  health,  this  is  by  no  nv.  ana  tho 
rule.     Chorea  may  develop  in  chlorotic  gl/ls  at  iiuberty. 

rrcfjnanci/. — Chorea  may  occur  during  pregnancy — most  often  during 
the  first  five  months.  It  is  more  common  in  a  first  pregnancy,  and  is  rare 
in  women  over  twenty-five  years  of  age.  The  disease  is  usually  severe  and 
maniacal  symptoms  may  develop.  Occasionally  it  comes  on  after  an  abor- 
tion or  after  delivery  at  term. 

A  tendency  to  tho  disease  is  found  in  certain  families.  In  eighty  cases 
there  was  a  history  of  attacks  of  chorea  in  other  members.  In  ono  instance 
both  mother  and  grandmother  had  been  afTected.  Iligli-strung,  excitable, 
nervous  children  aro  specially  liable  to  the  disease.  Fru/Jit  is  considered 
a  frequent  cause,  but  in  a  largo  majority  of  the  cases  no  close  connection 
exists  between  the  fright  and  tho  onset  of  the  disease.  Occasionally  the 
attack  sets  in  at  once.  Mental  worry,  trouble,  a  sudden  grief,  or  a  scold- 
ing may  apparently  be  the  exciting  cause.  The  strain  of  education,  par- 
tieularly  in  girls  during  tho  third  hcmidecade,  is  a  most  important  fac- 
tor in  the  etiology  of  tho  disease.  Bright,  intelligent,  active-minded 
girls  from  ten  to  fourteen,  ambitious  to  do  well  at  school,  ofton  stimulated 
09 


i   d  !li 


M\ 


im 


932 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


in  thoir  efforts  by  teachers  and  parents,  form  a  large  contingent  of  iho 
cases  of  cliorea  in  hospitivl  and  private  practice.  Stnrges  lias  called 
special  attenti'-i  to  this  school-mndc  chorea  as  one  serious  evil  in  our 
modern  method  of  forced  education.  Imilntion,  which  is  nicntionrd  sis 
an  exciting  cause,  is  extremely  rare,  and  does  not  appear  to  have  i-illu- 
enced  the  onset  in  a  single  case  in  the  Infirmary  records. 

'V\\o  disease  may  rapidly  follow  an  injury  or  a  slight  surgical  opciu- 
tion.  lleflex  irritation  was  believed  to  play  an  important  rule  in  the  di.s. 
ease,  particularly  the  presence  of  Avorms  or  genital  irritation;  l)ut  I  have 
met  with  no  instance  in  Avhich  the  disease  could  be  attributed  to  either  of 
these  causes.  Local  spasm,  particularly  of  the  face — the  habit  chorea  of 
Mitchell — may  be  associated  with  irritation  in  the  nostrils  and  adenoid 
growths  in  the  vaidt  of  the  ])harynx,  as  pointed  out  by  Jacolji. 

It  has  been  claimed  by  Stevens  that  ocular  defects  lie  at  the  basis  of 
many  cases  of  chorea,  and  that  with  the  correction  of  these  the  irregular 
movements  disappear.  To  test  the  truth  of  these  statements  a  carefuj 
study  was  made  at  the  Inflrmary  by  De  Schweinitz  of  the  condition  of  tiie 
eyes  in  50  cases  of  chorea  in  children,  with  t!ie  following  results:  Jlvper- 
metropia  was  present  in  'i'A,  or  forty-six  per  cent ;  hypermetropia  in  one 
eye  and  hypermetropic  astigmatism  in  the  other  in  7,  or  fourteen  i)or  cent ; 
hypcrmetro]»ic  astigmatism  in  1'^,  or  twenty-four  per  cent;  myopia  in  1, 
or  two  percent;  mj-opic  astigmatism  in  3,  or  six  per  cent;  mixed  astig- 
matism in  4,  or  eight  per  cent.  De  Schweinitz  then  adds  the  oases  re- 
ported by  Stevens  and  C.  S.  Bull,  of  New  York,  making  a  total  of  -IV! 
cases,  of  which  112  Avere  ametropic  and  Ho  emmetropic,  llis  conclusions 
are  as  follows  :  "  Ilyiiermetropia  and  hypermetroi)ic  astigmatism  are  va«tlv 
the  preponderating  condition  in  the  eyes  of  choreic  children,  being  found 
in  about  seventy-seven  per  cent  of  the  cases,  exactly  as  hyj)ermetropic  re- 
fraction is  the  preponderating  condition  in  childhood,  being  found  in 
seventy-six  percent  of  tlic  eyes  of  children  in  the  elementary  schools,"  and 
the  "  evidence,  however,  seems  quite  as  lacking  that  hypermetropic!  refrac- 
tion is  the  basal  cause  of  chorea,  as  it  is  that  the  chorea  is  the  cause  of  the 
liypermetropia." 

The  committee  of  the  Xmv  York  Xeurological  Society  which  investi- 
gated with  great  care  and  impartiality  Stjvens's  claims  came  to  the  ((in- 
clusion that  the  facts  did  Jiot  warrant  their  adoption. 

Morbid  Anatomy  and  Pathology.— No  constant  lesions  have 
been  found  in  the  nervous  system  in  acute  chorea.  Vascular  changes, 
such  as  hyaline  transformation,  exudation  of  leucocytes,  minute  liaMuor- 
rhages,  and  throml)osis  of  the  smaller  arteries,  have  been  descrilxd. 

Embolism  of  the  smaller  cerebral  vessels  has  often  been  found,  us 
might  be  expected  in  a  disease  with  Avhich  endocarditis  is  so  frequently  as- 
sociated. Based  npon  this  fact,  Kirkes,  Tuckwell,  Ilughlings  Jackson, 
and  Bastian  have  supported  Avhat  is  known  as  the  embolic  theory  of  the 
disease.     Endocarditis  is  by  far  the  most  frequent  lesion  in  Sydenham's 


iS,"  ilUll 

n'frai'- 

(,r  til.; 


m. 


ACUTE  CHOREA. 


933 


chorea.  With  no  disease,  not  excepting  rlieumatism,  is  it  so  constantly 
iissoeiated.  In  the  records  of  over  110  autopsies,  in  noarl\'  100  tliis  condi- 
ti(in  was  mentioned.  In  the  5  autopsies  of  which  I  liave  notes,  in  all  the 
mitral  valves  were  affected.  The  endocarditis  is  usually  of  the  simple 
variety,  but  the  ulcerative  form  has  occasionally  been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with 
cliorea.  Unforainately,  the  word  has  been  used  to  cover  a  series  of  totally 
diverse  disorders  of  movement,  so  that  there  are  still  excellent  observers 
who  hold  that  chorea  is  only  a  symptom,  and  is  not  to  be  regarded  as  an 
etiological  unit.  The  chorea  of  childhood,  the  disease  w  hich  Sydenham 
described,  presents,  however,  characteristics  so  unmistakable  that  it  must 
be  regarded  as  a  definite,  substantive  affection.  We  cannot  discuss  fully, 
hut  only  indicate  briefly,  certain  of  the  theories  Avhich  have  been  ulvanced 
with  regard  to  it.  The  most  generally  accepted  view  is  that  it  is  a  func- 
tional brain  disorder  affecting  the  nerve-centres  controlling  the  motor 
apparatus,  an  instability  of  the  nerve-cells,  brought  about,  one  supposes  by 
hypera^mia,  another  by  anremia,  a  third  by  psychical  influences,  a  fourth 
l)y  irritation,  centric  or  peripheric.  Of  the  actual  nature  of  this  derange- 
ment we  know  nothing,  nor,  indeed,  whether  the  changes  are  prin.ary  and 
the  result  of  a  f;  dty  action  of  the  cc'tical  cells  or  whether  the  impulses 
are  secondarily  disturbed  in  their  cour;-e  down  thu  motor  path.  The  pre- 
dominance of  the  disease  in  females,  and  its  onset  at  a  time  when  the 
education  of  the  brain  is  rapidly  developing,  are  etiological  facts  which 
Sturges  has  urged  in  favor  of  the  view  that  chorea  is  an  expression  of 
functional  instability  of  the  nerve-centres. 

The  embolic  theory  originally  advanced  by  Kirkes  and  supported  by 
the  English  writers  above  mentioned  has  a  solid  basis  of  fact,  but  it  is 
not  comprehensive  enough,  as  all  of  the  cases  cannot  be  brought  within  its 
limits.  There  are  instances  without  endocarditis  and  without,  so  far  as 
can  be  ascertained,  plugging  of  cerebral  vessels;  and  there  are  also  cases 
with  extensive  endocarditis  in  which  the  histological  examination  of  the 
brain,  so  far  as  embolism  is  concerned,  Avas  negative.  In  two  of  my  post- 
mortems there  were  certainly  no  emboli  in  the  ..dler  arteries  of  the 
branches  of  the  circle  of  Willis  or  of  the  cortex.  In  the  third  there  was 
a  sj)ot  in  one  corpus  striatum  of  red  softening,  probably  due  to  an  emboUis. 
In  favor  of  the  embolic  view  is  the  experimental  production  in  animals  of 
chorea  by  Rose'ithal,  and  later  by  Money,  by  injecting  fine  particles  into 
the  carotids  of  animals. 

Lately,  as  indeed  might  be  expected,  a  microbic  origin  has  been  sought 
for,  and,  however  improbable  such  a  theory  looks  at  first  sight,  the  case 
of  tetanus  gives  a  warrant,  at  least,  to  speculation  and  investigation  in 
this  direction.  Nothing  definite  has  yet  been  determined.  From  Nau- 
nyn's  clinic  a  case  is  reported  Avith  endocarditis  and  a  reddish-lirown 
infiltration  of  the  pia  at  the  base  of  the  brain  which  proved  to  be  a  micro- 
bic growth  similar  in  character  to  those  in  the  vegetations  ou  the  liear*' 


^19 

1 

,m 

1 

lii-  M 

1 

'-   mm 

Mm 


m  '  iil 


934 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


valves.  Recently,  in  a  fatal  case  in  my  wards  cultures  of  a  micrococcus 
were  obtained  from  the  blood  of  the  heart,  and  throughout  the  brain  thuio 
were  minute  foci  of  haemorrhage  similar  to  those  which  occur  in  jimii- 
monia  and  other  infectious  disease  associated  with  endocarditis.  In  favor 
of  this  view  it  has  been  urged,  as  it  is  imijossible  to  refer  tlio  chorea  to 
endocarditis  or  the  endocarditis  in  all  cases  to  rheumatism,  that  botli  have 
their  origin  in  a  common  cause,  some  infectious  agent,  which  is  capable 
also,  in  persons  predisposed,  of  exciting  artici;lar  disease.  Cases  have  been 
reported  in  scarlet  fever  with  arthritic  manifestations,  in  puerperal  fevc-r, 
and  rheumatism,  also  after  gonorrha^a,  and  such  facts  are  suggestive  at 
least  of  the  association  of  the  disease  with  infective  processes.  Possibly, 
as  has  been  suggested  by  some  writers,  the  paralytic  conditions  assoeiateii 
with  chorea  may  be  analogous  to  those  which  occur  in  typhoid  and  certain 
of  the  infectious  diseases.  On  the  other  hand,  there  are  conditions  I'x- 
tremely  difiicult  to  harmonize  with  this  view.  The  prominent  psychical 
element  is  certainly  one  of  the  most  serious  objections,  since  there  can  ixi 
no  doubt  that  ordinary  chorea  may  rapidly  follow  a  fright  or  a  sudden 
emotion.  It  cannot  be  supposed,  too,  that  the  forms  associated  with  rellex 
irritation,  as  from  the  nose  and  particularly  the  cases  of  so-callod  hal)it 
chorea,  can  be  dependent  upon  infection.  We  must  place  these  in  a  sepa- 
rate category,  and  yet  in  a  long  series  cases  shade  so  impcrceptil)ly  into 
each  other  that  it  is  extremely  dillicnlt  to  separate  them  properly.  TIk; 
question  deserves  careful  study,  and  the  possibility  of  a  special  infectious 
agent  has  of  late  been  advocated  by  several  writers. 

Symptoms. — Three  groups  of  cases  may  bo  recognized — the  mild, 
severe,  and  maniacal  chorea. 

Mild  Chorea. — In  this  the  afTection  of  the  muscles  is  slight,  the  speech 
is  not  seriously  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tory symptoms  are  shown  in  restlessness  and  inability  to  sit  still,  a  condi- 
tion well  characterized  by  the  term  "  fidgets."  There  are  emotional  dis- 
turbances, such  as  crying  spells,  or  sometimes  night-terrors.  There  may 
be  pains  in  the  limbs  and  headache.  Digestive  disturbances  and  aiKvniia 
may  be  present.  A  change  in  the  temperament  is  frequently  noticed, 
and  a  docile,  quiet  child  may  become  cross  and  irritable.  After  these 
symptoms  have  persisted  for  a  week  or  more  the  characteristic  involun- 
tary niu. -omen  ts  begin,  and  are  often  first  noticed  at  the  table,  when  the 
child  spills  a  tumbler  of  water  or  upsets  a  plate.  There  may  be  only  awk- 
wardness or  slight  incoordination  of  voluntary  movements,  or  constant  irrejf- 
ular  clonic  spasms.  The  jerky,  irregular  character  of  the  movements  diirer- 
entiates  them  from  ahnost  every  other  disorder  of  motion.  In  the  mild 
cases  only  one  hand,  or  the  hand  and  face,  are  alTeotod,  and  it  niiiy  not 
spread  to  the  other  side. 

In  the  second  grade,  the  severe  formal  the  movements  become  general 
and  the  patient  may  be  unable  to  get  about  or  to  feed  or  undress  herself, 
owing  to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle 


ACUTE  CHOREA. 


93S 


i^     I 


groups.  Tlie  speecli  is  also  affected,  and  for  days  the  child  may  not  be  able 
to  talk.  Often  with  the  onset  of  the  severer  symptoms  there  is  loss  of 
power  on  one  side  or  in  the  limb  most  affected. 

The  third  and  most  extreme  form,  the  so-called  maniacal  chorea,  or 
chorea  inmiiicns,  is  truly  a  terrible  disease,  and  may  develop  out  of  the 
ordinary  form.  A  young  girl,  aged  eighteen,  was  admitted  to  the  ^lont- 
real  Hospital  October  17.  She  was  a  waitress  at  a  hotel,  and  being  badly 
frightened  by  two  men  who  were  fighting,  she  dropped  a  tray  of  dishes 
which  she  was  carrying.  A  severe  reprimand  increased  her  worry  and 
trouble.  The  next  day  she  packed  her  trunk  and  went  home,  a  distance 
of  thirty  miles.  Her  father  insisted  that  she  should  return.  At  this 
time  her  hands  and  arms  began  to  twitch  in  a  violent  manner.  Five 
(hiys  after  tlie  first  fright  she  was  admitted.  The  arms  and  legs  were  in 
constant  motion,  jerking  in  all  directions.  Tlie  face  also  was  affc^cted. 
She  was  rational,  but  could  scarcely  speak.  On  the  night  of  the  19th  she 
had  no  sleep,  but  raved  and  talked  all  the  time,  and  the  movements  were 
incessant.  On  the  20th,  21st,  and  22d  the  condition  persisted  and  grew 
worse.  The  temperature  ranged  from  101°  to  103°,  the  tongue  became 
dry  and  cracked,  and  she  became  much  exhausted.  On  the  night  of  the 
2:ld  the  temperature  rose  to  105°  and  death  tollowed,  ten  days  after  the 
onset  of  the  symptoms.  These  cases  are  more  common  in  adult  womer 
and  may  develop  during  pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face, 
and  subsecpiently  the  legs.  The  movements  may  be  confined  to  one  side 
— hemichorea.  The  attack  begins  oftenest  on  tlio  right  side,  though  oc- 
casionally it  is  general  from  the  outset.  One  arm  and  the  opposite  leg 
may  be  involved.  In  nearly  one  fourth  of  the  cases  speech  is  affected ; 
when  slight  this  is  only  an  embarrassment  or  hesitancy,  but  in  other  in- 
stances it  becomes  an  incoherent  jumble.  In  very  severe  cases  the  child 
will  make  no  attempt  to  speak.  The  inability  is  in  articulation  ratlier 
than  in  phonation.  Tlie  lips  and  tongue  arr,  concerned  in  the  defect. 
Occasionally  tlie  inspiratory  muscles  arc  involved,  even  when  the  speech  is 
not  at  all  affected,  and  sobbing  and  sighing  may  result.  Paroxysms  of 
panting  and  of  hard  expiration  may  occur,  or  odd  sounds  may  be  pro- 
duced.    As  a  rule  the  movements  (!ease  during  sleep. 

A  prominent  symptom  is  muscular  weakness,  usually  no  more  than  a  con- 
dition of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may  be  shown 
hyan  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limping.  In  liis  original 
account  Sydenham  refers  to  tlie  "unsteady  movements  of  one  of  the  legs, 
which  the  patient  drags."  There  may  be  extreme  paresis  with  but  few 
movements — the  paralytic  chorea  of  Todd.  Occasionally  a  local  })aralysi3 
or  weakness  remains  after  the  attack,  (,'asc  229  of  the  Infirmary  series,  a 
lad  of  ten,  had  severe  general  chorea  in  September,  1880,  with  considcra- 
hlo  loss  of  power  in  the  legs.  Ilecovery  was  alow,  and  when  he  returned 
iu  September,  1883,  in  a  second  attack  of  chorea,  there  was  talipes  of  the 


If      ^1' 


I 


iS  -j 


h'    ■  k 


I'll   1 


036 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


left  foot,  which  liad  resulted  from  paralysis  iu  1880.  In  Case  21a  wrist- 
drop persisted  for  two  years,  the  result  of  a  palsy  which  came  ou  with 
chorea.     These  are  probably  instances  (»f  i)eri})heral  neuritis. 

A  question  of  some  interest  is  whetlier  choreic  spasms  extend  to  the 
muscles  of  organic  life.  The  great  gastro-intestiual  muscle  is  n(,'\or 
affected.  There  are  no  symi^toms  Avhich  can  be  referred  to  anoiiialniis 
contra(;tions  of  the  stomach  or  bowels.  The  sphincters  act  iu)rnuiliv. 
Incontinence  of  urine  occurs  occasionally,  but  it  is  )iot  noted  more  fre- 
quently, I  think,  in  chorea  than  in  other  nervous  affections.  Spasm  of 
the  bronchial  muscles  is  not  found  even  in  severe  cases,  in  which  the 
respiratory  muscles  are  involved.  The  pupils  are  usually  dilated,  hut  no 
irregular  contractions  occur.  'JMie  rapid  action  and  disturbed  rhylhiu  of 
the  heart  present  nothing  peculiar  to  the  disease,  and  there  is  no  support 
for  the  view  that  irregular  contractions  occur  in  the  papillary  muscles. 

Heart  Symptoms. — Xeurotic. — As  so  many  of  the  subjects  of  clioica 
are  nervous  girls,  it  is  not  sur})rising  that  a  common  symptom  is  rapidly 
acting  heart.  vVny  emotional  disturbance  causes  at  ojice  a  nuirked  in- 
crease in  the  number  of  the  beats,  and  the  actions  may  become  irregular 
and  tumultuous.  Irregularity,  however,  is  not  so  special  a  feature  iu 
chorea  as  rapidity.  The  })atients  seldom  complain  of  pain  about  the 
heart. 

Ilmmic  Murmurs. — AVith  anaiinia  and  debility,  not  uncommon  asso- 
ciates of  chorea  In  the  third  and  fourth  week,  we  lind  a  corresponding 
cardiac  condition.  The  impulse  is  diffuse,  perhaps  wavy  in  thin  children. 
The  carotids  throb  visibly,  aiul  in  the  recumbent  posture  there  may  he 
pulsation  in  the  cervical  veins.  On  auscultation  a  systolic  murmur  is 
heard  at  the  base,  i)erhaps,  too,  at  the  apex,"  soft  and  blowing  in  quality. 

Endocarditis. — As  in  rheumatism,  so  in  chorea,  acute  valvulitis  rarely 
gives  evidence  of  its  presence  by  symptoms.  It  must  be  sought,  and  clin- 
ical experience  has  shown  that  it  is  usually  associated  with  murmurs  at 
one  or  other  of  the  cardiac  orifices. 

For  the  guidance  of  the  practitioner  the  following  statements  may  bo 
made  : 

(1)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality  is  ex- 
tremely common  at  the  base,  ])articularly  at  the  second  left  costal  carti- 
lage, and  is  probably  of  no  moment. 

(2)  A  systolic  murmur  of  maximum  intensity  at  the  apex,  aiul  heard 
also  along  the  left  sternal  margin,  is  not  uncommon  in  anajmic,  enfeuhlod 
states,  and  does  not  necessarily  indicate  either  endocarditis  or  insiitH- 
ciency. 

(.'^'  A  murmur  of  maximum  intensity  at  apex,  with  rough  quality,  and 
trans...itted  to  axilla  or  angle  of  scapula,  indicates  an  organic  lesion  i  f 
the  mitral  valve,  and  is  usually  associated  with  signs  of  enlargement  of  tlio 
heart, 

(4)  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  oyo 


iiP 


ACUTE  CHOREA. 


937 


ami  liaiid  than  to  iV'it  of  tlio  car.  If  the  apex  beat  is  in  the  normal  posi- 
t'.Kii,  and  tho  area  of  dulnoss  not  iueroased  vertically  or  to  the  right  of  tlie 
strrnuin,  there  is  probably  no  serious  valvular  disease. 

(."))  Tlio  endocarditis  of  chorea  is  almost  invar" ably  of  the  simiilc  or 
warty  form,  and  in  itself  is  not  dangerous;  but  it  is  apt  to  lead  to  those 
s  li'rotic  changes  in  the  valve  which  produce  incompetency.  Of  1 10  choreic 
liatieats*  examined  more  than  two  years  after  the  attack,  Tj-i  jjresented 
signs  of  organic  heart-disease. 

(0)  Pt'ricarditis  is  an  oceasiojuil  complication  of  chorea,  usually  in 
Ciisos  with  well-marked  rheumatism. 

Sensori/  Disturbances. — Pain  in  the  affected  limbs  is  not  common. 
Oci'asionally  there  is  soreness  on  pressure.  There  are  cases,  usually  of 
hi'inichorea,  in  which  pain  in  tho  limbs  is  a  marked  symptom.  Weir 
Mitchell  has  spoken  of  these  as  ;)r?/'^//'»/ r//oref/.s.  The  pain  may  be  fjuite 
apart  from  any  arthritic  complications.  Tingling  and  pricking  sensations 
;iii(l  numbiiess  are  found  occasionally.  Ana'sthesia  is  very  uncommon, 
Ti'iiilcr  points  along  the  lines  of  emergence  of  the  spinal  nerves  or  along 
tlie  course  of  the  nerves  of  the  limbs  are  rare.  The  French  writers  have 
compared  tliese  to  the  hysterogenic  points  in  hy.steria,  and  have  also  de- 
scribed in  certain  cases  ovarian  tenderness.  Headache  may  be  a  very 
troublesome  symptom. 

rxjjchu'al  (UstiirbancpH  are  common,  though  in  a  majority  of  the  cases 
sli'.dit  ill  degree.  Irritability  of  temper,  marked  wilfulness,  and  emotional 
outbreaks  may  indicate  a  comi)lete  change  in  the  character  of  the  child. 
There  is  deliciency  in  the  powers  of  concentration,  the  memory  is  en- 
l'ool)lod,  and  the  aptitude  for  study  is  lost.  Iiarely  there  is  progressive 
impairment  of  the  intellect  with  termination  in  actual  denuMitia.  Acutt; 
iiivlanc'holia  has  been  described  (Hdes).  Hallucinations  of  sight  and 
hearing  may  occur.  Patients  may  behave  in  an  odd  and  strange  numncr 
luul  do  all  sorts  of  meaningless  acts.  By  far  the  most  serious  manifesta- 
tion of  this  character  is  the  maniacal  delirium,  occasionally  associated  with 
the  very  severe  cases — chorea  inmuiens.  Usually  the  motor  disturbance  in 
tlu'sa  cases  is  aggravated,  but  it  has  been  overlooked  and  jiatients  have 
hoon  sent  to  an  asylum. 

The  psychical  element  in  chorea  is  apt  to  be  neglected  by  the  practi- 
tid!  L.  It  is  always  a  good  plan  to  tell  the  parents  that  it  is  not  the 
muscles  alone  of  the  child  which  are  affected,  but  that  the  geiu>ral  irrita- 
hility  and  change  of  disposition,  so  often  found,  really  form  2)art  of  tho 
disease. 

Tho  condition  of  the  reflexes  in  chorea  is  usually  normal.  Sinkler 
made  observations  at  the  Philadelphia  Infirmary  in  50  cases  with  the  fol- 
lowing results:  In  20  the  knee-jerk  was  normal,  in  15  it  was  diminished 
ill  degree,  and  in  9  it  could  not  be  obtained.     Trophic  lesions  rarely  occur 

*  American  Journal  of  the  Medical  Sciences,  1887,  IL 


I 


k: 


i- 
j 


'11 


I'    ! 


938 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


in  chorea  unless,  as  some  writers  have  done,  we  regard  the  joint  trouLlos 
as  arthropathies  oecurring  in  the  course  of  a  cerel)ro-spinal  disoaso. 

Ferer  is  not,  as  a  rule,  present  in  chorea  unless  eoinplicatious  exist. 
There  may  be  the  most  intense  and  violent  movements  without  aiiv  rise 
of  temperature.  I  have  scon  instances,  however,  in  which  without  ii|)p!u-- 
cntly  any  visceral  or  articular  disturbances  thei'o  was  slight  daily  fever. 
II.  A.  Hare  states  that  in  monochorea  the  temperature  on  the  alTeeted 
side  may  be  elevated;  but  this  is  not  an  invariable  rule.  Fever  is  iouinl 
with  an  acute  arthritis,  when  there  is  marked  endocarditis  or  pericarditis 
though  the  former  may  certainly  occur  with  little  if  any  rise  in  tcmj)era- 
ture,  and  in  the  cases  of  maniacal  choi'ea,  in  which  the  fever  mav  raii^c; 
from  WZ"  to  104^ 

Cutaneoux  Affections. — 'J'hese  are  not  very  numerous,  and  in  a  major- 
ity of  the  cases  are  probably  due  to  arsenic.  There  may  be  an  crythoma- 
tous  papular  rash.  A  very  interesting  condition  is  the  pigmentation 
which  has  been  fouml  in  patients  who  }iave  been  taking  ansonic!  for 
some  time.  Herpes  zoster  occasionally  occurs.  It  was  noted  twice  in 
the  Infirmary  records.  Certain  skin  eruption?),  usually  regarded  as  rheu- 
matic in  character,  are  not  uncommon.  Thus,  erythema  nodosum  ha.s 
been  described  and  I  have  seen  several  cases  with  a  purpuric  urticaria. 
There  may,  indeed,  be  the  nrore  aggravated  condition  of  rheumatic  pur- 
pura, known  as  Schonlein's  poliosis  rheumatica.  Subcutaneous  filjroiis 
nodules,  which  have  been  noted  by  English  observers  in  many  cases  of 
chorea,  associated  with  rheumatism,  are  extremely  rare  in  this  country.  1 
have  not  seen  an  instance  in  a  choreic  patient  nor  is  there  a  reference  in 
the  Infirmary  records  to  a  case.  This  has  not  been  because  they  were 
not  looked  for,  as  I  have  seen  many  instarnjes  since  my  attention  was  called 
to  them  in  1881  by  Barlow  at  the  Great  Ormond  Street  Children's  Hospital. 
They  are  certainly  less  common  in  this  country  than  in  England.  In  the 
chorea  returns  of  the  Collective  Investigation  Committee  there  wee  12 
cases  out  of  439.     Cheadle  states  that  they  are  not  uncommon  in  chorea. 

Duration  and  Termination. — From  eight  to  ten  weeks  is  the 
average  duration  of  an  attack  of  moderate  severity.  Cases  may  be  so  mild 
as  to  get  well  in  two  or  three  weeks ;  on  the  other  hand,  th.ere  may  be 
found  at  every  clinic  for  diseases  of  the  nervous  system  choreic  i)atient.s 
who  have  been  under  treatment  for  three,  four,  or  even  six  montiis. 
Chronic  chorea  rarely  follows  the  minor  disease  which  we  have  been  con- 
sidering. The  cases  described  under  this  designation  in  children  are 
usually  instances  of  cerebral  sclerosis  or  Friedreich's  ataxia;  but  oeea- 
sionally  an  attack  which  has  come  on  in  the  ordinary  way  persists  for 
months  or  years,  and  recovery  ultimately  takes  place.  A  slight  grade  of 
chorea,  particularly  noticeable  under  excitement,  may  persist  for  montlis 
in  nervous  children. 

The  tendency  of  chorea  to  recur  has  been  noticed  by  all  writers  since 
Sydenham  first  made  the  observation.    Of  410  cases  analyzed  for  this  pur- 


ACUTE  CHOREA. 


pose,  240  had  one  uttack,  110  had  two  attacks,  35  three  attacks,  10  four 
attacks,  12  live  attacks,  and  3  six  attacks.  Tlio  rcciirreuco  is  apt  to  be 
vernal.  Rheumatism  seems  to  favor  this  tondenoy  ;  of  (iO  cases  in  whicli 
there  were  tlirce  or  more  attacks,  there  was  a  history  of  articular  disease 
ill  11,  a  much  higher  percentage  than  in  cases  with  only  one  or  two  at- 
taeks.  The  occurrence  of  heart-disease  has  been  thought  to  increase  tliis 
Hiibility,  but  I  tliink  it  i",  tlie  other  way — recurrences  tend  to  induce  endo- 
carditis and  valvular  disease,  (lowers  mentions  a  case  with  nine  recur- 
rences without  history  of  rheumatism  in  which  there  were  signs  of  mitral 
constriction. 

llecovery  is  the  rule  in  children.  The  statistics  of  out-patients'  depart- 
ments are  not  favorable  for  dettM-mining  the  mortality.  A  reliable  esti- 
mate is  that  of  the  Collective  Investigation  Committee  of  the  British 
Medical  Association,  in  which  0  deaths  were  reported  among  439  cases, 
about  two  per  cent. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  a 
time,  but  usually  passes  away ;  permanent  impairment  of  the  mind  is  an 
exceptional  sequence. 

Diagnosis. — There  are  few  diseases  which  present  more  character- 
istic features,  and  in  a  majority  of  instances  tlio  nature  of  the  trouble  is 
recognized  at  a  glance ;  but  there  are  several  affections  in  children  which 
may  simulate  and  be  mistaken  for  it. 

(a)  Multiple  and  diffuse  cerebral  sclerosis.  Cases  such  as  the  follow- 
ing are  often  mistaken  for  ordinary  chorea,  and  have  been  described  in 
literature  as  chorea  spastica  :  Xellio  P.,  aged  nine  years,  when  two  years  old 
had  fits  which  recurred  constantly  for  twenty-one  days  and  persisted  on  and 
oil  with  great  severity  for  nine  months ;  she  never  developed  satisfactorily  ; 
she  learned  to  talk,  but  gradually  began  to  have  irregular  movements.  In 
the  ninth  year  the  condition  was  as  follows:  Speech  hesitating;  is  unable 
to  sit,  stand,  or  feed  herself ;  can  move  every  muscle  of  the  body,  but  in 
an  irregular,  incoordiTiate  way,  which  prevents  her  from  using  any  group 
of  muscles.  In  attempting  to  grasp  an  object  the  fingers  are  thrown  out 
ill  a  stiff,  spasmodic  manner,  and  she  is  unalilo  to  close  them  over  the 
object. 

In  such  cases,  which  are  not  very  uncommon,  there  are  doubtless 
•■hronic  changes  in  the  cortex.  As  a  rule,  the  movements  are  readily  dis- 
tinguishable from  those  of  true  chorea,  but  the  simulation  is  sometimes 
very  close ;  the  onset  in  infancy,  the  impaired  intelligence,  increased  re- 
ilcxes,  and  in  some  instances  rigidity  and  the  chronic  course  of  the  disease, 
separate  them  sharply  from  true  chorea. 

{b)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were 
formerly  classed  as  chorea.  The  slow,  irregular,  incoordinate  movements, 
the  scoliosis,  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the 
family  character  of  the  disease  arc  points  v.'hich  should  render  the  diag- 
nosis easv. 


1 '. 


ill 


HUf  :1 


1....- 

li 

940 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


hi 

if. 

'M' 


?'!''.• 


(r)  In  rare  oiisos  the  purulytic  form  of  chorea  may  he  mistaken  U>r 
polio-myelitis  or,  when  Ijoth  legs  arc  atTe(!te(l,  for  itarai)le<ri;i  of  spinal 
origin  ;  biil  this  can  only  be  the  case  when  the  choreic  movi'nients  are  very 
sliglit.  1  have  at  present  under  my  care  a  young  girl  with  choroa  and 
loss  of  power  in  both  legs,  who  was  sent  to  the  hosi)ital  as  an  instance 
of  2>iii'iiplcgia  due  to  spinal  disease,  but  the  choreic  movements  were  dis- 
tinct though  slight,  anil  a  few  days' observation  suHiced  to  render  eleur  tlie 
nature  of  the  case. 

{(I)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  bo  impossible  to  make  a  diagiu)sis.  Most 
commoidy,  however,  the  movements  in  the  socalled  hysterical  chorea  are 
rhythmic!  and  diller  entirely  from  those  of  ordinary  chorea. 

{(')  As  mentioned  above,  the  mental  symptoms  in  maniacal  chorea  may 
mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to 
the  asylum. 

Treatment. — Abnormally  bright,  active-minded  children  belonging 
to  families  with  })ronounced  neurotic  taint  should  be  carefully  watched 
from  the  ages  of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental 
powers.  8o  frequently  in  children  of  this  chiss  does  the  attack  of  chorea 
date  from  the  worry  and  stress  incident  to  school  examinations  that  tiie 
competition  for  jirizes  or  places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic 
measures,  with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Par- 
ents shou!  1  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic 
children.  The  psychical  element,  strongly  developed  in  so  many  cases, 
is  best  treated  by  quiet  and  seclusion.  The  child  should  be  coniined  to 
bed  in  the  recumbent  posture  and  mental  as  well  as  bodily  quiet  enjoined. 
In  private  practice  this  is  often  impossible,  but  with  well-to-do  patients 
the  disease  is  always  serious  enough  to  demand  the  assistance  of  a  skilled 
nurse.  Toys  and  dolls  should  not  be  allowed  at  first,  for  the  child  should 
be  kept  amused  without  excitement.  The  rest  allays  the  hyper-exeitaltil- 
ity  and  reduces  to  a  minimum  the  possibility  of  daniage  to  the  valve  seg- 
ments should  endocarditis, exist.  Time  and  again  have  I  seen  very  severe 
cases  which  had  resisted  treatment  for  weeks  outside  a  hospital  become  quiet 
and  the  movements  subside  after  two  or  three  days  of  absolute  rest  in  bed. 

The  child  should  be  kept  apart  from  other  children  and,  if  i)()ssil)le, 
from,  other  members  of  the  family,  and  should  see  only  those  persons 
directly  concerned  with  the  nursing  of  the  case.  Though  irksome  and 
troublesome  to  carry  out,  this  is  an  important  part  of  the  treatment.  In 
the  latter  period  of  the  disease  daily  rubbings  may  bo  resorted  to  with 
great  benefit. 

The  medicinal  treatment  of  the  disease  is  unsatisfactory;  with  the 
exception  of  arsenic,  no  remedy  seems  to  have  any  influence  in  con- 
trolling the  progress  of  the  aflfectiou.  "Without  any  specific  action,  it 
certainly  does  good  in  many  cases,  probably  by  improving  the  general 


ACUTE  CHOREA. 


941 


nutrition.  It  is  conveniently  <,nvon  in  the  form  of  Fowler's  .solution,  and 
thc^'ood  ciTc'otsuro  rarely  seen  until  nmxinuini  doses  are  tuki-n.  ("Iiildrcn 
jitaiid  the  drug  so  well  that  I  usually  begin  with  live  minims  three  tinuvs  a 
ihiv,  and  after  three  days  increase  the  dose  by  one  minim  each  day.  AVhon 
the  dose  of  fifteen  nuninis  is  reached,  it  may  be  continued  for  a  week,  and 
tiieu  again  increased,  if  necessary,  every  day  or  two,  until  i)hysiol()gical 
elTects  are  manifest.  On  the  occurrence  of  the.se  the  drug  should  l)e  stoj)ped 
for  three  or  four  days.  The  practice  of  resuming  the  adndnistration  with 
smaller  doses  is  rarely  necessary,  as  tolerance  is  usually  established  and  we 
ciiii  begin  ■with  the  dose  wliich  the  child  was  taking  when  the  symptoms  of 
saturation  occurred.  I  have  fre(juently  given  as  much  as  twenty-live  min- 
ims three  times  a  day.  Usually  the  signs  of  saturation  are  trivial  but  ])lain, 
1111(1  I  have  never  seen  any  ill  effects  from  the  large  dose.s,  but  I  have  heard 
nceiitly  of  a  case  of  ui'senical  neuritis  due  to  the  administration  of  Fowler's 
solution  in  chorea. 

Of  other  medicines,  strychnine,  the  zinc  compounds,  nitrate  of  silver, 
broudde  of  potassium,  belladonna,  chloral,  and  especially  cimicifuga,  have 
been  recommended,  and  may  be  tried  in  obstinate  cases. 

l-'or  its  tonic  effect  electricity  is  sometimes  useful ;  but  it  is  not  neces- 
fiiuy  as  a  routine  treatment.  The  question  of  gymnastics  is  an  important 
one.  Early  in  the  disease,  when  the  movements  are  active,  it  is  not  ad- 
visal)le ;  but  during  convalescence  careftdly  graduated  exercises  are  un- 
doubtedly  beneficial.  It  is  not  well,  however,  to  send  a  choreic  child  to  a 
;<('liool  gymnasium,  as  the  stimulus  of  the  other  children  and  the  excite- 
ment of  the  romjjing,  violent  play  is  very  prejudicial. 

Other  points  in  treatment  may  be  mentioned.  It  is  important  to  regu- 
late the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For 
the  ana?mia  so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  niovements,  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  pur- 
pose chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform 
inhalations  nuiy  be  necessary  to  subdue  the  intensity  of  the  paroxysms, 
but  the  high  rate  of  mortality  in  this  class  of  cases  illustrates  how  often 
our  l)est  endeavors  are  fruitless.  1'he  wet  pack  is  sometimes  very  sooth- 
ing and  should  be  tried.  As  these  patients  are  apt  to  sink  rai)idly  into  a 
low  typhoid  state  with  heart  weakness,  a  su importing  treatment  is  required 
from  the  outset. 

Cases  are  found  now  and  then  which  drag  on  from  month  to  month 
without  gettiiig  either  better  or  worse  and  resist  all  modes  of  treatment. 
Change  of  air  and  scene  is  sometimes  followed  by  rapid  improvement,  and 
ill  these  cases  the  treatment  by  rest  and  seclusion  should  always  be  given  a 
full  trial. 

In  all  cases  care  should  be  taken  to  examine  the  nostrils,  and  glaring 
iicular  defects  should  bo  properly  corrected  either  by  glasses  or,  if  neces- 
sarv,  bj  operation. 


*  I 


»!P'5-  • 


042 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Ut 


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After  the  child  has  /ccoverod  from  tlio  attack,  the  parents  kIiouM  h,. 
warned  that  return  of  tlio  disease  is  by  no  means  infrequert,  ami  is  imr. 
ticularly  liable  to  follow  overwork  at  school  or  debilitatin;^'  inlhieiici's  of 
any  kind.  TIu'sc  rchipses  arc  ai)t  to  occur  in  the  spring,'.  Sydcnliain  ad- 
vised purging  in  order  to  prevent  the  vernal  recurrence  of  the  cU.scasc. 


IV.    OTHER  AFFECTIONS  DESCRIBED  AS  CHOREA. 

(n)  Chorea  Major;  Pandemic  Chorea. — 'IMie  common  name,  St.  VitusV 
dance,  applied  to  chorea  has  come  to  us  from  the  middle  ages,  when 
under  the  influence  of  religious  fervor  there  Avere  ei)idenu(:s  charucli'rizoil 
by  great  excitement,  gesticulations,  and  dancing.  For  the  relief  of  tlicsc 
symptoms,  when  excessive,  pilgrimages  were  made,  and,  in  the  lilu'iijsh 
provinces,  particularly  to  the  Chapel  of  St.  Vitus  in  Zebcrn.  E])i(loiiuc>i 
of  this  sort  have  occurred  also  during  this  century,  and  descriptions  (if 
them  among  the  early  settlers  in  Kentucky  have  been  given  by  lldhcrtsdn 
and  YandcU.  If  was  unfortunate  that  Sydenham  applied  the  term  clioiv.i 
to  an  affection  in  children  totally  distinct  from  this  chorea  major,  wiiich 
aiul  is  in  reality  an  hysterical  manifestation  under  the  influence  of  wl'v^- 
ious  excitement. 

(b)  Habit  Spasm  (Habit  Chorea) ;  Convulsive  Tic  (of  the  French). 

Two  groups  of  cases  nuiy  be  recognized  under  the  designation  of  huliit 
spasm — one  in  Avhich  there  is  simjdy  localized  spasmodic  movements,  ami 
the  otner  in  which,  in  addition  to  this,  there  are  explosive  utterances  and 
psychical  symptoms,  a  condition  to  which  French  writers  have  given  tl.f 
name  tic  ronvvlsif. 

(1)  ][(ilnt  Spasm. — This  is  found  chiefly  in  childhood,  most  frequontly 
in  girls  from  seven  to  fourteen  years  of  age  (Mitchell).  In  its  simplest 
form  there  is  a  sudden,  quick  contractioi]  of  ccrtiiin  of  the  facial  musclos. 
such  as  rajjid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  nock 
muscles  are  involved  and  there  are  unilateral  movements  of  the  head. 
The  head  is  given  a  sudden,  quick  shake,  and  at  the  same  time  the  cyu? 
wink.  A  not  infrequent  form  is  the  shrugging  of  one  shoulder.  The 
grimace  or  movement  is  repeated  at  irregular  intervals,  and  is  nuich  ajiirni- 
vated  by  emotion.  A  short  inspiratory  snilT  is  not  an  uncommon  symp- 
tom. The  eases  are  found  most  frequently  in  children  who  are  "'  out  of 
sorts,"  or  who  have  been  growing  rapidly,  or  who  have  inherited  a  tend- 
ency to  neurotic  disorders.  Allied  to  or  associated  with  this  are  some  of 
the  curious  tricks  of  children.  A  boy  at  myelinic  was  in  the  habit  every 
few  moments  of  putting  the  middle  finger  into  the  mouth,  biting  it.  and 
at  the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  Cole- 
ridge  is  said  to  have  had  a  somewhat  similar  trick,  only  ho  bit  his  arm. 
In  all  these  cases  the  habits  of  the  child  should  be  examined  carefully,  the 
nose  and  vault  of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately 


OTIlKIl   AFl-'KCTIONS   DKSCUIHKD   AS  CHOREA. 


943 


tested.  As  fi  riilt'  tlio  coiidilii)!!  is  transk'iit,  iiixl  after  |)or.sisting  for  u  few 
iiiiiiiths  or  lon^^'or  <,'radiiiilly  disappcarn.  Occasionally  a  local  spusin  persists 
— Iwitchiii;?  of  the  eyelids,  or  the  facia)  griiiuure. 

(•,*)  Tic  Cunvnlsif  {(rillrs  dc  la  Tourettc^s  JJisensc). — This  romarkaldo 
alTection,  often  mistaken  for  chorea,  more  frequently  for  hahit  s[)asni, 
is  really  a  psycliosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it 
hiis  the  features  of  mononumiu.  The  disease  begins,  us  a  rule,  in  young 
children,  occurring  as  early  as  the  sixth  year,  though  it  nuiy  develop  after 
l)ul)erty.  There  is  usually  a  markedly  neurotic  family  history.  The 
special  features  of  the  complaint  are: 

{(i)  Involuntary  muscular  mcjvements,  usually  afTecting  the  facial  or 
l)i'achial  muscles,  but  in  aggravated  cases  all  the  muscles  of  the  body  may 
be  involved  and  the  movements  may  bo  extremely  irregular  and  violent. 

{/))  Kxplosivo  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.  A  word  heard  nuiy  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  echo- 
hlia  has  l)een  appliiMl.  A  much  more  distressing  disturhame  in  these 
eases  is  cnprolaUa,  or  the  use  of  bad  language.  A  child  of  eight  or  ten 
may  shock  its  mother  and  friends  by  constantly  using  the  word  dnmn 
when  nuiking  the  invohuitary  movements,  or  by  uttering  all  sorts  of  ob- 
scene words.     Occasionally  actions  are  mimicked — cchokineais. 

{(•)  Associated  with  some  of  these  cases  arc  curious  mental  disturb- 
anci's ;  the  patient  becomes  the  subject  of  a  form  of  obsessio?i  or  a  iixed 
idea.  I  was  consulted  recently  about  a  young  girl  in  whom  the  s])asnis 
wavQ  very  slight,  amounting  only  to  twitching  of  the  eyes  and  sliglit  jerk- 
ing of  the  shoulder,  but  wlio  had  a  most  pronounced  grade  of  the  fixed  idea 
known  as  nrif/inwmania.  Almost  every  action,  even  the  most  trifling, 
was  preceded  by  the  counting  of  a  certain  number  of  figures,  before  she 
went  to  bed  she  had  to  tap  her  heel  upoi\  the  side  of  the  beilstead  a  cer- 
tain number  of  times;  before  drinking  the  tumbler  had  to  bo  rotated 
eight  or  ten  times,  and  then  when  set  down  again  the  same  act  Avas  re- 
]R'ate(l.  Before  opening  the  door  a  certain  number  of  knocks  had  to  bo 
in'ven.  The  greatest  difficulty  was  experienced  in  getting  her  to  brush 
her  hair,  as  it  took  her  so  long  to  count  the  necessary  number  of  figures 
hefore  she  began.  In  other  cases  the  fixed  idea  takes  the  form  of  the  im- 
\n\Uo.  to  touch  objects.  According  to  Guinon,  who  has  written  an  ex- 
haustive article  upon  it  in  the  Dictionnaire  Enoyclopedique,  the  prognosis 
is  l)ad. 

Tlie  disease  is  well  marked  and  readily  distinguished  from  ordinary 
chorea.  The  movements  have  a  larger  range  and  are  explosive  in  charac- 
ter. Tourette  regards  the  coprolalia  as  the  most  distinctive  feature  of  the 
ilisoase. 

('■)  Saltatoric  Spasm  {Lata;  Mjjriachit ;  Jumpers). — Bamberger  has 
described  a  disease  in  which  when  the  patient  ottempted  to  stand  thero 
were  strong  contractioua  in  the  leg  muscles,  which  caused  a  jumping  or 


1 

1 

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I-:J| 

fif 


Ir 


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044 


DISEASES  OP  THE  NERVOrS  SYSTEM. 


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Hprin^'inp;  motion.  'I'liis  occurs  only  when  tlic  patient  uttoinj)t8  t<i  stutul. 
Tlio  iitTcctioii  liaa  occurred  in  both  men  and  women,  more  fref|ut'ntly  in  the 
foftncr,  and  tlie  subjects  have  usually  whown  niarkeil  neurotic  tendencies. 
In  many  cases  the  condition  has  hecu  transitory;  in  others  it  lins  iier- 
Histed  for  years.  I{euiarkal)le  alTections  similar  to  this  in  certain  |iniiits 
occur  as  II  sort  of  endemic  neurosis.  One  of  tho  most  striking  of  these 
occurs  anion;,'  the  "jumping  FrenclinuMi"  of  Maine  ami  (/anachi.  As  dc- 
scrihed  hy  Heard  and  'I'hornton,  the  subjects  are  liable  on  any  suddei\  cuki- 
tion  to  jump  violently  and  utter  a  loud  cry  or  sound,  and  will  obey  aiiv 
command  or  imitate  any  action  without  regard  to  its  nature.  The  con- 
dition of  ocliolalia  is  present  in  a  nuirked  degree.  The  "  jumpini;  "  [mc- 
vails  iti  certain  families. 

A  very  similar  disease  ])revails  in  parts  of  Russia  and  in  -lava,  where  it  is 
known  by  the  names  of  myriachit  and  lata,  the  chief  feature  of  whicii  i.s 
mimicry  by  tho  patient  of  everything  ho  sees  or  hears. 

{(/)  Chronic  Chorea  {/fini/i>i(/(lon\^  Chorea). — An  atTection  character- 
ized l)y  irregular  movenu;nts,  disturbance  of  speech,  and  gradual  deincntiu. 
It  is  frefjucntly  hereditary.  The  disease  has  no  connection  with  Sydcnluiiu's 
chorea,  and  it  is  unfortunate  that  the  term  was  applied  to  it.  It  was  de- 
scribed by  Huntingdon,  of  I'omcroy,  Ohio,  at  the  time  a  practitioner  on 
l.ong  Island,  and  he  gave  in  three  brief  i)aragraphs  the  salient  points  in 
connection  with  the  disease — nanudy,  the  hereditary  nature,  the  assiniu- 
tion  with  })sychical  troubles,  and  the  late  onset — between  the  thirtietli  itml 
fortieth  years.  The  disease  seems  common  in  this  country,  and  iminy 
cases  have  been  reported  by  Clarence  King,  Sinkler,  and  others.*  I  liiivc 
seen  it  in  two  Maryland  families  within  the  past  two  years.  I'lidcr  the 
term  (dironic  chorea  may  be  grouped  the  hereditary  form  and  the 
cases  which  come  on  without  family  disjiosition,  either  at  middle  life  or, 
more  commonly,  in  the  aged — senile  chorea.  It  is  doubtful  whetlur  iIk; 
cases  in  children  with  chronic  choreiform  juovemcnts,  often  with  nieiital 
weakness  and  spastic  condition  of  the  legs,  should  go  into  this  categnry. 

'I'he  hereditary  (duiracter  of  the  disease  is  very  striking,  and  it  has  hwii 
traced  through  four  or  five  generations.  Huntingdon's  father  and  griuul- 
father,  also  physicians,  had  treated  the  disease  in  the  family  which  he  de- 
scribed. An  identical  affection  occurs  without  any  hereditary  dispo.^itioii. 
The  age  of  onset  is  late,  rarely  before  tlie  thirtieth  or  the  tliirty-lifth  Vfiir. 

The  symptoms  are  very  characteristic.  The  irrcgidar  movements  sire 
usually  first  seen  in  the  hands,  and  the  patient  has  slight  difficulty  in  |ht- 
forming  delicate  manipulations  or  in  writing.  .  When  well  establishnl  the 
movements  arc  disorderly,  irregular,  incoordinate  rather  than  choreic,  luul 
have  not  the  sharp,  brusque  motion  of  Sydenham's  chorea.  In  the  face 
there  are  slow,  involuntary  grinuices.  In  a  well-developed  case  the  put  is 
irregular,  swaving,  and  somewhat  like  that  of  a  drunken  man.    'i'hc  spetrn 


*  For  complete  literature,  see  Huet,  de  la  Choree  Chronique,  Paris,  1889. 


INFANTILK  CONVULSIONS. 


015 


i-;  slon'  and  diniciilt,  the  sylliililcrt  arc  hadly  |irnii(imi('i'(l  ami  iiidistiiict,  hut 
iiiit  di'liiiitcly  staccato.  'I'lic  iriciital  iiiipairriiciit  is  a  ^'radiial  cnfrcltlciiiciit, 
liiidin},'  liiially  to  dcmciitia.     At  lirst  tho  patioit  may  Itc  ciuntiniial. 

N'cry  few  [(ost-iiiortt'ins  liuvc  been  made  No  cliaractcristii!  lesions  have* 
lii'CM  found.  Atrophy  of  tlie  convohitions,  clironic  mcniii;,'o-cni'c|dialitis, 
and  vascuhir  ciian<;es  liuve  usually  hecn  present,  the  conditions  \vlii(di  onu 
\\nn\(l  expect  to  llnd  in  a  chronic  dt'iiientia.  These*  existccl  in  an  autopsy 
wluidi  I  have  on  one;  of  my  cuscs.  The  alToction  is  evidently  u  neuro- 
(Ji'LjcTU'rativo  di.sonler,  and  has  no  conneclion  with  the  simple  tdioreii  of 
childhood. 

(r)  Ehythmic  or  Hysterical  Chorea.— 'I'his  is  readily  recognized  l)y  tho 
rhythmical  character  of  tho  movoments.  It  nuiy  sitTect  tiio  muselea  of  tho 
iilHlomen,  i)roducin<i;  tho  salaam  (;otivulsion,  or  involve  tho  sterno-rnastctid, 
pmdiu'injj  a  rhythmical  movement  of  the  head,  or  the  psoas,  or  any  group 
of  muscles.     In  its  orderly  rhythm  it  resomblcs  tho  eaniiio  chorea. 


I' 


i 


', '■!•"/'  ' 


V.  INFANTILE   CONVULSIONS  (Erhmjmu). 

Convulsive  seizures  similar  to  those  of  ojiilopsy  are  not  infrequent  in 
cliildron  ami  in  adults.  Tho  fit  may  indoud  be  identical  with  epilepsy, 
fidiii  which  tho  condition  ditfors  in  that  when  tho  cause  is  removed  there 
is  no  tenden(;y  for  tho  fits  to  recur.  OccasioiuiUy,  however,  the  convul- 
sions in  children  continue  and  develop  into  true  e2)ilcpsy. 

Etiology. — A  convulsion  in  a  child  may  l)o  duo  to  many  causes,  all 
of  which  loail  to  an  unstable  condition  of  the  nervc-contros,  permitting  of 
sudden,  excessive  and  temporary  nervous  discharges.  The  following  are 
the  most  important  of  them  : 

(1)  Debility,  resulting  usually  from  gastro-intestinal  disturbance.  Con- 
vulsions frequently  sui)ervene  toward  the  close  of  an  attack  of  entero- 
colitis and  recur,  sometimes  ])roving  fatal.  Morris  J.  fiowis  has  shown 
tliiit  the  death  rate  in  children  from  eclampsia  rises  steadily  with  that  of 
gastro-intestinal  disorders. 

(3)  Peripheral  irritation.  Dentition  alone  Is  rarely  a  cause  of  convul- 
sions, but  is  often  one  of  several  factors  in  a  feeble,  unhealthy  infant. 
The  greatest  mortality  from  convulsions  is  during  the  first  six  months,  be- 
fore the  teeth  really  cut  through  tho  gums.  Other  irritative  canst  .■  are 
tiio  overloading  of  the  stomach  with  indigestil)le  food.  It  has  l)eon  sug- 
gested that  some  of  those  ca.ses  are  toxic,  oAving  to  the  absorption  of  poi- 
sonous ptomaines.  Worms,  to  whitdi  convulsions  are  so  frequently  attrib- 
uted, probably  have  little  influence.  Among  other  sources  possible  are 
phimosis  and  otitis. 

(;5)  Rickets.  Tho  observation  of  Sir  William  Jenner  upon  the  associa- 
tion of  rickets  and  convulsions  has  been  amply  confirmed.  The  spasms 
may  be  laryngeal,  the  so-called  child-crowing,  which,  though  convulsive  in 


1 


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94G 


DISEASES  OP  TUE  NERVOUS  SYSTEM. 


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M: 


nature,  can  scarcely  be  considered  witli  eclampsia.  The  influence  of  this 
condition  is  more  apparent  in  Europe  than  in  this  country,  altiiougli 
rickets  is  a  common  disease,  particularly  among  the  colored  peoj)le. 
Spasms,  local  or  general,  in  rickets  are  ])robably  associated  with  tlie  con- 
dition of  debility  and  malnutrition  and  with  crunio-tubcs. 

(4)  Fever.  In  young  children  the  onset  of  the  infectious  diseases  is 
frcfpiently  with  convulsions,  which  often  take  the  place  of  a  chill  in  the 
adult.  It  is  not  known  upon  what  they  depend.  Scarlet  fever,  ineasles, 
and  pneumonia  are  most  often  preceded  by  convulsions. 

(5)  Congestion  of  the  brain.  1'liat  extreme  engorgement  of  the  blood- 
vessels may  produce  convulsions  is  shown  by  their  occasional  occurreiieo 
ill  severe  whooping-cough,  but  their  rarity  in  this  disease  really  indi- 
cates how  small  a  i)art  mechanical  congestion  plays  in  the  produclioii 
of  fits. 

((>)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.  In  more  than  iifty  per  cent  of 
the  cases  of  infantile  hemi})legia  the  affection  follows  severe  convulsions. 
'I'hey  less  frequently  precctle  a  spinal  paralysis.  They  occur  Mitli  menin- 
gitis, tuberculous  or  sim])le,  and  with  tumors  and  other  lesions  of  the 
brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  per- 
sist for  weeks  or  months.  In  such  instances  there  has  probably  been 
meningeal  lutmorrhagc  or  serious  injury  to  the  cortex. 

The  most  important  question  is  the  relation  of  convulsions  in  children 
to  true  ejnlepsy.  In  Cowers's  figures  of  1,450  cases  of  epilepsy,  the  attacks 
began  in  180  during  the  first  three  years  of  life.  Of  4G0  cases  of  epilepsy 
in  children  which  I  have  aiudyzed,  in  lS'7  the  fits  began  within  the  iirst 
three  years.  Of  the  total  list  the  greatest  number,  74,  A\as  in  the  first 
year.  In  nearly  all  these  instances  there  was  no  interruption  in  the  con- 
vulsions. That  convulsions  in  early  infancy  are  necessarily  followed  by 
e{)ilepsy  in  after  life  is  certainly  a  mistake. 

Symptoms. — The  attack  may  come  on  suddenly  without  any  warn- 
ing ;  more  commoidy  it  is  preceded  by  a  stage  of  restlessness,  accompanied 
by  twitching  and  perha])S  grinding  of  the  teeth.  It  is  rarely  so  conipk'te 
in  its  stages  as  true  ejjilepsy.  The  spasm  begins  usually  in  the  hands, 
most  commonly  in  the  right  hand.  The  eyes  are  fixed  and  stariiij;  or  are 
rolled  up.  The  body  becomes  stiff  and  breathing  is  suspended  for  a 
moment  or  two  by  tonic  spasm  of  the  respiratory  muscles,  in  consef|uence 
of  Avhich  the  face  becomes  congested.  Clonic  convulsions  follow,  tlio  eyes 
are  rolled  about,  the  hands  and  arms  twitch,  or  arc  flexed  and  extended  in 
rhythmical  movements,  the  face  is  contorted,  and  the  head  is  retracted. 
The  attack  gradually  subsides  and  the  child  sleeps  or  passes  into  a  state  of 
stupor.  Following  indigestion  the  attack  may  be  single,  but  in  rick('t^^  and 
intestinal  disorders  it  is  apt  to  be  repeated.  Sometimes  the  attacks  fol- 
low^  each  other  with  great  ra])idity,  so  that  the  child  never  rouses  but  dies 


■■%'•> '. 


INFANTILE  CONVULSIONS. 


947 


m\  ^« 


in  a  deep  coma.  If  tlie  convulsion  has  been  limited  chiefly  to  one  side 
tliero  may  be  slight  paresis  after  recovery,  or  in  instances  in  which  the 
convulsions  usher  in  infantile  hemij)logia,  when  the  child  arouses  one  side 
is  completely  parah'zed.  During  the  lit  the  temperature  is  often  rai.sed. 
Death  rarely  occurs  from  the  convulsion  itself,  except  in  debilitated  chil- 
dren or  when  the  attacks  recur  with  great  frequency.  In  the  so-called 
liydrocephaloid  state  in  connection  with  protracted  diarrho-a  convulsions 
may  close  the  scene. 

Diagnosis. — Coming  on  when  the  subject  is  in  full  health,  the  at- 
tack is  probably  duo  either  to  overloaded  stomach,  to  some  perij)heral 
irritation,  or  occasionally  to  trauma.  Setting  in  with  high  fever  and 
vomiting,  it  may  indicate  the  onset  of  an  exanthem,  or  occasionally  be  the 
primary  symptom  of  encephalitis,  or  whatever  the  condition  is  which 
oiiuses  infantile  hemiplegia.  When  the  attack  is  associated  with  debility 
and  with  rickets  the  diagnosis  is  easily  made.  The  carpopedal  spasms 
and  pseudo-paralytic  rigidity  which  are  often  associated  with  rickets, 
laryngismus  stridulus,  and  the  liydrocephaloid  state  are  usually  confined 
to  the  hands  and  arms  and  are  intermittent  and  usually  tonic.  The  con- 
vulsions associated  with  tumor  or  which  follow  infantile  hemiplegia  are 
uHUiilly  at  first  Jacksonian  in  character.  After  the  second  year  convulsive 
seizures  which  come  on  irregularly  without  apparent  cause  and  recur 
while  the  child  i^s  apparently  in  good  health  are  likely  to  jn'ovc  true  epi- 
lepsy. 

Prognosis. — Convulsions  play  an  important  part  in  infantile  mor- 
tiility.  In  Morris  J.  Lewis's  table  of  deaths  in  children  under  ten,  8-5  per 
cent  were  ascribed  to  convulsions.  West  states  that  22-dii  per  cent  of 
deaths  under  one  year  are  caused  by  convulsions,  but  this  is  too  high  an 
estimate  for  this  country.  In  chronic  diarrhoea  convulsions  are  usually 
of  ill  omeu.  Those  ushering  in  fevers  are  rarely  serious,  and  the  same 
may  be  said  of  the  fits  associated  with  indigestion  and  periplieral  irrita- 
tion. 

Treatment. — Every  source  of  irritation  should  be  removed.  If  as- 
sociated with  indigestible  food,  a  prompt  emetic  should  be  given,  followed 
by  an  enemii.  The  teeth  -should  be  examined,  and  if  the  gum  is  swollen, 
hot,  and  tense,  it  may  bo  lanced ;  but  never  if  it  looks  normal.  When 
seen  at  first,  if  the  paroxysm  is  severe,  no  time  should  be  lost  by  giving 
a  hot  bath,  but  chloroform  should  be  given  at  once,  and  repeated  if  neces- 
sury.  A  child  is  so  readily  put  under  chloroform  and  with  such  a  small 
quantity  that  this  preccdiire  is  quite  harmless  and  saves  much  valuable 
time.  The  practice  is  almost  universal  of  putting  the  chikl  into  a  warm 
Uitl\,  and  if  there  is  fever  the  head  may  bo  douched  with  cold  water.  The 
temperature  of  the  bath  should  not  be  above  95°  or  90°.  The  very  hot 
bath  is  not  suitable,  particularly  if  the  fits  are  due  to  indigestion.  After 
the  attack  an  ice-cap  may  be  placed  upon  the  head.  If  there  is  much  irri- 
tability, particularly  iu  rickets  and  in  severe  diarrhu3a,  small  doses  of 
60 


'I 


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948 


DISEASES  OP   rnE  NERVOUS  SYSTEM. 


opium  will  bo  found  efficacious.  When  the  convulsions  recur  after  the  cliild 
comes  from  under  the  influence  of  chloroform  it  is  best  to  place  it  rapidly 
under  the  influence  of  opium,  which  may  be  given  as  morphia  hypodeniicallv, 
in  doses  of  from  one  twenty-fifth  to  one  thirtieth  of  a  grain  for  a  cliild  (jf 
one  year.  Other  remedies  recommended  are  chloral  by  enema,  in  five-grain 
doses,  and  nitrite  of  amyl.  After  the  attack  has  jiassed  the  bromides  aro 
useful,  of  which  five  to  eight  grains  may  be  given  in  a  day  to  a  child  a 
year  old.  Ivecurring  convulsions,  particularly  if  they  come  on  williout 
special  cause,  should  receive  the  most  thorough  and  careful  treatnioiit 
with  bromides.  When  associated  with  rickets  the  treatment  should  bo 
directed  to  improving  the  general  condition. 


1%    ■ai- 


Bi-V^ 


VI.   EPILEPSY. 

Definition. — An  affection  o^"  the  nervous  system  characterized  by 
attacks  of  unconsciousness,  with  or  without  convulsicms. 

The  transient  loss  of  consciousness  without  convulsive  seizures  is  known 
HspelU  mal ;  the  loss  of  consciousness  with  general  convulsive  seizures  is 
known  as  (/rand  rual.  Localized  convulsions,  occurring  usually  witliout 
loss  of  consciousness,  are  known  as  epileptiform,  or  moi'c  frequently  as 
Jucksonian  or  cortical  ejiilepsy. 

Etiology. — Afjc. — In  a  large  proportion  of  all  cases  the  disease  bogiim 
before  puberty.  Of  the  1,450  cases  observed  by  Gowcrs,  in  42;2  the  disease 
began  before  the  tonth  year,  and  three  fourths  of  the  cases  began  before 
the  twentieth  year.  Of  4G0  cases  of  epilepsy  in  children  which  I  have 
analyzed*  the  age  of  onset  in  427  was  as  follows:  First  year,  74;  second 
year,  02;  third  year,  51;  fourth  year,  24;  fifth  year,  17;  sixth  year,  18; 
seventh  year,  10  ;  eighth  year,  23  ;  ninth  year,  17  ;  tenth  year,  27  ;  eleventh 
year,  17;  twelfth  year,  18;  thirteenth  yea,r,  15;  fourteenth  year,  21 ;  fif- 
teenth year,  34.  Arranged  in  hemidecades  the  figures  are  as  follows: 
From  the  first  to  the  fifth  year,  229 ;  from  the  fifth  to  the  tenth  year,  104; 
from  the  tenth  to  the  fifteenth  year,  95.  These  figures  illustrate  in  a 
striking  manner  the  early  onset  of  the  disease  in  a  large  proportion  of  tlio 
cases.  It  is  well  always  to  be  suspicious  of  epilepsy  develo])ing  in  tlio 
adult,  for  in  a  majority  of  such  cases  the  convulsions  are  due  to  a  local 
lesion. 

Sex. — No  special  influence  appears  to  be  discoverable  in  this  relation, 
certainly  not  in  children.  Of  433  cases  in  my  tables,  232  were  males  ami 
203  were  females,  showing  a  slight  predominance  of  the  male  sex.  After 
puberty  unquestionably,  if  a  largo  number  of  cases  arc  taken,  the  males 

*  Three  hiirulrcd  and  nine  cases  from  the  records  from  the  Philadelphia  Inflrniiiry  for 
Diseases  of  the  Nervous  System,  126  cases  at  the  Ehvyn  Institution  for  I'Veblc-mimled 
Children,  and  25  from  the  records  of  my  neurological  clinic  at  the  Johns  Hopkins 
HospitaL 


EPILEPSY, 
.'ire  in  excess.     The  firrnres  of  "^Jn    i-  ^'^^ 

'li«  lil»y«  p-isi.  ,.     '"  "■l„cj,  tlio  mother  IicrscI/  ),.,h  i  "^  """rotic 

I''md  so  small  a  ,  .rt     I  T  ''1  °'  "»'  ''"^'■^  "-at  C  jiH  '     "^  ""'  " 

'^'i/p/n7is  -_-]']•  ^'^^  ^'"^s^s.  '     "^""'te  stutomeiit  be-      . 

sa  :&  £i? -=-=:=:H = i 

(>f  exciting  causes  fr;?       f  ^''^  ^«'"n^o"-  ^^"""'^ 

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DISEASES  OP  THE  NERVOUS  SYSTEM. 


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existing  from  cliildliood,  as  seen  in  the  post-hemiplegic  epilepsy.  Occa- 
sionally cases  follow  the  infectious  fevers.  Masturbation  has  been  stated 
to  be  a  special  cause,  but  its  influence  is  probably  overrated.  A  large 
group  of  convulsive  seizures  allied  to  epilepsy  are  due  to  some  toxi(!  agent, 
as  in  lead-poisoning  and  in  uneniia.  (ireat  stress  was  laid  upon  relic. \ 
causes,  such  as  dentition  and  Avorms,  the  irritation  of  a  cicatrix,  some  hjcul 
affection,  such  as  adherent  prepuce,  or  a  foreign  body  in  the  ear  or  the 
nose.  In  many  of  these  cases  the  fits  cease  after  the  removal  of  the  cause, 
so  that  there  can  be  no  question  of  the  association  between  the  two.  In 
others  the  attacks  persist.  Genuine  cases  of  reflex  epilepsy  arc,  I  believe, 
rare.  A  remarkable  instance  of  it  occurred  at  the  Philadelphia  Inllrniary 
for  Diseases  of  the  Nervous  System  in  the  case  of  a  man  with  a  testis  in  the 
inguiiud  canal,  pressure  upon  which  would  cause  a  typical  flt.  llemovul  of 
the  organ  was  followed  by  cure. 

Epilepsy  has  been  thought  to  be  associated  with  disturbance  of  the 
heart's  action,  and  some  have  spoken  of  a  special  cardiac  epilepsy,  par- 
ticularly in  cases  in  which  there  is  palpitation  or  slowing  of  the  aetiun 
prior  to  the  onset.  Epileptic  seizures  may  occur  during  the  passage  of  a 
gall-stone  or  occasionally  during  the  removal  of  pleuritic  fluid.  Indiges- 
tion and  gastric  troubles  arc  extremely  common  in  epilepsy,  and  in  niuny 
instances  the  eating  of  indigestible  articles  seems  to  precipitate  an  attack. 

An  attempt  to  associate  genuine  epilepsy  with  eye-strain  has  signally 
failed. 

Symptoms. — (1)  Grand  Mai. — Preceding  the  fits  there  is  usually  a 
localized  sensation,  known  as  an  aura,  in  some  part  of  the  body.  This 
may  be  somatic,  in  which  the  feeling  comes  from  some  particular  rogio7i 
in  the  periphery,  as  from  the  finger  or  hand,  or  is  a  sensation  felt  in  the 
stomach  or  about  the  heart.  The  peripheral  sensations  preceding  tlu;  lit 
are  of  great  value,  particularly  those  in  which  the  aura  always  occurs  in  a 
definite  region,  as  in  one  finger  or  toe.  It  \^  the  equivalent  of  the  signal 
symptom  in  a  fit  from  a  brain  tumor.  The  varieties  of  these  sensations 
are  numerous.  The  epigastr-^  sensations  are  most  common.  In  these  tlie 
patient  complains  of  an  uneasy  sensation  in  the  epigastrium  or  distress  in 
the  intestines,  or  the  sensation  may  not  be  unlike  that  of  heart-bnni  aiui 
may  be  associated  with  palpitation.  These  groups  are  sometimes  known 
as  pneumogastric  aura3  or  warnings. 

Of  psychical  aura)  one  of  the  most  common,  as  described  by  Iluglilings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  some- 
times of  terror.  The  auroe  may  be  associated  with  special  senses,  of  whieh 
the  visual  are  the  most  common,  consisting  of  flashes  of  light  or  sensa- 
tions of  color;  less  commonly,  distinct  objects  are  seen.  The  auditory 
aura?  consist  of  noises  in  the  car,  odd  sounds,  musical  tunes,  or  occasionally 
voices.  Olfactory  and  gustatory  aura?,  unpleasant  tastes  and  odors,  aro 
rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  by  ecrtam 


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EPILEPSY. 


951 


movements ;  the  patient  may  turn  round  rapidly  or  run  with  groat  speed 
for  a  few  minutes,  the  so-called  epilepsia  procursiva.  In  one  of  the  Elwyn 
(•ases  the  lad  stood  on  his  toes  and  twirled  with  extraordinary  rapidity,  so 
that  his  features  were  scarcely  recognizable.  At  the  onset  of  the  attack 
the  patient  may  give  a  loud  scream  or  yell,  the  so-called  epilei)tic  cry. 
The  patient  drops  as  if  shot,  making  no  effort  to  guard  the  fall.  In 
consequence  of  this,  epileptics  frequently  injure  themselves,  cutting  the 
face  or  head  or  burning  themselves.  In  the  attack,  as  described  by 
Hippocrates,  "  the  patient  loses  his  speech  and  chokes,  and  foam  issues 
from  the  mouth,  the  teeth  are  fixed,  the  hands  are  contracted,  the  eyes 
distorted,  he  becomes  insensible,  and  in  some  cases  the  bowels  are  affected. 
And  these  symptoms  occur  sometimes  on  the  left  side,  sometimes  on  the 
right,  and  sometimes  on  both."     The   fit  may  be  described  in  three 


stages ; 


(a)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the 
jaws  are  fixed.  The  hands  are  clinched  and  the  legs  extended.  This 
tonic  contraction  aftects  the  muscles  of  tiie  chest,  so  that  respiration 
is  impeded  and  the  initial  pallor  of  the  face  changes  to  a  dusky  or  livid 
hue.  The  muscles  of  the  two  sides  are  unequally  affected,  so  that 
the  head  and  neck  are  rotated  or  the  spine  is  twisted.  The  feet  are 
extended  and  the  knees  and  hip- joint  are  ilexcd.  The  arms  are  usually 
flexed  at  the  elbows,  the  hand  at  the  wrist,  and  the  fingers  are  tightly 
clinched  in  the  palm.  This  stage  lasts  only  a  few  seconds,  and  then 
the 

(b)  Clonic  stage  begins.  The  muscular  contractions  become  inter- 
mittent; at  first  tremulous  or  vibratory,  they  gradually  become  more 
rapid  and  the  limbs  are  jerked  and  tossed  about  violently.  The  mus- 
cles of  the  face  are  in  constant  clonic  spasm,  the  eyes  roll,  the  eyelids 
are  opened  and  closed  convulsively.  The  movements  of  the  muscles 
of  the  jaw  are  very  forcible  and  strong,  and  it  is  at  this  time  that  the 
tongue  is  apt  to  be  caught  between  the  teeth  and  lacerated.  The  cyan- 
osis, marked  at  the  end  of  the  tonic  stage,  gradually  lessens.  A  frothy 
saliva,  which  may  be  blood-stained,  escapes  from  the  mouth.  The  fa;ces 
and  urine  nuiy  be  discharged  involuntarily.  The  duration  of  this  stage  is 
variable.  It  rarely  lasts  more  than  one  or  two  minutes.  The  contrac- 
tions become  less  violent  and  the  patient  gradually  sinks  into  the  con- 
dition of 

((■)  Coma.  The  breathing  is  noi.sy  or  even  stertorous,  the  face  con- 
gested, but  no  longer  intensely  cyanotic.  The  limbs  are  relaxed  and  the 
unconsciousness  is  profound.  After  a  variable  time  tlie  patient  can  be 
aroused,  but  if  left  alone  he  sleeps  for  some  hours  and  then  awakes,  com- 
plaining only  of  slight  headache  or  mental  confusion. 

In  some  cases  one  attack  follows  the  other  with  great  rapidity  ami  con- 
sciousness is  not  regained.  This  is  termed  the  status  ppikpticus,  an  ex- 
ceptional condition,  in  which  the  patient  may  die  of  exhaustion  consequent 


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952 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


»!''  *  '    * 


upon  tho  repeated  attacks.  In  it  the  temperature  is  usually  elevated. 
After  the  attack  the  reflexes  are  sometimes  absent ;  more  frequently  tlioy 
are  increased  and  the  ankle  clonus  can  usually  be  obtained. 

The  state  of  tho  urine  is  variable,  jjarticularly  as  regards  the  S(jli(ls. 
The  quantity  is  usually  increased  after  the  attack,  and  albumen  is  not  in- 
frequently present. 

Fosf-cpilcptio  s7/mpf.ofns  are  of  great  importance.  The  patient  may  be 
in  a  trance-like  condition,  in  which  he  performs  actions  of  which  sulxse- 
(juently  he  has  no  recollection.  More  serious  are  the  attacks  of  nuiniii,  in 
which  the  patient  is  often  dangerous  and  sometimes  homicidal.  It  is  lield 
by  good  authorities  that  an  outbreak  of  mania  may  be  substituted  for  the 
lit.  And,  lastly,  the  mental  condition  of  an  epileptic  patient  is  often  seri- 
ously impaired,  and  profound  defects  are  common. 

Paralysis,  which  rarely  follows  the  epile])tic  fit,  is  usually  hemiplcnc! 
and  transient. 

Slight  disturbances  of  speech  also  may  occur ;  in  some  instances  forms 
of  sensory  aphasia. 

The  attacks  may  occur  at  night,  and  a  person  may  be  epileptic  for 
years  without  knowing  it.  As  Trousseau  truly  remarks,  when  a  person 
tolls  us  that  in  the  night  he  has  incontinence  of  urine  and  awakes  in  tlie 
morning  with  headache  and  mental  coldfusion,  and  complains  of  diflicultv 
in  speech  owing  to  the  fact  that  he  has  bitten  his  tongue ;  if,  also,  thens 
are  on  the  skin  of  the  face  and  neck  purpuric  spots,  the  probability  is  very 
strong  indeed  that  he  is  subject  to  noctur'iMl  epilepsy. 

(2)  Petit  Mai. — This  is  epilepsy  witho  .i  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  which  may  come  on  at  any  time, 
accompanied  or  unaccompanied  by  a  feeling  of  faintness  and  vorti^^o. 
Suddenly,  for  example,  at  the  dinner  table,  the  subject  stops  talking  and 
eating,  the  eyes  become  fixed,  and  the  face  slightly  pale.  Anything  which 
may  have  been  in  the  hand  is  usually  dropped.  In  a  moment  or  two  con- 
sciousness is  regained  and  the  patient  resumes  conversation  as  if  nothing 
had  hai)pened.  In  other  instances  there  is  slight  incoherency  or  the  pa- 
tient performs  some  almost  automatic  action.  He  may  begin  to  undress 
himself  and  on  returning  to  consciousness  find  that  he  has  partially  dis- 
robed. In  other  attacks  the  patient  may  fall  without  convulsive  seizures. 
A  definite  aura  is  rare.  Though  transient,  unconsciousness  and  giddiness 
are  the  most  constant  manifestations  of  petii  mal ;  there  are  many  other 
equivalent  manifestations,  such  as  sudden  jerkings  in  the  limbs,  sudden 
tremor,  or  a  sudden  visual  sensation.  Gowers  mentions  no  less  than  seven- 
teen different  manifestations  of  j^ctit  mal. 

After  the  attack  the  patient  may  be  dazed  for  a  few  seconds  and  per- 
form certain  automatic  actions,  which  may  seem  to  be  volitional.  As  men- 
tioned, undressing  is  a  common  action,  but  all  sorts  of  odd  actions  niiiy  ho 
performed,  some  of  which  are  awkward  or  even  serious.  One  of  my  pa- 
tients after  an  attack  was  in  the  habit  of  tearing  anything  he  could  lay 


EPILEPSY. 


953 


lick 

line, 

tii^o. 

aiul 

licU 

'011- 

lin.i,' 
pa- 
voss 
(lis- 

iires. 

llior 

(Idoii 

von- 

por- 
lincn- 
|iv  be 
|v  pu- 
ll I'ly 


hands  on,  particularly  books.  Violent  actions  have  boon  committed  and 
assaults  made,  froquontly  giving  riso  to  questions  which  come  before  the 
courts.  This  condition  has  been  termed  masked  epilepsy,  or  epilepsia 
larvatn. 

In  a  majority  of  the  cases  of  jirlit  mal  convulsions  finally  occur,  at 
(irst  slight,  but  ultimately  the  grand  mal  becomes  well  developed,  and  the 
attacks  may  then  alternate. 

(3)  Jacksonian  Epilepsy. — This  is  alsoknoAvn  as  cortical,  symptomatic, 
or  partial  epilepsy.  It  is  distinguished  from  the  ordinary  epilepsy  by  the 
important  fact  that  consciousness  is  retained.  The  attacks  are  usually  the 
result  of  irritative  lesions  in  the  motor  zone,  though  tliere  are  probably 
also  s3nsory  ecpiivalents  of  this  motor  form.  In  a  typical  attack  the  spasm 
l)e:,dns  in  a  limited  muscle  group  of  the  face,  arm,  or  leg.  The  zygomatic 
imiscles,  for  instance,  or  the  thumb  may  twitch,  or  the  toes  may  lirst  bo 
moved.  Prior  to  the  twitcbing  the  patient  may  feel  a  sensation  of 
numbness  or  tingling  in  the  part  affected.  The  spasm  extends  and  may 
involve  the  muscles  of  one  limb  only  or  of  the  face.  The  patient  is 
conscious  throughout  and  watches,  often  with  interest,  the  march  of  the 
spasm. 

The  onset  may  bo  slow,  and  there  may  be  time,  as  in  a  case  which  I 
have  reported,  for  the  patient  to  place  a  pillow  on  the  floor,  so  a^to  be 
as  comfortable  as  possible  during  the  attack.  The  spasms  may  be  local- 
ized for  years,  but  there  is  a  great  risk  that  the  partial  ei)ilepsy  may 
hcconie  general.  The  condition  is  duo,  as  a  rule,  to  an  irritative  lesion 
iu  the  motor  zone.  Thus  of  107  cases  analyzed  by  Ttoland,  there  were 
48  of  tumor,  21  instances  of  inflammatory  softening,  14  instances  of 
acute  and  chronic  meningitis,  and  8  cases  of  trauma.  The  remaining 
instances  were  due  to  hajmorrhago  or  abscess,  or  were  associated  with 
sclerosis  cerebri.  Two  other  conditions  may  be  mentioned,  which  may 
cause  typical  Jacksonian  epilepsy — namely,  urajmia  and  progressive  pa- 
ralysis of  the  insane.  A  considerable  number  of  the  cases  of  Jackso- 
nian epilepsy  are  found  in  children  following  hemiplegia,  the  so-called 
post-hem iplegic  epilepsy.  Tlie  convulsions  usually  begin  on  the  affected 
side,  cither  in  the  arm  or  leg,  and  the  fit  may  be  unilateral  and  with- 
out loss  of  consciousness.  Ultimately  they  become  more  severe  and 
general. 

Diagnosis. — In  major  epilepsy  the  suddenness  of  the  attack,  the 
abrupt  loss  of  consciousness,  the  order  of  tlio  tonic  and  clonic  s])asm,  and 
the  relaxation  of  the  sphincters  at  the  height  of  the  attack  are  distinctive 
features.  The  convulsive  seizures  due  to  uraemia  are  epileptic  in  character 
and  usually  readily  recognized  by  the  existence  of  greatly  increased  ten- 
sion and  the  condition  of  the  urine.  Practically  in  young  adults  hysteria 
causes  the  greatest  difficulty,  and  may  closely  simulate  true  epilepsy.  The 
following  table  from  Oowers's  work  draws  clearly  tho  chief  diifcreucos 
between  them  : 


954 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


1 


mm 

^^i> 

I 

H||)l  1 

Swk'  ^  'i   f^  < 

■ 

1 

EPILKITIC. 

IIVBTEIIOIU. 

Apparent  cause 

Warniiifj 

none. 

any,  but  especially  unilat- 
eral or  epigastric  ttura\ 

always  sudden. 

at  onset. 

rigidity  followed  by  "ierk- 
ing,"  rarely  rigidity  alone. 

tongue, 

frequent. 

occasional. 

never. 

a  few  minutes, 

to  jirevent  accident, 
spontaneous. 

emotion. 

l)alpitation,   malaise,  choking,  M- 

lateral  foot  aura, 
often  gradual, 
during  course, 
rigidity  or  "struggling,"  throwini,' 

about  of  iimbs  or  head,  arching 

of  back, 
lips,   hands,  or  other  people  uiid 

things, 
never.                                              , 

Onset 

Scream 

Convulsion 

Biting 

Micturition 

Defecation 

never. 

Talking 

Duration 

frequent. 

more  than  ten  minutes,  often  much 

longer, 
to  control  violence, 
spontaneous    or    induced    (water, 

etc.). 

llestraint  necessary. . 
Termination 

Recurring  epileptic  seizures  in  a  person  over  tliirty  wlio  has  not  liad 
previous  attacks  is  always  suggestive  of  organic  disease.  According  to  if, 
C.  Wood,  whose  oi)inion  is  supported  by  that  of  Fournier,  in  nine  cases 
out  of  ten  the  condition  is  due  to  syphilis. 

Petit  Dial  must  be  distinguished  from  attacks  of  syncope,  and  the  ver- 
tigo of  Meniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  tliose 
cases  there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic 
though  not  an  invariable  feature  of  petit  mal. 

Jacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is 
at  once  recognized.  It  is  by  no  means  easy,  however,  always  to  deter- 
mine upon  what  the  spasm  depends.  Irritation  in  the  motor  centres 
may  be  due  to  a  great  variety  of  causes,  among  which  tumors  and  lociil- 
izcd  mcningo-encephalitis  are  the  most  frequent;  but  it  must  not  he 
forgotten  that  in  uraemia  localized  epilepsy  may  occur.  The  most  typi- 
cal Jacksonian  spasms  also  are  not  infrequent  in  general  paresis  of  the 
insane. 

Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates ; 
"The  prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital, 
and  when  it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person 
without  any  previous  cause.  .  .  .  The  cure  may  be  attempted  in  yoiuig 
persons,  but  not  in  old." 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient 
falls  into  the  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally 
the  fits  seem  to  stop  spontaneously.  This  is  particularly  the  case  in  the 
epilepsy  in  children  which  has  followed  the  convulsions  of  teething  or  of 
the  fevers.  Frequency  of  the  attacks  and  marked  mental  disturbance  iiro 
unfavorable  indications.  Hereditary  predisposition  is  apparently  of  no 
moment  in  the  prognosis.  The  outlook  is  better  in  males  than  in  females. 
The  post-hemiplegic  epilepsy  is  rarely  arrested.     Of  the  cases  coming  ou 


EPILEPSY. 


955 


in  adults,  those  due  to  syphilis  and  to  local  affections  of  the  brain  allow  a 
more  favorable  prognosis. 

Treatment. — (icncmi — In  the  case  of  children  the  parents  should 
be  made  to  understand  from  the  outset  tluit  e])ilepsy  in  the  great  nuijority  of 
cases  is  an  incurable  affection,  so  thai  ,l>e  disease  may  interfere  as  little  as 
])Ossible  with  the  education  of  the  child.  The  subjects  need  firm  but  kind 
treatment.  Indulgence  and  yielding  to  caprices  and  whims  are  followed 
by  weakening  of  the  moral  control,  which  is  so  necessary  in  these  cases. 
The  disease  does  not  incapacitate  a  person  for  all  occupation.  It  is  much 
better  for  e])ileptics  to  have  some  definite  pursuit.  ^J'here  are  many 
instances  in  which  they  have  been  persons  of  extraordinary  mental  and 
bodily  vigor;  as,  for  example,  Julius  (!i1^sar  and  Napoleon.  One  of  the 
most  distressing  features  in  epilepsy  is  the  gradual  mental  impairment 
which  follows  in  a  certain  number  of  cases.  If  such  patients  become  ex- 
tremely irritable  or  show  signs  of  violence  they  shoukl  be  itlaced  under 
supervision  in  an  asylum.  Marriage  should  be  forbidden  to  epileptics. 
During  the  attack  a  cork  or  bit  of  rubber  should  be  placed  between  the 
teeth  and  the  clothes  should  be  loosened.  The  patient  should  be  in  the 
recumbent  posture.  As  the  attack  usually  passes  otf  with  rapidity,  no 
special  treatment  is  necessary,  but  in  cases  in  which  the  convulsion  is  pro- 
longed a  few  whiffs  of  chloroform  or  nitrite  of  amyl  or  a  hyiiodermic  of 
u  quarter  of  a  grain  of  morpliia  may  be  given. 

Dietetic. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy. 
The  important  point  is  to  give  the  patient  a  light  diet  at  tixeil  hours, 
and  on  no  account  to  permit  overloading  of  the  stomach.  Meat  should 
not  be  given  more  than  once  a  day.-  There  are  cases  in  which  animal 
food  seems  injurious.  A  strictly  vegetable  diet  has  been  warmly  recom- 
mended. The  patient  should  not  go  to  sleep  until  the  completion  of 
gastric  digestion. 

Medicinal. — The  bromides  are  the  only  remedies  which  have  a  special 
influence  upon  the  disease.  Either  the  sodium  or  potassium  salt  may  bo 
given.  Sodium  bromide  is  probably  less  irritating  and  is  better  borne  for 
a  long  period.  It  may  be  given  in  milk,  in  Avhich  it  is  scarcely  tasted. 
In  all  instances  the  dilution  should  be  considerable.  In  adults  it  is  well 
taken  in  soda  water  or  in  some  mineral  water.  The  dose  for  an  adult 
slioidd  be  from  half  a  drachm  to  a  drachm  and  a  half  daily.  As  Seguin 
recommends,  it  is  often  best  to  give  but  a  single  dose  daily,  about  four  to 
six  hours  before  the  attacks  arc  most  likely  to  occur.  For  instance,  in 
the  case  of  nocturnal  epilepsy  a  drachm  should  be  given  an  hour  or  two 
after  the  evening  meal.  If  the  attack  occurs  early  in  the  morning,  the 
patient  should  take  a  full  dose  when  he  awakes.  When  given  three  times 
a  day  it  is  best  given  after  meals.  Each  case  should  be  carefully  studied  to 
determine  how  much  bromide  should  be  used.  The  individual  suscepti- 
bility varies  and  some  patients  require  more  than  others.  Fortunately, 
children  take  the  drug  Avell  and  stand  proportionately  larger  doses  than 


1 

I 


:: 


:{ 


05(5 


DISKASES  OP  THE  NKIIVOUS  SYSTEM. 


B"|! 


**l' 


I.  * 


luliilts.  Saturation  is  indioiitcd  by  rortiiin  unplcasiiiit  offoft.-?,  |nirlif'ii- 
liirly  drowsiness,  iiU'iitiil  torpor,  ini<l  ^Mstrii;  uiid  cardiac  distress.  L(,<^  ,if 
palate  rellex  is  one  of  tiie  earliest  indications  tliat  tlie  system  is  under  llm 
influence  of  the  bromides,  and  is  a  condition  which  should  be  attained.  A 
vcM'y  uni)leasaiit  feature  is  the  dovelopnient  of  acne,  which,  however,  is  ^\^, 
indication  (jf  broinism.  Sc^iuiu  states  that  the  tendency  to  this  is  nmcli 
diminished  by  ^^nvinj^  the  drug  largely  diluted  in  alkaline  waters  and  ad- 
ministering from  time  to  time  full  doses  of  arsenic.  'I'o  be  elleetual  the 
treatment  should  bo  continued  for  a  ])rolonged  period  and  the  cases 
should  bo  iiujcssantly  Avatched  in  order  to  prevent  bromism.  'i'he  ineili- 
cine  should  be  (;ontinued  for  iit  least  two  \Tars  after  the  cessation  of  the 
fits;  indeed,  Seguin  recommends  that  the  reduction  of  the  bromides  should 
not  be  begun  until  the  patient  has  been  three  years  without  any  mani- 
festations. Written  directions  should  be  given  to  the  motlier  or  to  tlio 
friends  of  the  patient,  aiul  lie  should  not  himself  be  held  responsible  for 
the  administration  of  the  medicine.  A  book  should  be  ])rovided  in  which 
the  daily  number  of  attacks  and  the  amount  of  medicine  taken  should  bo 
noted. 

Among  other  remedies  which  have  been  rcoommendod  as  controllins; 
epilepsy  arc  chhn'al,  canmibis  indica,  zinc,  nitroglycerin,  and  borax.  Nitro- 
glycerin is  sometimes  advantageous  in  jjcfit  mal,  but  is  not  of  much  serv- 
ice in  the  major  form.  'Yo  be  benelicial  it  must  be  given  in  full  dosos, 
from  two  to  five  minims  of  the  one  per  cent  solution,  and  increased 
until  the  physiological  elfocts  arc  j)roduced.  Counter-irritation  is  rarely 
advisable.  AVheii  the  aura  is  very  definite  and  constant  in  its  onset,  as 
from  the  hand  or  from  the  toe,  a  blister  about  the  part  or  a  ligature 
tightly  applied  may  stop  the  oncoming  fit.  In  children,  care  should  bo 
taken  that  there  is  no  source  of  peripheral  irritation.  In  boys,  adherent 
prepuce  may  occjasionally  be  the  cause.  The  irritation  of  teething,  the 
presence  of  worms,  aiul  foreign  bodies  in, the  ears  or  nose  have  been  as-so- 
eiatcd  with  e})ilcptic  seizures. 

The  subjects  of  a  chronic  and,  in  most  cases,  a  hopelessly  incurable 
disease,  eidleptic  patients  form  no  small  portion  of  the  unfortunate  victims 
of  charlatans  and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father 
of  medicine,  "  purifications  and  spells  and  other  illiberal  practices  of  like 
kind." 

Snn/ical — In  Jacksonian  epilepsy  the  propriety  of  surgical  inter- 
ference is  universally  granted.  It  is  question: ible,  however,  whether  in  the 
epilepsy  following  hemiplegia,  considering  the  anatomical  condition,  it  is 
likely  to  be  of  any  benefit.  In  idiopathic  epilepsy,  when  the  fit  starts  in 
a  certain  region — the  thumb,  for  instance — and  the  signal  symptom  is  in- 
variable, the  centre  controlling  this  part  may  be  removed.  This  procedure 
has  been  practised  by  Macewen,  Ilorsley,  Keen,  and  others,  but  time  alono 
can  determine  its  value.  The  traumatic  epilepsy,  iu  which  the  fit  follows 
fracture,  is  much  more  hopeful. 


MIGRAINE. 


957 


The  operation,  per  se,  appears  in  srmo  cases  to  have  a  curativo  ciToct. 
Tliiis  of  50  cusoa  of  trephining;  fur  epilepsy  in  whieli  notliin<,'abM(»rnial  was 
/uuikI  to  aeeount  for  tlie  symptoms,  'i'i  were  reporti'il  as  enre(l  iiiid  IS  us  im- 
proved.* TIio  oj)erations  liavo  not  been  always  on  the  sl\ull,  and  Wiiite 
has  collected  an  interesting^  series  in  which  various  siirgi(;al  procedures 
iiiive  been  resorted  to,  often  with  curative  cll'ect,  such  as  lif^ation  of  the 
carotid  artery,  castration,  tracheotomy,  excision  of  the  superior  cervical 
f,'anglia,  incision  of  the  scalp,  circumcision,  etc. 


VII.   MIGRAINE  (Ilemicmnia ;  Sick  II,adache). 

Definition. — A  paroxysmal  affection  characterized  by  severe  head- 
ache, usually  unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — The  disease  is  frerpiently  hereditary  and  has  occurred 
through  several  generations.  Women  and  the  members  of  neurotic;  fami- 
lies are  mo?t  frequently  attacked.  It  is  an  affection  from  which  many  dis- 
tinguished men  have  suffered  and  have  left  on  record  an  account  of  the  dis- 
ease, notably  the  astronomer  Airy.  Edward  Liveing's  work  is  the  standard 
authority  upon  which  most  of  the  subsequent  articles  have  been  based.  A 
fTDuty  or  rlieumatic  taint  is  present  in  many  instatuses.  Sinklcr  has  called 
special  attention  to  the  frequency  of  reflex  causes,  ^ligraine  has  long  been 
known  to  be  associated  with  uterine  and  menstrual  disorders.  Many  of 
the  headaches  from  eye-strain  are  of  the  hemicraiiial  type.  Bruiiton  refers 
to  caries  of  the  teeth  jvs  a  cause  of  these  hea(hiches,  oven  when  not  asso(;i- 
uted  with  toothache.  Cases  have  been  described  in  coi\nect'ion  with  ade- 
noid growths  in  the  pharynx,  and  particularly  with  abnormal  conditions 
of  the  nose.  Many  of  the  attacks  of  severe  headaches  in  childi'cn  are  of 
tills  nature,  and  the  eyes  and  nostrils  should  be  examined  with  great  care. 
Sinkler  refers  to  a  case  in  a  child  of  two  years,  and  Gowers  states  that  a 
third  of  all  the  cases  begin  between  the  fifth  and  tenth  yeai's  of  age.  The 
direct  influences  inducing  the  attack  are  very  varied.  Powerful  emotions 
of  all  sorts  are  the  most  potent.  Mental  or  bodily  fatigue,  digestive  dis- 
turbances, or  the  eating  of  some  particular  article  of  food  may  bo  followed 
by  the  headache.  The  paroxysmal  character  is  one  of  the  most  striking 
features,  and  the  attacks  may  recur  on  the  same  day  every  week,  oveiy 
fortnight,  or  every  month. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the 
patient  can  tell  when  an  attack  is  coming  on.  Remarkable  prodromata 
have  been  described,  particularly  in  connection  with  vision.  Apparitions 
may  appear — visions  of  animals,  such  as  mice,  dogs,  etc.  Tran.sient  hc- 
mianopia  or  scotoma  may  be  present.  In  other  instances  there  is  spas- 
modic action  of  the  pupil  on  the  affected  side,  which  dilates  and  contracts 


*  J.  William  White,  Curative  Effects  of  Operations  ^Jer  «e,  Annals  of  Surger/,  1891. 


058 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


9^- 


;^^'; 


4  '- 


iiltorniitoly,  tho  conditioti  known  iih  /u'ppiis.  Kroquoiitly  the  dlstiirhanco 
of  vision  \n  only  ii  blurrinf;,  or  tl.crc  arc  Itiiilx  of  lifjlit,  or  zij^'za;,'  liiK  <.  nr 
tlic  so-oalU'(l  fortilication  six'ctni  (toidiopsia),  which  may  he  ilhiiniiiutiil 
with  j^orj^coiis  colors.  Disturhanccs  of  the  other  senses  are  rare.  Niimii. 
ness  of  the  tongue  and  face  and  occasionally  of  tho  hand  may  occur  with 
titif^ling.  More  rarely  there  are  cramps  or  spasms  in  the  muscles  of  the 
alTccted  side.  Transient  aphasia  has  also  been  noti'd.  Some  patiiiit-; 
show  marked  jtsy(;hical  disturbance,  either  excitement  or,  more  coiiiiiKiuly, 
mental  confusion  or  great  depression.  Dizziness  occurs  in  some  caHcti. 
'riu!  lieadache  follows  a  short  time  after  the  prodromal  syniptonis  Imvc 
appeared.  It  is  curnulative  and  expansile  in  chariu'tcr,  begiiiniiiir  as  a 
localized  snudl  spot,  which  is  generally  constant  either  on  the  teiuiilr  or 
forehead  or  in  tiic  eyeball.  It  is  usually  described  as  of  a  penetrating', 
sharp,  boring  characitcr.  At  first  unilateral,  it  gradually  spreads  and  in- 
volves the  side  of  tho  head,  sometimes  the  neck,  and  the  i)ains  may  pass 
into  tho  arm.  In  other  cases  both  sides  are  atfected.  Mausea  and  vmnit- 
ing  are  common  symptoms.  If  the  attack  comes  on  when  the  stomach  is 
full,  vomiting  usually  gives  relief.  Vaso-motor  symptoms  may  he  pres- 
ent.  I'ho  face,  for  instance,  may  be  pale,  and  there  may  be  a  marked 
difrerence  between  the  two  sides.  Subsequently  the  face  and  ear  on  the 
affected  side  may  become  a  burning  red  from  tlie  vaso-dilator  intluentTS. 
The  pulse  may  bo  slow.  The  temporal  artery  on  the  alTected  side  may  lie 
firm  and  hard,  and  in  a  condition  of  arterio-sclerosis — a  fact  which  has 
been  confirmed  anatomically  by  Thoma.  Few  afTections  are  more  ]iros- 
trating  than  migraine,  and  during  tho  paroxysm  tlie  ])atient  may  sciuvcly 
bo  able  to  raise  the  head  from  the  pillow.  The  slightest  noise  or  light 
af'gravates  the  condition. 

The  duration  of  tho  entire  attack  is  variable.  The  severer  forms  usually 
incapacitate  tho  person  for  at  least  three  days.  In  other  instances  the  en- 
tire attack  is  over  in  a  day.  Tho  disease  r,ecurs  for  years,  ami  in  cases  witli 
a  marked  hereditary  tendency  may  persist  throughout  life.  In  women  the 
attacks  often  cease  after  the  climacterio,  and  in  men  after  the  age  of  fifty. 
Two  of  the  greatest  sufferers  I  h;ive  known,  who  had  recurring  attacks 
every  few  weeks  from  early  boyhood,  now  have  complete  freedom. 

Tho  nature  of  the  disease  is  unknown.  Liveing's  view,  that  it  is  a 
nerve  storm  or  form  of  periodic  discharge  from  certain  sensory  centres  and 
is  related  to  epilepsy,  has  found  much  favor.  According  to  this  view,  it 
is  the  sensory  equivalent  of  a  true  epileptic  attack.  Mollendorf,  Tjatham, 
and  others  regard  it  as  a  vaso-motor  neurosis,  and  hold  that  the  early 
symptoms  are  duo  to  vaso-constrictor  and  the  later  symptoms  to  vaso-dila- 
tor influences.  Tho  fact  of  the  development  of  arterio-sclerosis  in  the 
arteries  of  the  affected  side  is  a  point  of  interest  bearing  xxpon  this  view. 

Treatment. — The  patient  is  fully  aware  of  the  causes  which  ])n'eipi- 
tate  an  attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and 
modcratiou  in  diet  are  important  rules.     The  treatment  should  be  directed 


NKUHAliOIA. 


059 


towaril  tljo  removal  of  the  fonditiouM  upon  which  the  uttuckrt  depend.  In 
( liildren  much  niiiy  h(!  done  by  wulchfuhiesH  and  euro  on  tlio  part  of  the 
mother  in  re},'nlutini.(  the  howels  un<l  watching;  tiu!  diet  of  the  child, 
llrrors  of  refra<'tion  .shotdd  he  adjusted.  On  no  account  sliould  such  chil- 
dren he  all(»wed  to  compel(i  in  .sciiool  for  prizes.  A  prolonjfcd  cour.se  of 
i)ron)i(h\s  Hometimcs  ])rove.s  successful.  If  aiuinnia  is  present,  iron  and 
arsenic  should  he  given.  When  the  arterial  tension  is  increased  u  courso 
of  Mitrof,'lycerin  may  he  trit;d.  Not  too  nuich,  however,  should  h(f  expect- 
(mI  of  die  i)reventive  treatnu'ut  oi  miffraine.  It  nuist  be  confcs.sed  that  in 
a  very  lari,'e  j)roportion  of  the  eases  the  heudi..'hes  recur  iti  spite  of  all  we 
ciin  do.  ])urinj(  the  paroxysm  the  j)atient  should  be  kept  in  bed  and  ab- 
solutely (piiet.  If  the  patient  fi^els  faint  and  nauseated,  a  snnill  cup  of 
hot,  stronjj  colTee  or  twenty  drops  of  chloroform  give;  n^licf.  (Cannabis 
iiidica  is  jirobably  the  most  .satisfactory  remedy.  Sej^uin  recommends  a 
pnjlongcd  cour.so  of  the  drug.  Antipyrin,  antifehrin,  and  phenacetin 
luive  been  nmch  used  of  late.  When  given  early,  at  the  very  outset  of  the 
paroxy.sm,  they  are  sometimes  elTective.  Tho  doses  which  have  l)eeji  reo 
ommended  of  antifehrin  and  antipyrin  are  often  dangerous,  and  I  huvo 
seen  in  a  ease  of  migraine  unjileasant  collapse  symptoms  follow  a  twenty- 
iive-grain  dose  of  antii)yrin  which  the  patient  had  taken  on  her  own  ro- 
.sponsil)ility.  Snuiller,  re])eated  doses  are  more  satisfactory.  Of  otli(;r 
remedies,  calTeine,  in  five-grain  doses  of  the  citrate,  nux  vomica,  and  ergot 
have  been  recommended.  Electricity  does  uot  appear  to  bo  of  much 
service. 


'fa 

\i 


'/■  it  ; 


VIII.  NEURALGIA. 

Definition. — A  painful  atTectiou  of  the  nerves,  due  cither  to  func- 
tional disturbance  of  their  central  or  peri])heral  extremities  or  to  neuritis 
in  their  course. 

Etiologfy. — Members  of  neuropathic  families  are  most  subject  to  the 
disease.  It  affects  women  more  than  men.  Children  are  rarely  attacked. 
Of  all  causes,  debility  is  the  most  frequent.  It  is  often  the  first  indication 
of  an  enfeebled  nervous  system.  The  various  forms  of  amemia  are  fi'e- 
quently  associated  with  neuralgia.  It  may  be  a  prominent  feature  at  tho 
onset  of  certain  acute  diseases,  particularly  typhoid  fever.  ^lalaria  is  be- 
lieved to  be  a  potent  cause,  but  it  has  not  been  shown  that  neuralgia  hi 
more  frequent  in  malarial  districts,  and  the  error  has  probably  arisen  from 
regarding  periodicity  as  a  special  manifestation  of  paludism.  It  occasion- 
ally occurs  in  malarial  cachexia.  Exposure  to  cold  is  a  cause  in  very  sus- 
ceptible persons.  Reflex  irritation,  particularly  from  carious  teeth,  may  in- 
duce neuralgia  of  the  fifth  nerve.  The  disease  occurs  sometimes  in 
rheumatism,  gout,  lead  poisoning,  and  diabetes. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  uneasy  sen- 
sations, sometimes  tingling  in  the  part  which  will  be  alTected.     The  pain 


•,  :1 


OGO 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


U'' 


mi 


1 ,,  1 


ll 


1,  ^, 


l(i 


is  localized  to  a  certain  group  or  division  of  nerves,  isually  afTcctintr  one 
side.  Tlic  pain  is  not  constant,  but  paroxysmal,  and  is  described  as  .stub- 
bing, burning,  or  darting  in  cbaracter.  The  skin  may  be  exquisitely  t(;n- 
der  in  the  affected  region,  particularly  in  certain  points  along  tlie  coiu-se 
of  the  nerve,  the  so-called  tender  points.  Movements,  as  a  rule,  are  pain- 
ful. Trophic  and  vaso-motor  changes  may  accompany  the  paroxysm ;  the 
skin  may  be  cool,  and  subsequently  hot  and  burning,  occasionally  local 
oedema  or  erythema  occurs.  More  remarkable  still  are  the  changes  in  the 
hair,  which  may  become  blanched  (canities),  or  even  fall  out.  Fortunate- 
ly, such  alterations  arc  rare.  Twitchings  of  the  muscles,  or  even  spasms, 
may  be  present  during  the  paroxysm.  After  lasting  a  variable  time — from 
a  few  minutes  to  many  hours — the  attack  subsides.  Recurrence  may  bo 
at  definite  intervals — every  day  at  the  same  hour,  or  at  intervals  of  two, 
three,  or  even  seven  days.  Occasionally  the  paroxysms  develop  only  at 
the  catamenia.  This  periodicity  is  quite  as  marked  in  non-malarial  as  in 
malarial  regions. 

Clinical  Varieties,  depending  on  the  Nerve  Groups  affected.— (i)  7'//- 
facial  Neuralgia  ;  Tic  Douloureux  ;  Prosopalgia. — All  the  branches  arc 
rarely  involved  together.  The  ophthalmic  is  most  often  affected,  but  in 
severe  attacks  the  pains,  though  more  intense  in  one  division,  radiate  over 
the  other  branches.  At  the  outset  there  may  be  hypera}sthesia  of  the  skin 
and  sensitiveness  of  the  mucous  membrane.  IVessure  is  painful  at  the 
points  of  emergence  of  the  nerve  trunk,  and  where  the  nerves  enter  the 
muscles.  Sometimes  in  i"Idition,  as  Trousseau  pointed  out,  there  aiv 
pains  at  the  occipital  protuberance  and  in  the  upper  cervical  spines. 
AVhen  the  ophthalmic  division  is  affected  the  eye  may  weep  and  the  con- 
junctiva? are  injected  and  painful.  In  the  upper  maxillary  division  there 
is  a  tender  jioint  Avhere  the  nerve  leaves  the  infraorbital  canal,  and  the 
pain  is  specially  marked  along  the  upper  teeth.  In  the  lower  branches, 
which  are  more  frequently  involved,  there  are  painful  points  along  the 
auriculo-temporal  nerve  aiul  the  pain  radiates  in  the  region  of  the  car 
along  the  lower  jaw  and  teeth.  The  movements  of  mastication  and  speak- 
ing may  be  painful.  Salivation  is  not  imcommon.  Herpes  may  occur 
about  the  eye  or,  the  lips.  In  protracted  cases  there  may  be  atrophy  (tr 
induration  of  the  skin.  Some  of  the  forms  of  facial  neuralgia  are  of 
frightful  intensity  and  the  recurring  attacks  render  the  patient's  lifi.' 
almost  insupportable. 

(2)  Cervico-occipilal  ncurahjin  involves  the  posterior  branches  of  the 
first  four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  einor- 
gence  of  which  there  is  a  painful  point  about  half-way  between  the  mastoid 
process  and  the  first  cervical  vertebra.  It  may  be  caused  by  cold,  ami 
these  nerves  are  often  affected  in  cervical  caries. 

(.'})  Cervico-hrachial  neurahjia  involves  the  sensory  nerves  of  the 
brachial  plexus,  particularly  in  the  cubital  division.  When  the  circunillo^ 
nerve  is  involved  the  pain  is  in  the  deltoid.     The  pain  is  most  commonly 


NEURALGIA. 


9G1 


nbout  the  shoulder  and  down  the  course  of  the  ulnar  nerve.  Tliere  is 
usually  a  miirkod  tender  point  upon  this  nerve  at  tlic  elbow.  This  form 
rarely  follows  cold,  but  more  fre(piciitly  results  from  rheumatic  afiections 
of  the  joints,  and  trauma. 

(4)  Neuralgia  of  (he.  phrenic  nerve  is  rare.  It  is  sometimes  found  in 
])leurisy  and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  tlio 
thorax  on  a  line  with  the  insertion  of  the  diaphraf^m,  and  here  may  bo 
painful  points  on  deep  pressure.  Full  inspiration  is  painful,  and  there  is 
great  sensitiveness  on  coughing  or  in  the  perfornuiuce  of  any  movement 
by  which  the  diaphragm  is  suddenly  depressed. 

(5)  Intercostal  Xeurahjia. — ^Jext  to  the  tic  douloureux  this  is  the 
most  important  form.  It  is  most  frequent  in  women  and  very  common 
in  hysteria  and  anaunia.  The  pain  in  caries  and  aneurism  is  felt  in  the  in- 
ter(;ostal  nerves.  They  arc  also  the  seat  of  the  intense  pain  in  inflammation 
of  the  pleura.  The  pain  is  often  constant  and  exaggerated  by  movements. 
Pleurodynia  is  supposed  by  some  to  be  local  intercostal  neuralgia,  con- 
fined to  one  spot,  usually  along  the  course  or  at  the  exit  of  the  nerves. 
Herpes  zoster  or  zona  occurs  with  the  most  aggravated  form  of  intercostal 
neuralgia.  The  pain  usually  precedes  the  eruption,  whi  -h  consists  of  a 
series  of  pearly  vesicles,  which  take  two  or  three  days  to  develop  ami 
gradually  disappear.  The  eruption  may  occur  Avithout  miu'h  pain.  The 
most  distressing  feature  in  the  complaint  is  the  persistence  in  the  pain 
after  the  eruption  has  sulxsided.  The  eruption  and  the  neuralgia  are  in 
reality  manifestations  of  neuritis.  Changes  have  been  found  in  the  tu^rves 
and  in  the  ganglia  of  the  posterior  roots.  The  pain  of  zona  may  ])ersist 
indefinitely,  and  it  has  been  known  to  be  so  intractable  that  in  despair  the 
person  has  committed  suicide. 

(0)  Lumbar  KcHrahjia. — The  affected  nerves  are  the  posterior  fibres 
of  the  lumbar  plexus,  particularly  the  ilio-scrotal  branch.  The  ])ain  is  in 
the  region  of  the  iliac  crest,  along  the  inguinal  canal,  in  the  spermatic 
cord,  and  in  the  scrotum  or  labium  majus.  The  alfecliou  known  as  irri- 
t;ible  testis,  probably  a  neuralgia  of  this  nerve,  may  bo  very  severe  and 
dccomi)anied  by  syncopal  sensations. 

(T)  Cocciiihjnia. — This  is  regarded  as  a  neuralgia  of  the  coccygeal 
plexus.  It  is  most  common  in  women,  and  is  aggravated  by  the  sitting 
posture.  It  is  very  intractable,  and  nuiy  necessitnte  the  removal  of  the 
coccyx,  an  operation,  however,  which  is  not  always  successful.  Neuralgiiia 
of  the  nerves  of  the  leg  have  already  been  considered. 

(8)  Xcurahfias  of  the  Xerrrs  of  the  Fcrt. 

Painful  Heel. — lioth  in  women  and  men  tiiere  nuiy  be  about  I  he  hoel 
severe  pains  which  interfere  seriously  with  walking — the  j)0(lodynia  of 
S.  D.  dross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no 
affection  of  the  joints.  The  pain  is  usually  most  .''cverc  over  t'.'c  heel; 
sometimes  in  a  very  limited  spot,  sometimes  in  the  line  of  the  nu'tau:rso- 
plialang^al  joint.     Probably  this  painful  alloctiou  depends  upon  many 


9G2 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


differeut  conditions.  It  niuy  be  associated  with  rlicumatism  or  gout,  and 
witli  certain  occupations — persons  wlio  have  to  stand  for  a  long  time  on 
their  feet.    In  other  instances  it  occurs  with  flat-foot. 

Plantar  Xeurahjla. — Tliis  is  often  associated  with  a  definite  neiiriti:*, 
such  as  follows  typhoid  fever,  ami  has  been  seen  in  an  aggravated  form 
in  caisson  disease  (Hughes).  The  pain  may  be  limited  to  the  tijjs  of  the 
toes  or  to  the  ball  of  the  great  toe.  Numbness,  tingling,  and  hypor- 
aesthesia  or  sweating  may  occur  with  it.  Following  the  cold-bath  treat- 
ment in  typhoid  fever  it  is  not  uncommon  for  patients  to  complain  of 
great  sensitiveness  in  the  toes. 

ErythromclaUjia. — Under  this  term  Weir  Mitchell  describetl  a  con- 
dition which  is  associated  with  great  pain  in  the  heel  or  in  the  sole  of  the 
foot,  with  vascular  changes,  either  an  acute  hypertr^mia  or  cyanosis.  Some 
of  the  cases  should  unquestionably  be  regarded  as  Kaynaud's  disease. 

(!))  Viscfral  Xcurahjias. — The  more  important  of  these  have  already 
been  referred  to  in  connection  with  the  cardiac  and  the  gastric;  neurosci^, 
They  are  most  frequent  in  women,  and  are  constant  accompanimcT^is  of 
neurasthenia  and  hysteria.  The  pains  arc  most  common  in  the  p^  ivi- 
region,  ])articularly  about  the  ovaries.  Xejihralgia  is  of  great  interest,  n.ir, 
as  has  already  been  mentioned,  the  symptoms  may  closely  simulate  those 
of  stone. 

Treatment. — Causes  of  reflex  irritation  should  be  carefully  removcil. 
The  neuralgia,  as  a  rule,  recurs  unless  the  general  health  improves;  so 
that  tonic  and  hygienic  measures  of  all  sorts  should  be  employed.  Often 
a  change  of  air  or  surroundings  Avill  relieve  a.  severe  neuralgia.  I  have 
known  obstinate  cases  to  be  cured  by  a  prolonged  residence  in  the  mount- 
ains, with  an  out-of-door  life  and  plenty  of  exercise.  Of  general  remedios, 
iron  is  often  a  specific  in  the  cases  associated  with  chlorosis  and  anaMnia. 
Arsenic,  too,  is  very  beneficial  in  these  forms,  and  should  be  given  in 
ascending  doses,  'j'he  value  of  quinine  has.been  much  overrated.  It  j)rob- 
ubly  has  no  more  influence  than  any  other  bitter  tonic,  except  in  the  rare 
instances  in  which  the  neuralgia  is  definitely  associated  with  malarial  poi- 
soning. Strychnine,  cod-liver  oil,  and  ])hosi)horns  are  also  advantageous. 
Of  remedies  for  the  pain,  the  new  analgesics  should  first  1  "  tri"d — anti- 
pyrin,  antifebrin,  and  phenacetin — for  they  are  sometimes  of  service. 
Morphia  should  be  given  with  great  caution,  and  only  after  other  reme- 
dies have  been  tried  in  vain.  On  no  consideration  should  the  patient  bo 
allowed  to  use  the  hypodermic  syringe.  Gelsemium  is  Jiighly  recom- 
mended. Of  nervine  stimulants,  valerian  and  ether,  which  often  act  well 
together,  may  be  given.  Alcohol  is  a  valuable,  1  hough  dangerous,  remedy, 
and  should  not  be  ordered  for  women.  In  the  trifacial  neuralgia  nitro- 
glycerin in  large  doses  nuiy  be  tried.  Aconitia  in  doses  of  from  one  t\ii>- 
Imndredth  to  one  one-hundred-and-fiftieth  of  a  grain  may  be  trie<l.  i" 
gouty  and  rheumatic  subjects  cannabis  indica  and  ciniicifuga  are  recom- 
mended with  the  lithium  salts. 


;out,  and 
tiim.'  on 

noiirilis, 
icd  form 
ps  of  the 
A  liyper- 
ith  tivat- 
nplaiii  of 

id  a  0(Ui- 
ole  of  the 
is.  Home 
nise. 

■0  already 
neuroses, 
imoris  of 
the  :>:•; 
tere.it,  lor, 
ihito  those 

'  removed, 
iroves;  so 
■d.     Often 
I.     I  have 
he  mount- 
remedies, 
anivnua. 
jviveu  in 
It  prob- 
n  the  rare 
iirial  poi- 
iiitageous. 
,,] — anti- 
■   serviee. 
ler  renie- 
liitient  be 
y  reeoin- 
11  act  well 
jj,  remedy, 
giii  nitro- 
1  one  two- 
tried.     I" 
ire  rex)m- 


Ai 


PROFESSIONAL  SPASMS;  OCCUPATION  NEUROSES. 


963 


Of  local  applications,  the  thermo-cautery  is  invaluable,  particularly  in 
zona  and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  be 
u.sed,  or  aquapuncture,  the  injection  of  distilled  water  beneath  the  skin. 
Chloroform  liniment,  camphor  and  chloral,  menthol,  the  oleates  of  mor- 
j)liia,  atropia,  and  belladonna  used  with  lanolin  may  be  tried.  Freezing 
over  the  tender  point  with  ether  spray  is  sometimes  successful.  The  con- 
tiiiuoua  current  may  be  used.  The  sponges  should  be  warm,  and  the  posi- 
tive pole  should  be  placed  near  the  seat  of  the  pain.  The  strength  of  the 
current  should  be  such  as  to  cause  a  slight  tingling  or  burning,  but  not 
pain. 

The  surgical"  treatment  of  intractable  neuralgia  embraces  nerve  stretch- 
ing and  excision.  The  latter  is  the  most  satisfactory,  but  too  often  the 
pain  returns. 


IX.  PROFESSIONAL  SPASMS;  OCCUPATION   NEUROSES. 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  certain 
movement  may  be  followed  by  an  irregular,  involuntary  spasm  or  cramp, 
which  may  completely  check  the  performance  of  the  action.  The  condi- 
tion is  found  most  frequently  in  writers,  hence  the  term  writer's  cramp 
or  scrivener's  palsy;  but  it  is  also  common  in  piano  and  violin  players  and 
in  telegraph  operators.  The  spasms  occur  in  many  other  persons,  such  as 
milkmaids,  weavers,  and  cigarette-rollers. 

The  most  common  form  is  writer's  cramp,  which  is  much  more  fre- 
quent in  men  than  in  women.  Of  7j  cases  of  impaired  writing  power  re- 
})ortcd  by  Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in 
men.  Morris  J.  Lewis  states  that  in  this  country,  in  the  telegrapher's 
("ainp,  women,  who  are  eni])loyed  a  great  deal  in  telegraphy,  are  much 
Uvi'i  frequently  affected  (only  4  out  of  43  cases).  Persons  of  a  nervous 
tf'iot  ..>rament  are  more  liable  to  the  disease.  Occasionally  it  follows  slight 
'I  jnrv. 

TwVfers  states  that  in  a  majority  of  the  cases  a  faulty  method  of  writing 
Ita..  ')'■  .1  employed,  using  either  the  little  finger  or  the  wrist  as  the  lixed 
point  Persons  who  write  from  the  middle  of  the  forearm  or  from  the 
elbow  are  rarely  affected. 

No  aiiaioinical  changes  have  been  found.  The  most  reasonable  ex- 
planation of  the  disease  is  that  it  results  from  a  deranged  action  of  the 
nerve  centres  presiding  over  the  muscular  movements  involved  in  the  act 
of  writing,  a  condition  which  has  been  termed  irritable  weakness.  "  The 
eilucation  of  centres  which  may  be  widely  separated  from  each  other  for 
the  performance  of  any  delicate  movement  is  mainly  accomplished  by  less- 
ening the  lines  of  resistance  between  them,  so  that  the  movement,  which 
was  at  first  produced  by  a  considerable  mental  effort,  is  at  last  executed 
almost  unconsciously.     If,  therefore,  through  i)rolonged  excitation,  tliis 


61 


■:i 


m  m 


'iiiiafiJii^i 


964 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Iff 

41  r 


III , 

r   t 


IT 


lessened  resistance  be  carried  too  far,  there  is  an  increase  and  irregular 
discharge  of  nerve  energy,  which  gives  rise  to  spasm  and  disordered  move- 
ment. According  to  tliis  view,  tlie  mnscnhir  weakness  is  explained  by  an 
impairment  of  nutrition  accompanying  that  of  function,  and  the  dimin- 
ished faradic  excitability  by  the  nutritional  disturbance  descending  the 
motor  nerves."     (Oay.) 

Symptoms. — Those  may  l)e  described  under  five  heads  (Lewis). 

(a)  Cramp  or  Spasm. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb  ;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  j^en  may  be  twistod 
from  the  grasp  and  thrown  to  some  distance.  "Weir  Mitchell  has  descrilicd 
a  lock-spasm,  in  Avhich  the  fingers  become  so  firmly  contracted  upon  the 
pen  that  it  cannot  be  removed. 

{b)  Paresi:  and  Paralysis. — This  may  occur  with  the  spasm  or  alone. 
The  patient  fe^  -  so  of  weakness  and  debility  in  the  muscles  of  the 

hand  and  arm  anti  vis  the  pen  feebly.  Yet  in  these  circumsUiiices  the 
grasp  of  the  hand  nuiy  be  strong  and  there  may  be  no  paralysis  for  ordi- 
nary acts. 

(r)  Tremor. — This  is  most  commonly  seen  in  the  forefinger  and  may 
bo  a  premonitory  symptom  of  atrophy.  It  is  not  an  important  symptom, 
and  is  rarely  sufficient  to  produce  disability. 

('/)  Pain. — Abnormal  sensations,  particularly  a  tired  feeling  in  the 
muscles,  are  very  constantly  present.  Actual  pain  is  rare,  but  there  may 
be  irregular  shooting  pains  in  the  arm.  Numbness  or  soreness  may  exir^t. 
If,  as  sometimes  hai)pens,  a  subacute  neuritis  develops,  there  may  be  pain 
over  the  nerves  and  numbness  or  tingling  in  the  fingers. 

{c)  Vasomotor  Disturbances. — These  may  occur  in  severe  cases.  There 
may  be  hypera>sthesia.  Occasionally  the  skin  l)ecomes  glossy,  or  there  is 
a  condition  of  local  asphyxia  resembling  chilblains.  In  attempting  to 
write,  the  hand  and  arm  may  become  flushed  and  hot  and  the  veins  increased 
in  size.  Early  in  the  disease  the  electrical  reactions  are  normal,  but  in  ad- 
vanced cases  there  may  be  diminution  of  faradic  and  sometimes  increase 
in  the  galvanic  irritability. 

Diagnosis. — A  well-marked  case  of  writer's  cramp  or  palsy  could 
scarcely  be  mistaken  for  any  other  affection.  Care  must  be  taken  to  ex- 
clude the  existence  of  any  cerebro-spinal  disease,  such  as  progressive  mus- 
cular atrophy  or  hemiplegia.  The  physician  is  sometimes  consulted  by 
nervous  persons  who  fancy  they  are  becoming  subject  to  the  disease  and 
complain  of  stiffness  or  weakness  without  displaying  any  characteristic 
features. 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken 
in  time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  im- 
prove rapidly,  but  too  often  there  is  a  strong  tendency  to  recurrence.  1'lic 
patient  may  learn  to  write  with  the  left  hand,  but  this  also  may  after  u 
time  be  attjicked. 


TETANY. 


965 


Treatment. — Various  prophylactic  measures  have  been  advised.  As 
mentioned,  it  is  important  that  a  proper  method  of  writing  be  adoi)ted. 
GoAvers  suggests  tliat  if  all  persojis  wrote  from  the  shoulder  writer's  cramp 
would  practically  not  incur.  Various  devices  have  been  invented  for  re- 
lieving the  fatigue,  but  none  of  them  are  very  satisfactory.  The  use  of  the 
type-writer  has  diminished  very  much  the  frequency  of  scrivener's  jmlsy. 
Kest  is  essential.  No  measures  are  of  value  without  this,  ^[assage  and 
manipulation,  when  combined  with  systematic  gymnastics,  give  the  best 
results.  I'oore  recommends  the  galvanic  current  applied  to  the  muscles, 
which  arc  at  the  same  time  rhythmically  exercised. 

'J'he  nutrition  of  the  patients  is  apt  to  be  much  impaired,  and  cod-liver 
oil,  strychnia,  and  other  tonics  will  be  found  advantageous.  Local  appli- 
cations are  of  little  benefit.  Tenotomy  and  nerve-stretching  have  been 
abandoned. 

X.  TETANY. 

Deflnition. — An  affection  characterized  by  peculiar  tonic  spasms, 
either  paroxysmal  or  continued,  of  the  extremities. 

Etiology. — The  disease  occurs  under  very  different  conditions.  Four 
varieties  may  be  recognized. 

(a)  Epidemic  tetany,  also  knoAvn  as  rheumatic  tetany.  In  certain 
parts  of  the  continent  of  Eui'ope  the  disease  has  prevailed  widely,  particu- 
larly in  the  winter  season.  Von  Jaksch,  who  has  described  an  epidemic 
form  occurring  in  young  men  of  the  working  classes,  sometimes  with 
slight  fever,  regards  the  disease  as  infectious.  This  form  is  acute,  lasting 
only  two  or  three  weeks  and  rarely  proving  fatal. 

(h)  A  majority  of  the  cases  are  found  in  association  with  debility  fol- 
lowing lactation  and  chronic  diarrha^a,  or  in  the  malnutrition  of  rickets. 
From  its  occurrence  in  nursing  women  Trousseau  called  it  nurse's  con- 
tracture. It  may  also  occur  during  pregnancy.  It  has  been  found  as  a 
sequence  of  the  acute  fevers,  and  in  some  typhoid  epidemics  many  cases 
have  occurred. 

(c)  Tetany  may  follow  removal  of  the  thyroid  gland.  Thirteen  cases, 
for  example,  followed  seventy-eight  operations  on  enlarged  thyroid  in  Bill- 
roth's  clinic,  and  six  of  them  proved  fatal.  James  Stewart  has  reported 
an  instance  in  which  with  the  tetany  there  were  symptoms  of  myxcedema, 
and  no  trace  of  the  thyroid  gland.  Removal  of  the  thyroid  in  dogs  has 
also  been  followed  by  tetany. 

{(1)  And,  lastly,  there  is  a  form  of  fatal  tetany  which  is  associated 
with  dilatation  of  the  stomach,  particularly  after  the  organ  has  been 
washed  out.     A  case  has  been  reported  in  this  country  by  F.  T.  Miles. 

On  this  continent  tetany  is  an  extremely  rare  disease.  In  the  discus- 
sion on  Stewart's  case  at  the  xVssociation  of  American  Physicians,  "Wash- 
ington, 1889,  Weir  Mitchell  stated  that  he  had  seen  but  two  instances  in 


mn 


'I' 


^M 


966 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


KMf 

t'V; 


his  long  and  varied  experience,  while  Pepper  had  seen  but  one  case,  and 
that  was  in  a  child. 

The  nature  of  the  disease  is  unknown,  but  it  probably  depends  upon 
the  action  of  some  toxic  agent  on  the  motor-nerve  cells. 

Symptoms. — In  cases  associated  with  general  debility  or  in  childicn 
with  rickets  the  spasm  is  limited  to  the  hands  and  feet.  The  fingers  sre 
bent  at  the  metacari)o-phalangeal  joint,  extended  at  the  terminal  joints, 
pressed  close  together,  and  the  thumb  is  contracted  in  the  palm  of  the 
hand.  The  wrist  is  flexed,  the  elbows  are  bent,  and  the  arms  are  folded 
over  the  chest.  In  the  lower  limbs  the  feet  are  extended  and  the  toes  ad- 
ducted.  The  muscles  of  the  face  and  neck  are  less  commonly  involved, 
but  in  severe  cases  there  may  be  trismus,  and  the  angles  of  the  mouth  are 
drawn  out.  The  skin  of  the  hands  and  feet  is  sometimes  tense  and  o'do- 
matous.  The  spasms  are  usually  paroxysmal  and  last  for  a  variable  time. 
Ii.  children  the  attack  may  pass  off  in  a  few  hours.  In  some  of  the 
severer  chronic  cases  in  adults  the  stiffness  and  contracture  may  contiiuio 
or  even  i)icrease  for  many  days,  and  the  attack  may  last  as  long  as  two 
weeks.  In  the  acute  cases  the  temperature  may  be  elevated  and  the  pulse 
quickened.  In  the  severe  paroxysms  there  may  be  involvement  of  the 
muscles  of  the  back  and  of  the  thorax,  inducing  dyspnani  and  cyanosis. 
Two  additional  features,  valuable  in  diagnosis,  are  present.  The  irritabil- 
ity of  the  nerves  is  enormously  increased  both  during  the  period  of  tetany 
and  subsequently.  Thus  a  mininud  strength  of  current  necessary  to  pio- 
duce  a  contracture  during  the  quiescent  period  is  sufficient  during  tlio 
attack  to  cause  a  distinct  tetanic  contraction.  The  second  point  is  tlio 
so-called  Trousseau's  phenomenoii :  pressure  on  the  larger  arteries,  some- 
times on  the  nerve  trunk,  will  excite  the  sjjasm,  which  continues  while  the 
pressure  is  kept  uj). 

Diagnosis. — The  disease  is  readily  recognized.  It  is  a  mistake  to 
call  instances  of  carpo-pedal  spasm  of  chiklren  true  tetany.  It  is  com- 
mon to  find  in  rickety  children  or  in  cases  of  severe  gastro-intestinal 
catarrh  a  transient  spasm  of  the  fingers  or  even  of  the  arms.  By  many 
authors  these  are  considered  cases  of  mild  tetany,  and  there  are  all  grades 
ill  rickety  children  between  the  simple  carpo-pedal  spasm  and  the  con- 
dition in  which  the  four  extremities  are  involved;  but  it  is  well,  I  think, 
to  limit  the  term  tetany  to  the  severer  affection. 

With  true  tetanus  the  disease  is  scarcely  ever  confounded,  as  the  com- 
mencement of  the  spasm  in  the  extremities,  the  attitude  of  the  hands, 
and  the  etiological  factors  are  very  different.  Hysterical  contractures  am 
usually  unilateral. 

Excejjt  in  the  cases  associated  with  dilated  stomach  and  those  whi  'li 
follow  thyroidectomy  the  prospnct  of  recovery  is  good. 

Treatment. — In  the  case  of  children  the  condition  with  whicli  tlii' 
tetany  is  associated  should  be  treated.  Baths  and  cold  sponging  are  rec- 
ommended and  often  relieve  the  spasm  as  promptly  as  in  child-crowing 


HYSTERIA. 


967 


Bromide  of  potassium  may  be  tried.  In  severe  cases  cliloroform  inliala- 
tions  may  be  given.  Massage,  electricity,  and  the  spinal  ice-bag  have  also 
been  nsed  with  success.  Cases,  however,  may  resist  all  treatment,  and  the 
spasms  recur  for  many  years. 


XI.  HYSTERIA. 

Definition. — A  state  in  which  ideas  control  the  body  and  produce 
morbid  changes  in  its  functions  (Mobius). 

Etiology. — The  affection  is  most  common  in  women,  and  usually  ap- 
pears first  about* the  time  of  puberty,  but  the  numifestations  may  coiitinue 
until  the  menopause,  or  even  until  old  age.  Men  and  boys,  however,  are 
by  no  means  exempt,  and  of  late  years  hysteria  in  the  male  has  attracted 
much  attention.  It  occurs  in  all  races,  but  is  much  more  prevalent,  |)ar- 
ticularly  in  its  severer  forms,  in  members  of  the  Latin  race.  In  thi. 
country  the  milder  grades  are  common,  but  the  graver  forms  are  rare  in 
comparison  with  the  frequency  with  which  they  are  seen  in  France. 

Of  predisposing  causes,  two  are  important — heredity  and  education. 
The  former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensi- 
tive nervous  organization.  We  see  cases  most  frecpiently  in  families  with 
marked  neuropathic  tendencies,  the  members  of  which  have  suffered  from 
neuroses  of  various  sorts.  Education  at  home  too  often  fails  to  inculcate 
habits  of  self-control.  A  child  grows  to  girlhood  with  an  entirely  errone- 
ous idea  of  her  relations  to  others,  and  accustomed  to  have  every  whim 
gratified  and  abundant  sympathy  lavished  on  every  woe,  however  trifling, 
she  reaches  Avomanhood  with  a  moral  organization  unfitted  to  withstand 
the  cares  and  worries  of  every-day  life.  At  school,  between  the  ages  of 
twelve  and  fifteen,  the  most  important  period  in  her  life,  when  the  vital 
energies  are  absorbed  in  the  rapid  development  of  the  body,  she  is  often 
cramming  for  examinations  and  cooped  in  close  school-rooms  for  six  or 
eight  hours  daily.  The  result  too  frequently  is  an  active,  bright  mind  in 
an  enfeebled  body,  ill  adapted  to  subserve  the  functions  for  Avhich  it  was 
framed,  easily  disordered,  and  prone  to  react  abnormally  to  the  ordinary 
stimuli  of  life.  Among  the  more  direct  influences  are  emotions  of  various 
kinds,  fright  occasionally,  more  frequently  love  tiffairs,  grief,  and  domestic 
worries.  Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they 
may  follow  directly  upon  an  injury  or  develop  during  the  convalescence 
from  an  acute  illness  o-'be  associated  with  disease  of  the  generative  organs. 
The  name  hysteria  indicates  how  important  was  believed  to  be  the  part 
played  by  the  uterus  in  the  causation  of  the  disease.  Opinions  differ  a 
good  deal  on  this  question,  but  undoubtedly  in  many  cases  there  are  ova- 
rian and  uterine  disorders  the  rectification  of  which  sometimes  cures  the 
disease.  Sexual  excess,  particularly  masturbation,  is  an  important  factor,, 
both  in  girls  and  boys. 


i*i. 


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Hili 


9G8 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


i':,. ',.■■■' 


SI' 


J !  '     'I 


Symptoms. — A  useful  division  is  iuto  the  convulsive  and  nou-cou- 
vulsivo  varieties. 

Convulsive  Hysteria. — {a)  Minor  Forms. — The  attack  most  commonly 
follows  cinolioiial  disturbaiice.  It  may  set  in  suddenly  or  be  preceded  by 
sym|)tonis,  called  by  the  laity  "  hysterical,"  such  as  laughing  and  crying 
alternately,  or  a  sensation  of  constriction  in  the  neck,  or  of  a  ball  rising  in 
the  throat — the  yhbus  hystericus.  Sometimes,  preceding  the  convulsive 
movements,  there  may  be  i)ainful  sensations  arising  from  the  pelvic,  al)- 
dominal,  or  thoracic  regions.  From  the  description  these  sensations 
rescndde  aura?.  They  become  more  intense  with  the  rising  sensatiiju  of 
choking  in  the  neck  and  difliculty  in  getting  breath,  and  the  patient  falls 
into  a  more  or  less  violent  convulsion.  It  will  be  noticed  that  the  fall  is 
not  sudden,  as  in  ei)ilepsy,  but  the  subject  falls,  as  a  rule,  easily,  often 
picking  a  soft  spot,  like  a  sofa  or  an  easy  chair,  and  in  the  movements 
apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  quite  unconscious.  The  movements  are  clonic  and 
disorderly,  consisting  of  to-and-fro  motion  of  the  trunk  or  pelvic  mus- 
cles, and  the  head  and  arnis  arc  thrown  about  in  an  irregular  manner. 
The  jtaroxysm  after  a  few  nunutes  slowly  subsides,  then  the  patient 
becomes  emotional,  and  gradually  regains  consciousness.  When  ques- 
tioned the  patient  may  confess  to  having  some  knowledge  ol  the  events 
which  have  taken  place,  but,  as  a  rule,  has  no  accurate  recollection.  Dur- 
ing the  attack  the  abdomen  may  be  much  distended  with  flatus,  and  sub- 
sequently a  large  amount  of  clear  urine  may  be  passed.  These  attacks 
vary  greatly  in  character.  There  may  be  scarcely  any  movements  of  the 
limbs,  but  after  a  nerve  storm  the  patient  sinks  into  a  torpid,  semi-uncon- 
scious condition,  from  which  she  is  roused  with  great  difficulty.  In  sonic 
cases  from  this  state  the  patient  passes  into  a  condition  of  catalepsy. 

{}))  Major  Forms;  Hystcro-vpilcpsy. — This  condition  has  been  specially 
studied  by  Charcot  and  his  pupils.  Typical  histances  passing  through  the 
various  phases  are  very  rare  in  this  country.  The  attack  is  initiated  by 
certain  prodromata,  chiefly  minor  hysterical  manifestations,  either  foolish 
or  unseemly  behavior,  excitement,  sometimes  dyspeptic  symptoms  with 
tympanites,  or  frequent  micturition.  Areas  of  hypersesthesia  may  at  this 
time  be  marked,  the  so-called  hysterogenic  spots  so  elaborately  described 
by  Ilichet.  These  are  usually  symmetrical  and  situated  over  the  upper 
dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on 
the  chest  and  abdomen,  the  most  marked  being  those  in  the  inguinal 
regions  over  the  ovaries.  Painful  sensations  or  a  feeling  of  oppression 
and  a  ylobus  rising  in  the  throat  may  be  complained  of  prior  to  the  onset 
of  the  convulsion,  which,  according  to  French  writers,  has  four  distinct 
stages :  (1)  Epileptoid,  condition,  which  closely  simulates  a  true  epileptic 
attack  with  tonic  spasm  (often  leading  to  opisthotonos),  grinding  of  the 
teeth,  congestion  of  the  face,  followed  by  clonic  convulsions,  gradual 
relaxation,  and  coma.     This  attack  lasts  rather  longer  than  a  true  epi- 


HYSTERIA. 


900 


loptio  nttiick.  (2)  Suoocoding  this  is  a  period  which  Clmrcot  has  tcrnii'd 
downixm,  in  wliich  thcrt'  is  an  emotional  display  and  a  reinarlvahlo  sorios 
of  contortions  or  of  cataleptic  poses.  (3)  Then  in  typical  cast's  there  is 
a  stage  in  which  the  j)atient  assumes  certain  attitudes  expressive  of  the 
various  passions — ecstasy,  fear,  beatitude,  or  erotism.  (4)  Finally  con- 
sciousness returns  and  the  patient  enters  upon  a  stage  in  which  she  may 
display  very  varied  symptoms,  chiefly  manifestations  of  a  delirium  with 
the  most  extraordinary  hallucinations.  Visions  are  seen,  voices  heard, 
and  conversations  held  with  imaginary  i)ersons.  In  this  stage  patients 
will  relate  with  the  utmost  solemnity  imaginary  events,  and  make  ex- 
traordiiuiry  aiul  serious  chai-ges  against  individuals.  This  sometimes  gives 
a  grave  aspect  to  these  seizures,  for  not  only  will  the  patient  at  this  stage 
make  and  believe  the  statements,  but  when  recovery  is  complete  the  hal- 
lucination sometimes  persists.  Wo  seldom  see  in  this  country  attacks 
having  this  orderly  sequence.  Much  more  commonly  the  convulsions 
succeed  each  other  at  intervals  for  several  days  in  succession.  Here  is  a 
striking  ditference  between  hystero-epilepsy  aiul  true  e})ilei)sy.  In  the 
latter  the  status  epilej)ticus,  if  persistent,  is  always  serious,  associated 
with  fever,  and  frecjuently  fatal,  while  in  hystero-ei)ilepsy  attacks  may 
recur  for  days  without  special  (huiger  to  life.  After  an  attack  of  hystero- 
epilepsy  the  patient  may  sink  into  a  state  of  trance  or  lethargy,  in  which 
she  may  remain  for  days. 

Non-convulsive  Forms. — So  complex  and  varied  is  the  clinical  ]ncture 
of  hysteria  that  various  manifestations  are  best  considered  according  to 
the  systems  which  are  involved. 

(1)  Disorders  of  Motion. — («)  Pdrah/scn. — These  may  be  hemiplegic, 
pivvaplegic,  or  nionoplegic.  Hysterical  diplegia  is  extremely  rare.  1'he 
jiaralysis  either  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain 
its  full  development.  77iere  is  no  type  or  form  of  organic  jinnthjxis  which 
vimj  not  be  simnhtted  in  hysteria.  According  to  Weir  ^litchell,  the  hemi- 
plegias are  most  frequent  in  the  ratio  of  four  on  the  left  to  one  on  the 
right  side.  The  face  is  not  affected ;  the  neck  may  be  involved,  but  the 
leg  suffers  most.  Sensation  is  either  lessened  or  lost  on  the  atTected  side. 
The  hysterical  paraplegia  is  more  common  than  hemiplegia.  The  loss  of 
power  is  not  absolute;  the  legs  can  usually  be  moved,  but  do  not  support 
the  patient.  The  reflexes  nuiy  be  increased,  though  the  knee-jerk  is  often 
normal.  A  spurious  ankle  clonus  may  sometimes  be  present.  The  feet 
are  usually  extended  and  turned  inward  in  the  equino-varus  position.  The 
muscles  do  not  waste  and  the  electrical  reactions  are  normal.  Other  mani- 
festations, such  as  paralysis  of  the  bladder  or  aphonia,  are  usually  associ- 
ated with  the  hysterical  paraplegia.  Hysterical  monoi)legias  may  be  facial, 
crural,  or  brachial.  A  condition  of  ataxia  sometimes  occurs  with  paresis. 
The  incoordination  may  b^  a  marked  feature,  and  there  are  usually  sen- 
sory manifestations. 

{b)    Contractures  and  Sjiasms. — An  cxtraordiaary  Asariety  of  spas- 


.;'  J- 1 


970 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


m-  ■ 


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Mi 


iModic  afToction3  occurs  in  hysteria,  of  which  the  most  common  arc  tho 
following:  Tho  livHtorical  contractures  may  attack  almost  any  group  of 
voluntary  mi.sdes  aiul  he  of  the  hemiplegic,  jjaraplegic,  or  niouoplcgic 
type.  They  may  come  on  suddejily  or  slowly,  persist  for  months  or  v(iir<, 
and  disappear  rapidly.  Tho  contracture  is  most  commonly  seen  in  the 
arm,  which  is  flexed  at  the  elhow  and  wrist,  and  the  fingers  tightly  grasp 
the  thumh  in  the  j)alm  of  the  hand ;  more  rarely  the  terminal  phaliiugcs 
are  hyperextended  as  in  athetosis.  It  may  occur  in  one  or  in  both  legs, 
more  commonly  tho  former.  The  anklo  clonus  is  present ;  the  foot  i.s 
inverted  and  the  toes  arc  strongly  flexed.  '^Phese  cases  may  bo  mistaken 
for  lateral  sclerosis  anil  the  ditllculty  in  diagnosis  may  really  bo  very  great. 
The  spastic  gait  is  very  typical,  aiid  with  the  exaggerated  knee-jerk  and 
anklo  clonus  the  picture  may  be  characteristic.  In  IHTl)  I  froipu'iitlv 
showed  such  a  case  at  the  ^[ontreal  General  Hospital  as  a  typical  example 
of  lateral  sclerosis.  The  condition  persisted  for  more  than  eighteen  mouths 
and  then  disappeared  completely.  Other  forms  of  contracture  may  he  in 
the  muscles  of  the  hip,  shoulder,  ov  lU'ck  ;  more  rarely  in  those  of  the  jaws 
— hysterical  trismus — or  in  the  tongue.  Ketnarkable  indeed  are  the  local 
contractures  in  the  diaphragm  and  abdominal  muscles,  ))roducing  a  phan- 
tom tumor,  ii  which  just  below  uiul  in  the  neighborhood  of  the  umbilicus 
is  a  firm,  appi.rently  solid  growth.  According  to  (Jowers,  this  is  produced 
by  relaxation  )f  the  recti  and  a  spasmodic  contraction  of  the  diaphragm, 
together  with  inflsition  of  the  intestines  with  gas  and  an  arching  forward 
of  the  vertebral  column.  They  ctre  apt  to  occur  in  middle-aged  women 
abo'  "■.  the  menopause,  aiul  arc  frequently  associated  with  the  symiitoins  of 
spurious  pregnancy — psrxdo-rycsia.  The  resemblanc!o  to  a  tumor  may  lie 
striking,  and  I  have  known  skilful  diagnosticians  to  be  deceived.  The 
only  safeguard  is  to  bo  found  in  complete  ansBstheaia,  when  the  tumor 
entirely  disappears.  Some  years  ago  I  went  by  chaiu'e  into  the  -operating- 
room  of  a  hospital  and  found  a  patient  on  the  tiible  under  chloroform  and 
the  surgeon  prepared  to  perform  ovariotomy.  The  tumor,  however,  had 
completely  disappeared  with  full  anfeathesia.  Mitchell  has  reported  an 
instance  of  a  i)hantom  tumor  in  the  left  pectoral  region  just  above  the 
breast,  which  was  tender,  hard,  and  dense. 

Clonic  spasms  are  more  common  in  hysteria  in  this  country  tlnin 
(!ontractures.  The  following  are  the  important  forms:  JUii/fhniic  In/s/cr- 
ical  spasm.  This,  unfortunately,  is  sometimes  known  as  rhythmic  chorea 
or  hysterical  chorea.  The  movements  may  be  of  the  arm,  cither  flexion 
and  extension,  or,  more  rarely,  promition  and  su[)ination.  Clonic  contrae- 
tions  of  tho  sterno-cleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  tlio 
rotatory  muscles  of  the  head  may  produce  rhythmic  movements  of  these 
parts.  The  spasm  may  be  in  one  or  both  psoas  muscles,  lifting  the  leg  in 
a  rhythmic  manner  eight  or  ten  times  in  a  minute.  In  other  instances 
the  muscles  of  the  trunk  are  affected,  and  every  few  moments  there  is  a 
bowing  movement — salaam  convulsions — or  the  muscles  of  the  back  may 


HYSTERIA. 


m 


contract,  cansirifj  atronfj  iirohin;^  of  the  vertebral  column  and  retraction 
of  the  head.  'I'hese  nioveinents  may  often  alternate,  as  in  a  ea^o  in  my 
wards,  in  whicli  the  patient  on  fnie  days  had  regular  salaam  convul- 
sions,  while  on  wet  days  the  rhythmic  spasm  was  in  the  muscles  of  the 
back  and  neck,  ^liteliell  has  described  a  rotatory  spasm  in  which  the 
jtatient  rotated  involuntarily,  usually  to  the  left.  More  unusual  cases  are 
those  in  which  the  contractions  closely  simulate  paramyoclonus  multiplex. 
A  characteristic  example  of  this  was  recently  at  my  clinic.  Hysterical 
athetosis  is  a  rare  form  of  spasm.  Tremor  may  be  a  i)ure  hysterieal  mani- 
festation, occurrinji^  either  alone  or  with  ))aralysis  aiul  contraeture.  It 
most  conuuoply  involves  the  hands  and  arms;  more  rarely  the  head  and 
legs.  The  movements  are  small  and  quick.  N'olitioual  or  intentional 
tremor  may  exist,  simulating  closely  the  movements  of  insular  sclerosis. 
Huzzard  states  that  many  instances  of  this  disease  in  young  girls  are  mi.s- 
taken  for  hysteria. 

(v)  Disorders  of  Sensation. — Amesthcsia  is  most  common,  and  usually 
confined  to  one  half  of  the  bo«t^'.  It  may  not  be  noticed  by  tlie  patient. 
Usually  it  is  accurately  limited  to  the  middle  line  and  involves  the  mucous 
surfaces  and  deejjcr  ])arts.  The  conjunr-tiva,  however,  is  often  spared. 
'I'here  may  be  hemianopia.  This  symptom  may  come  on  slowly  or  follow 
a  convulsive  attack.  Sonu'times  the  various  sensations  are  djssociated  and 
the  anaesthesia  may  be  only  to  pain  and  to  touch.  The  skin  of  the  aifected 
side  is  usually  pale  and  cool,  and  a  pin-prick  may  not  be  followed  by  blood. 
With  the  loss  of  feeling  there  may  be  loss  of  muscular  power.  Curious 
trophic  changes  nuiy  l)e  present,  as  in  an  interesting  case  of  Weir  Mitdi- 
ell's,  in  which  there  was  unilateral  swelling  of  the  hemiplegic  side. 

A  i)henomenon  to  which  much  attention  has  been  paid  is  that  of  trans- 
ference. By  metallotherapy,  the  application  of  certain  metals,  the  ana'S- 
thesia  or  analgesia  can  be  transferred  to  the  other  side  of  the  body.  It 
has  been  shown,  however,  that  this  phenomenon  may  be  caused  by  the 
electro-magnet  and  by  wood  and  various  other  agents,  and  is  probably 
entirely  a  mental  effect.  The  subject  has  no  practical  importance,  but  it 
remains  an  interesting  and  instructive  chapter  in  Gallic  medical  history. 

Ifi/perceslhesia. — Increased  sensitiveness  and  pains  occur  in  various 
parts  of  the  body.  One  of  the  most  frequent  complaints  is  of  ]i!'in  in  the 
head,  usually  over  the  sagittal  suture,  less  frequently  in  the  occiput.  This 
is  described  as  agonizing,  and  is  compared  to  the  driving  of  a  nail  into  the 
part;  hence  the  name  dnvus  liystcricus.  Neuralgias  are  common,  lly- 
peroesthetic  areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax 
and  abdomen,  pressure  upon  which  may  cause  mitior  manifestations  or 
even  a  convulsive  attack.  Increased  sensitiveness  exists  in  the  ovarian 
region,  but  is  not  peculiar  to  hysteria.  Pain  in  the  back  is  an  almost  con- 
stant complaint  of  hysterical  patients.  The  sensitiveness  may  be  limited 
to  certain  spinous  processes,  or  it  may  be  diffuse.  In  hysterical  women 
the  pains  in  the  abdomen  may  simulate  those  of  gastralgia  and  of  gastric 


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DISEASES  OP  THE  NERVOUS  SYSTEM. 


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ulcer,  or  tlic  condition  may  bo  almost  identical  with  that  of  peritonitis; 
moro  rarely  the  ubdominal  paina  closely  resemble  those  of  ajtpeiidix 
disease. 

Special  Senses. — Disturbances  of  taste  and  smell  are  not  uncornmdU 
and  may  cause  a  good  deal  of  distress.  Of  oi;ular  symptoms,  retinal  hyixr- 
a^sthesia  is  the  most  common,  and  the  patients  always  jirefer  to  I)e  in  a 
darkened  room.  Ketraction  of  the  field  of  vision  is  eominon  and  usually 
fullows  a  convulsive  seizure.  It  may  persist  for  years.  The  color  per(t|)- 
tiou  imiy  be  normal  oven  with  complete  anaesthesia,  and  hi  this  country 
the  achroimitoi)sia  does  not  seem  to  be  nearly  so  common  an  hysterical 
manifestation  as  in  Europe.  Hysterical  deafness  may  bo  complete  and 
may  alternate  or  come  on  at  the  same  time  with  hysterical  blindness. 

(3)  Visceral  Manifestations. — Respimtonj  Apparatus. — Of  distuil)- 
ances  in  the  respiratory  rhythm,  the  most  frefpient,  ])erhaps,  is  an  exagj^eru- 
tion  of  the  deeper  breath,  which  is  taken  normally  every  fifth  or  sixth 
inspiration,  or  there  may  be  a  "catchinj^"  bi'oathing,  such  as  is  seen  when 
cold  water  is  poured  over  a  })erson.  Hysterical  dyspnani  is  readily  recog- 
nized, us  there  is  no  special  distress  and  the  pulse  is  usually  normal.  I 
have  met  with  a  remarkable  case  following  traunui  in  which  the  rosjiiia- 
tions  rose  above  one  hundred  and  thirty  in  the  minute.  Anu)ng  laryiigiul 
manifestations  aphonia  is  the  most  frequent  and  nmy  persist  for  mouths 
or  even  years  without  otiier  special  symptoms  of  the  disease.  Spasm 
the  muscles  may  occur  with  violent  inspiratory  efforts  and  great  distr 
an<l  may  even  lead  to  cyanosis.  Hiccough,  or  sounds  resembling  it,  may  bo 
present  for  weeks  or  months  at  a  time.  Among  the  most  remarkul)le  of 
the  resi)iratory  numifestations  are  the  hysterical  cries.  Those  may  niiuiic 
the  sounds  produced  by  animals,  such  as  barking,  mewing,  or  grunting, 
and  in  France  epidemics  of  them  have  been  repeatedly  observed.  Extraor- 
dimiry  cries  nuiy  be  i)roduced,  either  inspiratory  or  expiratory.  I  saw 
at  Wagner's  clinic  at  Leipsic  a  girl  of  thirteen  or  fourteen,  who  had  for 
many  weeks  given  utterance  to  a  remarkable  inspiratory  cry  somewhat  like 
the  whoop  of  whooping-cough,  but  so  intense  that  it  was  heard  at  a  long 
distance.  It  was  incessant,  and.  the  girl  was  worn  to  a  skeleton.  Attacks 
of  gai)ing,  yawning,  and.  sneezing  may  also  occur. 

The  hysterical  cough  is  a  frequent  symptom,  particularly  in  young 
girls.  It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking 
cough,  extremely  monotonous  and  unpleasant  to  hear.  Sir  Andrew  Clark 
has  called  attention  to  a  loud,  barking  cough  occurring  about  the  time 
of  puberty,  chiefly  in  boys  belonging  to  neurotic  families.  The  attacks, 
which  last  about  a  minute,  recur  frequently. 

There  is  a  peculiar  form  of  haemoptysis  which  may  be  very  deceptive 
and  lead  to  the  diagnosis  of  pulmonary  disorders.  Wagner  describes  the 
sputum  as  a  pale-red  fluid — not  so  bright  in  color  as  in  ordinary  haemop- 
tysis, and  on  settling  presents  a  reddish-brown  sediment.  It  contains  par- 
ticles of  food,  pavement  epithelium,  red  corpuscles,  and  micrococci,  but 


Ml 


HYSTERIA. 


973 


IK)  oylimlriciil  or  ciliiitod  epitlicliuin.  It  proljubly  como.s  from  tlu'  iinmtli 
or  })liiiryiix. 

DiijvHtive  System. —  Disturbed  or  dcpnivcd  appt'titi',  dysj)('|isia,  and 
{gastric  pains  iiro  cominoii  in  hysterical  jiutit'iits.  Tlio  i)atic'iit  may  have 
dilliculty  in  swallowing,'  the  food,  apparently  from  spasm  of  the  jrullet. 
There  are  instances  in  which  the  food  seems  to  be  exjtelled  bi'fore  it  reaches 
the  stomach.  In  other  cases  there  is  incessant  ;,'ajr^nn;j;.  In  the  hysterical 
voinitinj,'  tlio  food  is  regiir;:fitated  without  much  elTort  and  without  nausea. 
Tiiis  feature  may  persist  for  years  without  great  disturl)anee  of  nutrition. 
Tlio  most  striking  and  rcmarka))le  digestive  disturbance  in  hysteria  is  the 
(Diorcriu  ncrvoHU  described  by  Sir  William  (iull.  "To  call  it  loss  of  ajtpe- 
tito — anorexia — but  feebly  characterizes  the  symptom.  It  is  rather  un 
annihilation  of  appetite,  so  complete  that  it  seems  in  some  eases  impossible 
ever  to  eat  again.  Out  of  it  grows  an  antagonism  to  food  which  results 
at  last  and  in  its  worst  forms  in  s[)asm  on  the  api)roach  of  food,  and  tiiis  in 
turn  gives  rise  to  some  of  those  remarkable  cases  of  survival  for  long  periods 
without  food  "  (Mitchell).  As  this  goes  on  there  may  be  an  extreme  degree 
of  muscular  restlessness,  so  that  the  patients  wander  about  until  exhausted. 
This  feature  has  not  been  })rescnt  in  the  cases  which  have  come  under 
my  observation.  Nothing  more  ])itiable  is  to  be  si  ii  in  practice  than  an 
advanced  case  of  this  sort.  It  is  usually  in  a  young  girl,  sometimes  as 
early  as  the  eleventh  or  twelfth,  more  commonly  between  the  lifteenth  and 
twentieth  years.  The  emaciation  is  frightful,  and  scarcely  exceeded  by 
that  of  cancer  of  the  (esoi)hagus.  The  i)atient  iViially  lakes  to  bed,  and  in 
extreme  cases  lies  upon  one  side  with  the  thighs  and  legs  tlexcd,  and  con- 
tractures may  occur.  Food  is  either  not  taken  at  all  or  only  upon  urgent 
compulsion.  The  skin  becomes  wasted,  dry,  and  covered  with  bran-like 
scales.  No  food  may  be  taken  f(jr  several  weeks  :«t  ii  time,  and  attem^jts  to 
feed  may  be  followed  by  severe  spasms.  Although  the  condition  looks  so 
alarming,  these  cases,  when  removed  from  their  home  surroundings  and 
treated  by  AVeir  Mitchell's  method,  sometimes  recover  in  a  remarkable 
way.  Death,  however,  may  follow  with  extreme  emaciation.  In  a 
fatal  case  recently  xmder  my  care  the  girl  weighed  only  forty-nine  pounds. 
Xo  lesions  were  found  post  mortem. 

Among  intestinal  symptoms  flatulency  is  one  of  the  most  distressing, 
aud  is  usually  associated  with  the  condition  of  peristaltic  unrest  (Kiiss- 
iiuiul).  Frequent  discharges  of  fa'ces  may  be  due  to  disturbance  in  either 
the  small  or  largo  bowel.  An  obstinate  form  of  diarrhoia  is  found  in  some 
hysterical  patients,  which  proves  very  intractable  and  is  associated  espe- 
cially with  the  taking  of  food.  It  seems  an  aggravated  form  of  the  loose- 
ness of  bowels  to  which  so  many  nervous  people  are  subject  on  emotion 
or  the  tendency  which  some  have  to  diarrhcea  immediately  after  eating.  An 
entirely  different  form  isthatproducedby  what  Mitchell  calls  the  irritable 
rectum,  in  which  scybala  are  passed  frequently  during  the  day,  sometimes 
with  great  violence.     Constipation  is  more  frequent,  however,  and  may  bo 


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A^  i 


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iiiftlii 


974 


DISEASES  OP  TUB  NERVOUS  SYSTEM. 


due  to  a  loss  of  power  in  the  musck'S  of  the  bowi !  or  in  the  abdoiniiuil 
musc'los.  In  extreme  cases  the  bowels  may  not  be  moved  for  two  or 
tliree  weeks,  leading  to  great  accumulation  of  fseces.  Other  disturbaiues 
are  ano-spasm  or  intense  pain  in  tiie  rectum  apart  from  any  fissure. 

Cnrdio-vascuhtr. — Rapid  action  of  the  heart  on  the  slightest  emotidii, 
with  or  without  the  subjective  sensation  of  palpitation,  is  often  a  sourco 
of  great  distress.  A  slow  pulse  is  less  frequent.  I'ains  about  the  heurt 
may  simulate  angina,  the  so-called  hysterical  or  pseudo-angina,  which  has 
already  been  considered.  Flushes  in  various  parts  are  among  the  most 
common  symptoms,  and  may  be  seen  in  the  head,  biick,  hands,  or  feet. 
Sweating  occasionally  occurs. 

Among  the  more  remarkable  vaso-motor  phenomena  are  the  so-ca'lcd 
stigmata  or  hiPmorrhag(!s  in  the  skin,  such  as  were  present  in  the  vv\v- 
l)rated  case  of  Louise  Lateau.  In  many  cases  these  are  undoubtc^dly 
fraudulent,  but  if,  as  appears  credible,  such  bleeding  may  exist  in  the 
hypnotic  trance,  there  seems  no  reason  to  doubt  its  occurrence  in  the 
trance  of  prolonged  religious  ecstasy. 

Joint  Affections. — To  Sir  Benjamin  lirodie  and  Sir  James  Paget  we 
owe  the  recognition  of  these  extraordinary  manifestations  of  hysteria. 
Perhaps  no  single  att'ection  has  brought  more  discredit  upon  the  profes- 
sion, for  the  cases  are  very  refractory,  and  finally  fall  into  the  hands  of  a 
charlatan  or  faith-healer,  under  whose  touch  the  disease  may  disappear  at 
once.  Usually  it  affects  the  knee  or  the  hip,  and  may  follow  a  trilliiij: 
injury.  The  joint  is  usually  fixed,  sensitive,  and  swollen.  The  surface 
may  be  cool,  but  sometimes  the  local  temperature  is  increased.  To  tlie 
touch  it  is  very  sensitive  and  movement  causes  great  pain.  In  protracted 
cases  the  muscles  about  the  joint  are  somewhat  wasted,  and  in  conse- 
quence it  looks  larger.  The  pains  are  often  nocturnal,  at  which  time  the 
local  temperature  may  be  much  increased.  While,  as  a  rule,  neuromimetic 
joints  yield  to  prcper  management,  there  "are  interesting  instances  i!i  tlio 
literature  in  which  organic  change  has  succeeded  the  functional  disturb- 
ance. In  the  remarkable  case  reported  in  Weir  MitcheU's  lectures,  the 
hysterical  features  were  pronounced,  and,  on  account  of  the  chronicity, 
the  disease  of  the  knee-joint  was  considei'cd  organic  by  such  an  authority 
as  Billroth.  Sands  operated  aud  found  the  joint  surfaces  normal,  luid 
the  thickeinng  to  be  due  to  non-tuberculous  inflammatory  products  out- 
side the  capsule. 

Mental  Symptoms. — The  psychical  condition  of  an  hysterical  patient 
is  alwavs  abnormal,  and  the  disease  occupies  the  ill-defined  territory  hc- 
twoen  sanity  and  insanity.  In  a  large  number  of  cases  the  jiatients  are 
really  insane,  parti(!ularly  ir  the  perversion  witnessed  in  the  moral  sphi'.c. 
Not  the  slightest  dependence  can  be  placed  upon  their  statements,  iiiid 
they  will  for  months  or  years  deceive  friends,  relatives,  and  physiciiin. 
This  appears  to  result  partly,  but  not  wholly,  from  a  morbid  craviriir  for 
sympathy.     It  is  really  due  to  an  entire  unhinging  of  tl.c  moral  nature. 


HYSTERIA. 


975 


lomiiiiil 

two  (ir 

irbances 

imotion, 
u  source 
he  lieurt 
hic'h  has 
;he  most 
,  or  feet. 

so-culled 

the  eelt'- 
loubtedly 
st  in  the 
tie  in  the 

Paget  we 
hysteria. 
he  profes- 
iiands  of  a 
sappear  ut 
a  triiUiijr 
le  siirra<'(' 
To  the 
protracted 
in  conse- 
1  time  the 
romimetic 
oes  in  the 
il  di.sturh- 
;tures,  the 
dironieity, 
authority 
jrmal,  and 
duets  out- 

.•al  ])atieiit 
Irritory  he- 
latieiits  are 

ral  sphere. 

^lents.  and 

physieiiiii. 

Iravini;  f<»r 
nature. 


Hysterical  patients  may  heoonie  insane  and  uisphiy  persistent  h'ill""ina- 
tions  and  delirium,  alternating  perh'ips  with  emotional  outbursts  '•:  an 
aggravated  character.  For  weeks  or  mouths  they  may  be  conlined  to  bed, 
entirely  oblivious  to  their  surrounding.s,  with  a  delirium  whici  'Uu;  simu- 
late that  of  delirium  tremens,  particularly  in  being  associated  y>'a  loath- 
.some  and  unpleasant  aninvil'-:,  ihe  nutrition  nuiy  be  nuiintained,  but  in 
these  cases  there  is  always  a  very  heav}',  foul  breatli.  With  secdusion  and 
I'are  recovery  usually  takes  i)laee  witiiin  three  or  four  months.  At  the 
onset  of*  these  attacks  and  during  convalescence  the  patients  must  be 
incessantly  watched,  as  a  suicidal  tendency  is  by  no  means  uncommon. 

Of  hysterical  manifestatioiis  in  the  higher  centres  that  of  trance  is  the 
most  remarkable.  This  may  develop  spontaneously  without  any  convul- 
sive seizure,  but  more  frequently,  in  this  country  at  least,  it  follows  hys- 
teroid  attacks.  Catalepsy,  a  condition  in  which  the  limbs  are  j)lastic  and 
remain  in  any  position  in  which  they  are  placed,  may  or  may  not  be  pres- 
ent with  this  condition. 

The  Metabolism  in  Hysteria. — The  studies  of  (Jilles  de  la  Tourette 
and  Cathelineau,  under  Charcot's  direction,  have  shown  that  in  tlie  ordi- 
nary forms  of  hysteria  the  urine  does  not  show  quantitative  or  qualitative 
changes,  but  in  the  severe  types,  characterized  by  convulsions,  etc.,  there 
are  important  modifications:  reduction  in  the  urates  and  phosphates;  the 
ratio  '^t  the  earthy  to  the  alkaline  phosphates,  normally  1 :  13,  is  1 : 2,  or 
oven  1  : 1.  The  urine  is  also  reduced  in  amount.  They  think  that  these 
(diangcs  jnight  sometimes  serve  to  differentiate  convulsive  hysteria  from 
epilepsy,  in  which  there  is  always  an  increase  in  the  solid  constituent?- 
after  a  seizure. 

nysterical  Fever. — In  hysteria  the  temperature,  as  a  rule,  is  nonind. 
The  cases  with  fever  may  be  groui)ed  as  follows  :  {a)  In.stances  in  which 
the  fever  Is  the  sole  manifestation.  These  are  rare,  but  I  have  seen  at 
least  two  cases  in  which  the  chroni(!  course,  the  retention  of  the  nutrition, 
aiul  the  entirely  negative  condition  of  the  organs  left  no  other  diagnosis 
possible.  In  a  case  recently  under  observation  the  patient  has  had  for  four 
or  five  years  an  afternoon  rise  of  temperature,  rea(diing  usually  to  10,'"  or 
103°.  She  was  well  nourished  and  presented  no  nvonounceil  liysterical 
svmptoms,  but  there  was  a  nnirked  neurotic  history  on  one  side  and  a  form 
if  interrupted  sighing  respiration  so  often  seen  in  hysteria. 

{b)  Cases  of  hysterical  fever  with  spurious  local  nuinifestations.  These 
are  very  troublesome  and  deceptive  oases.  The  patient  nn'.y  be  siuhlenly 
taken  ill  with  pain  in  various  regions  and  elevation  of  temj)erature.  The 
ease  may  simulate  meningitis.  There  may  be  pain  in  the  head,  vomiting, 
contracted  pupils,  and  i-etraction  of  the  neck— symptoms  whi(di  nniy  per- 
sist for  weeks — and  some  aiu)malous  manifestation  during  convalescence 
nuiy  alone  indicate  to  the  physician  that  he  has  had  to  deal  with  a  case  of 
hysteria,  a)id  has  not,  as  he  perhaps  llattered  himself,  cured  a  case  of  men- 
ingitis.    Mary  Putnam  Jacobi,  in  a  recent  article  oi'   hysterical  fever, 


:S! 


•-If' 


im, 


970 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


m 


moiitioii3  a  case  in  the  service  of  Cornil  which  was  admitted  witli  dyspnd'u 
sliglit  cyanosis,  and  a  temperature  at  39°  C  The  conditicm  ])rovod  to  be 
hysterical.  Tliere  is  also  an  hysterical  pseudo-phthisis  with  pain  in  the 
chest,  slight  fever,  and  the  expectoration  of  a  blood-stained  mucus.  'I'hi' 
cases  of  hysterical  peritonitis  may  also  show  fever.  Only  by  incessant 
watchfuliu'ss  (!an  mistakes  be  prevented  in  these  cases. 

(c)  Jfi/Mfcrictd  Jfijperpyrexin. — It  is  a  suggestive  fact  that  the  cases  of 
paradoxical  temperatures  reported  of  late  years,  in  which  the  theruioiueter 
has  registered  112°  to  130°  or  more,  have  been  in  women.  Fraud  lias 
been  practised  in  some  of  these,  but  in  others  the  high  fever  has  been  as- 
sociated with  neurotic  features  and  may  really  have  been  of  an  hysterical 
character. 

Diagnosis. — Inquiry  into  the  occurrence  of  previous  manifestations 
and  the  mental  conditions  may  give  important  information.  These  ques- 
tions, as  a  rule,  should  not  l)e  asked  the  mother,  who  of  all  others  is  least 
likely  to  give  satisfactory  information  about  the  patient's  condition.  The 
occurrence  of  the  glo])us  hystericus,  of  emotional  attacks,  of  wee])ing  aiul 
crying,  are  always  suggestive.  The  points  of  difference  between  the  con- 
vulsive attacks  and  true  epilepsy  were  referred  to  in  their  description, 
and  as  a  rule  little  dilHculty  is  experienced  in  distinguishing  between  the 
two  conditions.  The  hysteiical  paraly^^es  are  very  variable  and  apt  to  he 
associated  with  ansesthcsia.  The  contractures  may  at  times  be  very  deeej)- 
tive,  but  the  occurrence  of  areas  of  anaesthesia,  of  retraction  of  the  visual 
field,  and  the  development  of  minor  hysterical  manifestations,  give  valua- 
ble indications.  The  contractures  disappear  under  full  anaesthesia.  Spe- 
cial care  uiust  be  taken  not  to  confound  the  spastic  paraplegia  of  hysteria 
with  lateral  sclerosis. 

The  visceral  manit'ostati<»ns  are  usually  recognized  Avithont  much  difli- 
culty.  The  i)ractitioner  has  constantly  to  bear  in  mind  the  strong  tend- 
ency in  hysterical  patients  to  practise  deception. 

Treatment. — The  prophylaxis  in  hysteria  may  be  gathered  from  the 
remi"'ks  on  the  relation  of  education  to  the  disease.  The  successful  treat- 
ment of  hysteria  demands  qualities  possessed  by  few  physicians.  The  first 
element  is  a  due  appreciation  of  the  nature  of  the  disease  on  the  part  nf 
the  physician  and  friends.  It  is  pitiable  to  think  of  the  misery  which  Im 
been  inllii'ted  on  these  unhappy  victims  by  the  harsh  and  unjust  treat- 
ment which  has  resulted  from  false  viev/s  of  the  nature  of  the  trouble; 
on  the  other  hand,  worry  and  ill-health,  often  the  wrecking  of  niiml 
bidy,  and  estate,  are  entailed  upon  the  near  relatives  in  the  mu'sing  of  a 
protracted  case  of  hysteria.  The  minor  manifestations,  attacks  of  tlu' 
vapors,  the  crying  and  weeping  spells,  are  not  of  much  moment  ami 
rarely  require  treatment.  The  physical  condition  should  be  carefully 
looked  into  and  the  mode  of  life  rcgulat(Hl  so  as  to  insure  system  and 
order  in  everything.  A  congenial  occupation  olfers  the  best  remedy  for 
many  of  these  manifestations.    Any  functional  disturbance  siiould  be  at- 


HYSTERIA. 


977 


tended  to  and  a  course  of  tonics  proscribed.    Special  attention  should  be 
paid  to  the  action  of  the  bowels. 

Valerian  and  asafoetida  are  oftoii  of  service.  For  the  pains  in  various 
parts,  particularly  in  the  back,  the  thcnno-cautery  and  static  electricity 
will  be  found  invaluable.  Mori)hia  should  be  withheld.  In  the  convulsive 
seizures,  particularly  in  the  minor  forms,  it  is  often  best,  after  settling  the 
patieiit  comfortably,  to  leave  her.  When  she  comes  to,  and  finds  her- 
self alone  and  without  sympathy,  the  attacks  are  less  likely  to  be  repeated. 
There  is,  as  a  rule,  no  cure  for  the  hysterical  manifestations  of  women, 
otherwise  in  good  health,  who  are,  as  Mitchell  says,  "  fat  and  ruddy,  with 
sound  organs  and  good  appetites,  but  ever  complain  of  pains  and  aches, 
and  ever  liable  on  the  least  emotional  disturbance  to  exhibit  a  quaint 
variety  of  hysterical  })henomena." 

To  treat  hysteria  as  a  physical  disorder  is,  after  all,  radically  wrong. 
It  is  essentially  a  mental  and  emotional  anomaly,  and  the  important  ele- 
ment in  tlie  treatment  is  moral  control.  At  home,  surrounded  by  loving 
relatives  who  misinterpret  entirely  the  symptoms  aiul  have  no  appreciation 
of  the  nature  of  the  disease,  the  severer  forms  of  hysteria  can  rarely  bo 
cured.  The  necessary  t;ontrol  is  impossible;  hence  the  special  value  of 
the  method  introduced  by  Weir  Mitchell,  which  is  particularly  ap])licablc 
to  the  advanced  cases  which  have  become  chronic  and  bedridden.  Tlie 
treatment  consists  in  isolation,  rest,  diet,  massage,  and  electricity.  Sepa- 
ration from  friends  and  symjiuthetic  relatives  must  be  absolute,  and  can 
rarely,  if  ever,  be  obtained  in  the  individuaFs  home.  An  essential  element 
in  the  treatment  is  an  intelligent  nurse.  No  small  share  of  the  success 
Avhich  has  attended  the  author  of  this  plan  h  icen  due  to  the  fact  that 
he  has  ])ersistently  chosen  jis  his  allies  briglii,  i  tilliLrent  women.  The 
details  of  the  plan  are  as  follows:  The  patient  is  contined  t"  i)ed  and  not 
allowed  to  get  up,  nor,  at  first,  in  aggravated  cases,  to  road,  write,  or  even 
to  feed  herself.  Massage  is  used  daily,  at  first  for  twenty  minutes  or  half 
an  hour,  subsequently  for  a  longer  pericxL  It  is  essential  as  a  stibstitute 
for  exercise.  The  induction  current  is  apjtliecl  to  the  various  muscles  nid 
to  the  spine.  Its  use,  however,  is  not  so  essential  as  that  of  massage.  The 
<liet  may  at  first  be  entirely  of  milk,  four  ounces  every  two  hours.  It  is 
better  to  give  skimmed  milk,  and  it  may  be  diluted  with  soda  water  or 
barley  water  and,  if  necessary,  peptonized.  After  a  week  or  ten  days  the 
diet  may  be  increased,  the  amount  of  milk  still  being  kej)t  up.  A  choj. 
may  be  given  at  midday,  a  cup  of  coffee  or  cocoa  with  toast  or  bread  and 
butter  or  a  biscuit  with  the  milk.  The  patients  usually  fatten  rapidly  as 
the  solid  food  is  added,  and  with  the  gain  there  is,  as  a  rule,  a  diminution 
or  cessation  of  the  nervous  symptoms.  The  milk  is  the  essential  element 
in  the  diet,  and  is  itself  amply  sufficient. 

The  remarkable  results  obtained  by  this  method  are  now  universally 
recognized.  The  plan  is  more  applicable  to  the  lean  than  to  fat,  fial)l)y 
hysterical  patients.     Not  only  is  it  suitable  for  the  more  ol)stinate  varie- 


■'  ; 


'i    !  ^ 


f  11 


M] 


'■;»T' 


978 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


ties  of  hysteria  with  bodily  manifestations,  but  in  the  cases  with  mental 
symptoms  the  seclusion  and  separation  from  relatives  and  friends  are  par- 
ticularly advantageous.  In  the  hysterical  vomiting  Debove's  methoil  of 
forced  feeding  may  be  used  with  benefit.  For  the  innumerable  minor 
n;anifostations  of  hysteria  and  for  the  simulations  the  indications  for  treat- 
ment arc  usually  clear.  Of  late,  hypnotism  has  been  extensively  used  in 
the  treatment  of  hysteria.  Occasionally  in  cases  of  hysterical  contractions 
or  paralysis  it  is  of  benefit,  but  any  one  who  has  seen  the  development  of 
this  method  as  practised  at  })resent  in  France  must  feel  that  it  is  a  two- 
edged  sword  and  that  the  constant  repetition  in  the  same  patient  is  fraui:jlit 
with  danger.  In  the  cases  which  avc  have  tried  here  the  success  has  not 
been  marked. 


XII.  NEURASTHENIA. 


n 

m 

Hi 

sri;,?..,„ 


i:k:. 


Deflnition. — A  condition  of  weakness  or  exliaustion  of  the  nervous 
system. 

The  term,  invented  by  Beard,  covers  an  ill-defined,  motley  group  of 
symptoms,  Avliich  may  be  either  general  and  the  expression  of  derange- 
ment of  the  entire  system,  or  local,  limited  to  certain  organs;  hence  the 
terms  cerebral,  spinal,  cardiac,  and  gastric  Jieurasthenia.  In  certain  re- 
spects it  is  the  physical  counterpart  of  insanity.  As  the  essential  feature 
in  the  latter  condition  is  the  abnormal  response  to  stimuli,  from  within  or 
without,  upon  the  higher  centres  presiding  over  the  mind,  so  neurasthenia 
appears  to  be  the  expressifm  of  a  morbid,  unhealthy  reaction  to  stinuili 
acting  on  the  nervous  centres  which  preside  over  the  functions  of  organic 
life.  No  hard  and  fast  line  can  ])e  drawn  between  neurasthenia  and  cer- 
tain mental  states,  particularly  hysteria  and  hypochondria. 

Etiology. — Although  the  causes  are  apparently  varied,  they  may  be 
grouped  as  hereditary  and  acquired. 

{(i)  Hereditary. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  Avho  have  been  the  subjects  of  nervous  complaiius 
or  of  mental  troubles  transmit  to  Uicir  children  an  organization  which 
is  defective  in  wluit,  for  want  of  a  bei  i^  r  term,  we  must  call  "  nerve  force." 
Such  individuals  start  hnndicapped,  and  furnish  a  considerable  proportion 
of  our  neurasthenic  patients.  So  long  as  they  are  content  to  transact  a 
moderate  business  with  their  life  ca})ital,  all  may  go  well,  but  there  is  no 
reserve,  and  in  the  emergencies  which  constantly  arise  in  the  cxigencio-! 
of  modern  life  these  small  capitalists  go  under  and  come  to  us  as  bank- 
rupts. 

(b)  Acquired. — The  functions,  though  perverted  most  readily  in  per- 
sons who  have  inherited  a  feel)le  organization,  uniy  also  be  damaged  liy 
exercise  which  is  excessive  in  proportion  to  the  strength — i.  e.,  by  strain. 
The  cares  and  anxieties  attendant  upon  the  gaining  of  a  livelihood  may 
be  borne  without  distress,  but  in  many  persons  the  strain  becomes  excess- 


ti 

w 

'1 

W\ 

NEURASTHENIA. 


979 


ive  and  is  first  nr.inifested  as  wornj.  The  iiulividiial  loses  the  (listiuctioii 
])etwcen  e-sentials  and  non-essentials,  trifles  cause  annoyance,  and  the 
entire  organism  reacts  witli  unnecessary  readiness  to  slight  stimuli,  and  ia 
in  a  state  which  the  older  writers  called  irritable  weakness.  If  such  a 
condition  be  taken  early  and  the  patient  given  rest,  the  balance  is  quickly 
restored.  In  this  grou])  may  be  placed  a  large  proportion  of  the  neuras- 
thenics which  we  see  in  this  country,  particularly  among  business  men. 
Other  causes  more  subtle,  yet  potent,  and  less  easily  dealt  with,  are  the 
worries  attendant  upon  love  affairs,  religious  doubts,  and  the  sexual  pas- 
sion. 

Symptoms. — These  are  extremely  varied,  and  may  be  general  or 
localized ;  more  often  a  combination  of  both.  The  a))pearance  of  the 
patient  is  suggestive,  sometimes  characteristic,  but  ditlicult  to  describe. 
Loss  of  weight  and  slight  anajmia  may  be  present.  The  physical  debility 
may  i-each  a  high  grade  and  the  patient  may  be  confined  to  bed.  Men- 
tally the  i)atients  are  usually  low-spirited  and  des])ondent,  in  women  fre- 
quently emotional. 

The  local  symptoms  may  dominate  the  situation,  in  which  case  the 
clinical  picture  is  of  the  so-called  cerebral  or  spiiud  neurasthenia.  Other 
local  forms  are  cardio-vascular,  gastric,  and  sexual. 

In  the  cerebral  form  the  symptoms  are  chiefly  connected  with  an 
inability  to  i)erforni  the  ordinary  mental  work.  Thus  a  row  of  figures 
cainiot  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is 
a  painful  effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this 
condition  there  may  be  no  headache,  the  ajipetite  nuiy  be  go<)d,  and  the 
patient  may  sleep  well.  As  a  rule,  however,  there  are  sensations  of  fulness 
and  weight  or  flushes,  if  not  actual  headache.  Sleeplessness  is  a  frequent 
concomitant,  and  may  be  the  first  manifestation.  tSome  of  these  patients 
arc  gootl-tcmjiered  and  cheerful,  but  a  majority  are  moody,  irritable,  and 
depressed.*  The  special  senses  may  be  disturbed,  particularly  vision.  An 
aching  or  weariness  of  the  eyeballs  after  reading  a  few  minutes  or  flashes 
of  light  are  common  symptoms.  A  diiference  between  the  i)Upils  may  be 
present. 

When  the  spinal  si/mptoms  predominate — spinal  irritation  or  spinal 
neurasthenia— in  addition  to  many  of  the  features  just  mentioned,  the 
patients  complain  of  weariness  on  the  least  exertion,  of  weakness,  pain  in 
the  back,  and  of  achiiig  pains  in  the  legs.  There  may  be  spots  of  local 
tenderness  on  the  spine.  Occasionally  there  may  be  disturbances  of  sen- 
sation, particularly  a  feeling  of  numbness  and  tingling,  and  the  reflexes 
may  be  increased.  The  aching  pain  in  the  back  or  in  the  back  of  the 
neck  is  the  most  constant  complaint  in  these  cases.     In  women  it  is  often 

*  For  an  exhaustive  considoration  of  the  mental  symptoms  of  neurasthenia,  see  the 
Shattuck  Lecture,  by  Cowlcs.    Boston  Medical  and  Surgical  .Journal,  1891. 

C2  . 


'<   :»! 


::4i 


k. '' 


w 


5 1-1  i 


\m 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


impossible  to  say  whctlier  this  condition  is  one  of  neurasthenia  or  hys- 
toria. 

In  otlier  cases  tlie  cardio-vascular  symptoms  are  the  most  distrcssinir, 
and  may  occur  with  only  slight  disturbance  of  the  cerebro-spinal  fuuctidiis, 
though  the  conditions  may  bo  combined.  Palpitation  of  the  heart,  irrc-u- 
lar  and  very  rapid  action,  and  i)ains  in  the  cardiac  region  are  the  most 
common  symptoms.  The  slightest  excitement  may  be  followed  by  in- 
creased action  of  the  heart,  and  the  patients  frccpiently  have  the  idea  lliat 
they  sulTer  from  serious  disease  of  this  organ. 

Vaso-motor  disturbances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat  and  transient  hyiteriKniia  of  the  skin  nuiy  be  very  distress- 
ing syjuptoms.  Profuse  sweating  may  occur,  either  local  or  general,  and 
sometimes  nocturnal.  The  pulse  may  show  interesting  features,  owin^f 
to  the  extreme  relaxation  of  the  peripheral  arterioles.  The  arterial  thiol)- 
bing  may  be  everywhere  visible,  ahnost  as  much  as  in  aortic  iiisudicieiuy. 
The  pulse,  too,  jnay  under  these  circumstances  have  a  somewhat  water- 
hammer  quality.  The  capillary  pulse  may  be  seen  in  the  nails,  on  the 
lips,  or  on  the  margins  of  a  line  drawn  upon  the  forehead,  and  I  have  on 
several  occasions  seen  pulsation  in  the  veins  of  the  back  of  the  hand. 
A  characteristic  symptom  in  some  cases  is  the  f/iru/iOi/if/  aurtn.  The  e])i- 
f  a^tric  pulsation  nuiy  be  extremely  forcible  and  suggest  the  existence  ( f 
abdominal  aneurism.  The  subjective  sensations  associated  with  it  may  be 
very  unpleasant,  particularly  when  the  stomach  is  empty. 

The  general  features  of  gastro-intcstinal  neurasthenia  have  been  dealt 
with  under  the  section  of  nervous  dyspepsia.  The  connection  of  tlieso 
cases  with  dilatation  of  the  stomach,  floating  kidney,  and  the  conditioa 
which  Glenard  calls  oitcroptosis  has  already  been  mentioned. 

Sexual  neurastheiua  is  a  condition  in  which  there  is  an  irritable  weak- 
ness of  the  sexual  organs  manifested  by  nocturnal  emissions,  unusual  de- 
pression after  intercourse,  and  often  by  a  distressing  dread  cf  inipotenec 
The  mental  coiulition  of  these  patients  is  most  pitiable,  and  they  fall  an 
easy  prey  to  quacks  and  charlatans  of  all  kinds. 

In  all  forms  of  neurasthenia  the  coiulition  of  the  urine  is  important. 
Many  cases  are  complicated  with  the  symptoms  of  tlie  condition  kiuiwa 
as  litha'mia,  and  so  marked  may  this  be  that  some  have  indeed  made  a 
special  form  of  litha)mic  neurasthenia.  Polyuria  may  be  present,  but  is 
more  common  in  hysteria.  With  disturbed  digestion  the  urates  and  oxa- 
lates may  be  in  excess. 

The  (/i(f(/>iosis  is  readily  made.  It  is  sometimes  difficult  to  distinguish 
tho  cases  from  hysteria,  and  this  is  not  surjirising,  as  wo  cannot  always 
differentiate  the  two  conditions.  Neurasthenia  occurs  chiefly  in  men ;  in 
fact,  it  is  in  many  ways  in  them  the  equivalent  of  hysteria. 


fall  iiu 

[portiiut. 
\\  known 

niiult'  ii 
|t,  but  i.-^ 

and  ox:i- 

Itingnirfh 
It  always 


THE  TRAUMATIC  NEUROSES.  981 

XIII.    THE  TRAUMATIC  NEUROSES 

{Railway  Brain  and  liailway  Spine;  Traumatic  Hysteria), 

Definition. — A  morbid  condition  following  shock  which  presents  the 
Bym])tonis  of  neuriisthcnia  or  hy.stcria  or  of  both.  The  condition  is  known 
iis  "  railwiiy  bruin  "  and  "  railway  .'^pine." 

Erichsen  regarded  the  condition  as  the  result  of  inflammation  of  the 
meninges  and  cord,  and  gave  it  the  name  railway  i  nh  \  Walton  and 
J.  J.  Putnam,  of  Boston,  were  the  first  to  recognize  the  h3'steri('al  nature 
of  many  of  the  cases,*  and  to  Westphal's  pupils  wo  owe  the  name  traumatic 
neurosis. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway 
train,  in  which  injury  lias  been  sustained,  or  succeeds  a  shock  or  concus- 
sion, from  which  the  patient  nuiy  apparently  lujt  have  suffered  in  his  body. 
A  man  jnay  ap})oar  })erfectly  well  for  several  days,  or  even  a  week  or 
more,  and  then  develo])  marked  symptoms  of  the  neurosis.  Hodily  shock 
or  concussion  is  not  necessary.  The  aifection  may  follow  a  profound 
mental  impression;  thus,  an  engine  driver  ran  over  a  child,  and  received 
thereby  a  very  severe  sliock,  subsequent  to  which  the  most  pronounced 
symptoms  of  neurasthenia  developetl.  Severe  mental  strain  combined  with 
bt)dily  exposure  may  cause  it,  as  in  a  case  of  a  naval  ofiicer  wiio  was 
wrecked  in  a  violent  storm  and  exposed  for  more  than  a  day  in  the  rig- 
ging before  he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage  or  on 
the  stairs  may  sutHce. 

Symptoms. — The  cases  may  be  divided  into  three  groups :  simple 
neurasthenia,  cases  with  nnirk(ul  hysterical  manifestations,  and  cases  with 
severe  symptoms  indicating  or  simulating  organic  disease. 

{(i)  Si)iij)ln  Traumatic  yciivasthcina. — The  first  symptoms  usually  de- 
velop a  few  weeks  after  the  acc'ident,  wlu'^h  may  or  may  not  have  been 
associated  with  an  actual  trauma.  The  patient  complains  of  headache 
and  tired  feelings.  He  is  sleejiless  and  finds  himself  unable  to  concentrate 
his  attention  properly  upon  his  work.  A  condition  of  nervous  irritability 
develops,  which  may  have  a  host  of  trivial  manifestations,  and  the  entire 
mental  attitude  of  the  person  nuiy  for  a  time  be  changed,  lie  dwells  con- 
stantly upon  his  condition,  gets  very  despoiulent  and  low-spirited,  and  in 
extreme  cases  melancholia  may  develop.  lie  may  complain  of  iuim])nes8 
aiul  tingling  in  the  extremities,  aiul  in  somo  cases  of  much  pain  in  the 
back.  The  bodily  functions  may  be  well  performed,  though  such  jtatients 
usually  have,  for  a  time  at  least,  disturbed  digestion  aiul  loss  in  weight. 
The  ])hysical  examination  may  be  entirely  negative.  U'he  reflexes  are 
slightly  increased,  as  in  ordinary  neurasthenia.  The  pupils  may  be  un- 
equal ;  the  cardio- vascular  changes  already  described  in  neurasthenia  may 
he  present  in  a  marked  degree.     According  as  the  symptoms  are  moro 

•  See  Lii  Ncurasthenle,  pur  L.  Bouvcret,  Paris,  1891. 


n  ■ 


V 

f*. 
V 

I 


iSt^ 


p 


;3: 


I 


982 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


M 


hi 

i  w'i 

I  '■  I  ivfc 


spinal  or  more  ccrobral,  the  condition  is  known  us  railway  bruin  or  railway 
spine. 

{■i)  Cases  icith  Marhnl  Jfi/sicriral  Foatnrcs. — Following  an  injury  of 
any  sort,  nourasthenie  symptoms,  like  those  described  above,  may  develop, 
and  in  addition  syniptoms  regarded  as  characteristic  of  hysteria.  The 
emotional  element  is  prominent,  and  there  is  but  slight  control  over  tlio 
feelings.  The  patients  have  headache,  backache,  and  vertigo.  A  violent 
tremor  may  be  present,  and  indeed  constitutes  the  most  striking  feature  of 
the  case.  I  have  recently  seen  an  engineer  who  developed  subsequent  to 
an  accident  a  series  of  nervous  phenomena,  but  the  most  marked  feature 
was  an  excessive  tremor  of  the  entire  body,  which  was  specially  manifest 
during  emoti(mal  excitement.  The  most  pronounced  hysterical  symptoms 
are  the  .-ensory  disturbances.  As  first  noted  by  Putnam  and  Walton, 
hemianfi'sthesia  may  occur  as  a  sequence  of  traumatism.  This  is  a  com- 
mon symptom  in  France,  but  rare  in  England  and  in  this  country.  In 
a  considerable  inimber  of  cases  of  traumatic  neuroses  which  I  have  seen 
only  one  presented  typical  hemir.najsthesiu.  A  second,  more  common, 
manifestation  is  limitation  of  the  field  of  vision. 

Remarkable  disturbances  may  develop  in  some  of  these  cases.  A  few 
months  ago  I  saw  a  man  who  hud  been  struck  by  an  electric  cur,  whose 
chief  symptom  wus  an  extraordinary  increase  in  the  number  of  res])irii- 
tions.  lie  was  a  stout,  powerfully  built  man,  and  presented  practically  no 
other  symptom  than  dyspnu'a  of  the  most  extreme  grade.  At  the  time  of 
ol)servation  his  respirations  were  over  130  per  minute,  and  he  stated  tliut 
they  had  been  counted  at  over  150. 

(3)  Cases  in  which  the  Sympioms  sugfjest  Organic  Disease  of  ihr 
Brain  and  Cord. — As  a  result  of  spinal  concussion,  without  fracture  or 
external  injury,  there  may  subsequently  develop  symptoms  suggestive  of 
organic  disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case 
reported  by  Leyden  the  symptoms  following  the  concussion  were  at  first 
slight  and  the  patient  was  regarded  as  a  simulator,  but  finally  the  condi- 
tion became  aggravated  and  death  resulted.  The  post-mortem  showed  u 
chronic  j)achymeningitis,  which  had  doubtless  resulted  from  the  accident. 
The  cases  in  this  group  about  which  there  is  so  much  discussion  are  those 
which  display  marked  sensory  and  motor  changes.  Following  an  accident 
in  which  the  patient  has  not  received  external  injury  a  condition  of  ex- 
citement may  develop  within  a  week  or  ten  days ;  he  complains  of  head- 
ache  and  backache,  and  on  examination  sensory  disturbances  are  fouuil, 
either  hemiunaisthesiu  or  areas  on  the  skin  in  which  the  sensation  is  much 
benunibed  ;  or  painful  and  tactile  im])ressions  may  be  distinctly  felt  in 
certain  regions,  and  the  temperature  sense  is  absent.  The  distributinn 
may  be  bilateral  and  symmetrical  in  limited  regions  or  hemiplegic  in  type. 
Limitation  of  the  field  of  vision  is  usually  marked  in  these  cases,  and  there 
may  bo  disturbance  of  the  senses  of  taste  and  smell.  The  sujjerficial  re- 
flexes may  be  diminished ;  usually  the  deep  reflexes  are  exaggerated.    The 


THE  TRAUMATIC  NEUROSES. 


983 


pupils  mny  bo  unoquul ;  the  motor  distiirbunci's  are  viirluhlo.  The  French 
writers  (los(!riI)e  cusc's  of  monoplegia  with  or  without  contracture,  Kvmp- 
toms  upon  which  Charcot  lays  great  stress  as  a  manifestation  of  profoui'l 
liysteria.  The  combination  of  sensory  disturbanc^es — antv'sthesia  or  hyper- 
lesthesia — with  paralysis,  ]);'.rticularly  if  monoiilegie,  and  the  occurrence  of 
contractures  without  atrophy  and  witii  normal  electrical  reactions,  nuiy  be 
regarded  as  distimitivo  of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 
have  been  regarded  as  neurasthenic  or  hysterical,  there  are  organic  changes 
which  may  prove  fatal.  That  this  sequence  occurs  is  demonstrated  clearly 
by  recent  jjost-mortsm  examinations.  The  features  upon  which  the 
greatest  reliance  can  be  placed  as  iiulicating  dellnite  organic  change  arc 
optic  atrojjhy,  bladder  symptoms,  particularly  in  combination  with  tremor, 
paresis,  aiid  exaggerated  reflexes. 

The  aiuitomical  changes  in  this  condition  have  not  been  very  deiinite. 
When  death  follows  si)inal  concussion  within  a  few  days  there  may  be  no 
apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  })unc- 
tiform  ha-morrhages.  Edes  has  reported  four  cases  in  which  a  gradual 
degeneration  in  the  pyramidal  tracts  followed  concussion  or  injury  of  the 
spine ;  but  in  all  these  cases  there  was  marked  tremor  and  the  spinal 
symptoms  developed  early  or  followed  immediately  upon  the  accident. 
Post-mortems  upon  cases  in  which  organic  lesions  have  supervened  upon 
a  traumatic  neurosis  are  extremely  rare.  Bernhardt  reports  an  instance 
of  a  man,  aged  thirty-three,  who  in  1880  received  a  kick  from  a  horse 
on  the  epigastrium  and  subsequently  developed  the  symptom-complex  of 
neurasthenia  and  hysteria  with  attacks  of  vertigo  and  great  psychical  de- 
pression. He  afterward  had  more  nuirked  mental  symptoms  and  attacks 
of  unconsciousness.  He  committed  suicide  and  the  brain  and  cord  showed 
a  beginning  multiple  sclerosis  in  the  white  matter,  which  was  })Ossibly 
associated  with  an  advanced  grade  of  arterio-sclerosis.  In  a  second  case 
a  man,  aged  forty-two,  received  a  shock  in  a  railway  accident  in  July, 
1884.  He  was  rendered  unconscious  aiul  had  a  slight  injury  in  the  but- 
tock region.  In  a  few  Aveeks  symptoms  of  traumatic  neurosis  devcloj)ed, 
particularly  great  depression  of  spirits,  with  headache  and  sensory  disturb- 
ances in  the  feet  and  hands.  Tremor  and  great  weakness  were  com- 
plained of  when  he  attempted  to  work.  There  was  no  increase  in  the 
reflexes.  The  case  was  regarded  as  an  instance  of  simulation  and  a  defect 
in  objective  symptoms  favored  this  view.  Subsequently  this  judgment 
was  reversed,  but  he  did  not  imi>rove.  He  died  in  January,  188!>,  with 
symptoms  of  cardiac  dyspmea.  Macroscopically  the  brain  and  cord  a[)- 
peared  nornud.  There  was  extreme  arterio-sclerosis,  particularly  of  the 
vessels  of  tlie  brain  and  cord.  In  the  latter  there  were  scattered  areas  of 
degeneration  in  the  white  substance,  and  degeneration  in  the  sympathetic 
ganglia. 
•     I  have  entered  somewhat  fully  into  this  question  because  of  its  extreme 


U: 


Mr  .:' 


084 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


iinpnrtaiicn  and  on  accroimt  of  the  paucity  of  the  obsorviitimis  upon  cusoh 
which  hiivo  subsoquenlly  dovclopcd  ssyinjjtom.s  of  or^iuii(!  disease.  Tlxaui- 
ples  of  it  arc  extremely  rare.  So  far  as  1  Iviiow  no  easi;  witli  autopsy  has 
been  reported  in  thia  country,  nor  have  I  seen  an  instaneo  in  whicii  the 
clinical  features  pointed  to  an  organic  disease  which  hud  followed  up(»n  u 
traumatic  neurosis. 

Diagnosis.— A  condition  of  frij,dit  and  exciteiuent  f(tllo\vinj;  an  acci- 
dent may  jiersist  for  days  or  even  weeks,  and  then  gradually  |iuss  aw.iy. 
The  symptoms  of  neurasthenia  or  of  hysteria  which  subsequently  develop 
present  nothing  peculiar  ami  are  identical  with  those  whii'h  oct-ur  under 
other  circumstances,  ('are  nni.st  be  taken  to  avoid  simulation,  and,  as  in 
these  cases  the  condition  is  largely  subjective,  this  is  sometimes  extremely 
diUlcult.  In  a  careful  cxamimition  a  sinudator  will  often  reveal  himself 
l)y  exaggeration  of  certain  symptoms,  particularly  sensitiveness  of  the 
spine,  and  by  increasing  voluntarily  the  reflexi's.  It  may  require  a  careful 
study  of  the  case  to  determine  whether  the  individual  is  honestly  suifuring 
from  the  symptoms  of  which  he  complains.  A  still  more  im[)ortant  (jues- 
tion  in  tliesc  cases  is,  lias  the  patient  organic  disease  'i  The  sym])t()ms 
given  under  the  first  two  groups  of  cases  may  exist  in  a  marked  degree 
and  may  persist  for  several  years  without  the  slightest  evidence  of  orgaiut; 
change.  It  must  be  noted  that  in  the  two  autopsies  above  referred  to  the 
patients  were  the  subjects  of  extreme  arterio-sclerosis,  with  which,  in  all 
])robability,  the  areas  of  multiple  sclerosis  were  associated.  llemiana?sthe- 
sia,  limitation  of  the  field  of  vision,  monoplegia  with  contracture,  may  all 
be  present  as  hysterical  manifestations,  from  which  recovery  may  be  com- 
plete. In  our  present  knowledge  the  diagnosis  of  an  organic  lesion  should 
be  limited  to  those  cases  in  which  optic  atrophy,  bladder  troubles,  and  signs 
of  sclerosis  of  the  cord  are  well  marked — indications  either  of  degeneration 
of  the  lateral  columns  or  of  multiple  sclerosis. 

Prognosis. — A  majority  of  ])atient!i  with  traumatic  hysteria  recover. 
In  railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the 
hands  of  lawyers  the  symptoms  usually  persist.  Settlement  is  often  the 
starting  point  of  a  speedy  and  i)erfoct  recovery.  I  have  known  return  to 
health  after  the  persistence  of  the  most  aggravated  symptoms  witii  com- 
plete disability  of  from  three  to  five  years'  duration.  On  the  otiier  hand, 
there  are  a  few  cases  in  which  the  symptoms  persist  oven  after  the  litiga- 
tion has  been  closed  ;  the  patient  goes  from  bad  to  worse  and  psychoses 
develop,  such  as  melancholia,  dementia,  or  occasionally  progressive  paresis. 
And,  lastly,  in  extremely  rare  cases,  organic  lesions  may  develop  us  a 
sequence  of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  thcs-.  cases 
fsonsists  ill  determi)\ing  (ft)  the  existence  of  actual  disease,  and  (/;)  its  char- 
acter, whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion. 
The  outlook  for  ultimate  recovery  is  good  except  in  cases  which  present  the 
more  serious  symptoms  above  mentioned.     Nevcrtheloss,  it  must  bo  boruo 


OTIIEII   FORMS  OP  FUNCTIONAL   PAUAIiYSIS. 


085 


in  mind  Unit  tniiiinatii;  liystcM-iii  is  ono  of  tho  moat  intrucUiblo  ulT«jctiona 
which  wo  aro  calk'd  upon  to  trout. 

Treatment  of  Neurasthenia.— M^iiny  jjuticnts  conio  under  our 
caw  11  ffciuMalidii  too  laU'  for  satisfactory  tivattnciit,  and  it  iiiav  be  imp(/s- 
Kihle  to  rcstoro  tho  cxliaiislod  cajiital.  Ju  other  instances,  the  recovery 
takes  place  rapidly,  the  patient  remains  well  for  a  few  months  or  u  year, 
and  then  overwork,  or  even  the  ordinary  wear  and  tear  of  lifo,  a^^ain  pros- 
trates hun.  Other  persons  drift  into  a  condition  of  chroiii''  invalidism  or 
become  slaves  to  morphia  or  chloral.  In  the  case  of  business  or  ])rofes- 
tiional  men,  in  whom  tho  condition  develops  as  a  result  of  overwork  or 
overstudy,  it  nuiy  bo  sullicient  to  enjoin  absolute  rest  with  chanj^'o  of  soono 
and  diet.  A  trip  abroad,  with  a  residence  for  a  month  or  two  in  Switzer- 
land, or,  if  there  an-  sytn[)tonis  of  m'rvous  dysptjtsia,  a  residence  at  one  of 
the  Sj)as,  will  usually  prove  Kufllcient.  The  excitement  of  the  larj^'e  cities 
abroad  should  be  avoided.  IJetter  still  for  these  cases,  if  they  carry  it  out, 
is  a  lifo  in  tho  woods  or  on  tho  ])lains.  'J'liree  months  of  tent-life  in  tho 
Adirondacks  or  tho  same  lcnfi;th  of  time  in  the  Hoeky  Mountains  will 
Kometinu's  <'ure  tho  most  marked  cases  <d"  this  kind.  Such  a  plan  is  not, 
however,  within  the  circutnstances  of  all.  In  a  much  lar-jfcr  class,  in(!lud- 
in<f  a  large  proportion  of  neurasthenic  women,  u  systematic  Weir  Mitchell 
treatment  ri;^idly  carried  out  should  be  tried  (see  hysteria).  I-'or  obstinate 
and  protracti'd  cases,  particularly  if  cond)ined  with  the  chloral  or  mor{)hia 
habit,  no  other  jilan  is  so  satisfactory.  The  treatment  of  the  gastric  and 
intestinal  sym])toms  so  important  in  this  condition  has  already  been  con- 
sidered. In  milder  grades  of  tho  condition  nui.ssago  aloni;  will  be  found 
very  useful.  For  the  irregular  })ains.  jiarticularly  in  the  back  and  neck, 
the  thermo-cantery  is  invaluablo.  Medicines  are  of  little  avail.  Strychina 
in  full  doses  is  often  bene'icial.  For  tho  relief  of  sleeplessness  all  possible 
measures  should  bo  resorted  to  before  the  employment  of  drugs. 


XIV.  OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS. 


t  ...:■;. 


J-s 


I.  PinuoDicAii  Paualysis. 

I  have  already  referred  to  tho  renuvrkable  periinlical  j'-aralysis  of  tho 
ocular  muscle:',  which  may  recur  at  intervals  for  many  years.  '^Pherc  is  a 
form  of  periodical  paralysis  involving  the  general  nnisi'lcs,  avIucIi  may 
recur  with  great  reg'darity,  and  which  is  also  u  "  family  "  alfeclion.  In 
WestphaFs  case,  a  boy  of  twelve,  the  attacks  began  in  the  ciglith  }ear,  and 
at  first  rocurred  every  four  or  six  weeks,  and  lasted  from  a  few  hours  to 
two  days.  Goldilam*  has  described  a  family  in  which  twelve  membcra 
were  affected  with  this  disease,  the  heredity  being  through  the  mother. 


*  Zeitschrift  filr  klinischo  Mcdicin,  DJ.  xis,.1801. 


986 


DISEASES  OF  TIIK   NKRVOUS  SYSTEM. 


m. 


Couaot  has  also  met  with  a  fumily  iti  which  tlio  mother  and  four  (iliihh-cn 
woro  attacked.  'IMic  discaso  occuirs  in  yotitli,  atid  tlic  tciuU'iicy  to  the 
attacks  diiiiiiiishos  with  a<?c. 

The  clinical  picture  is  very  inucii  alike  in  all  the  recorded  oa.scs.  'JMio 
paralysis  involves,  as  a  rule,  the  arms  and  leijs.  It  comes  on  when  the 
patients  are  in  full  health,  and  without  any  apparent  cause,  often  duriufj 
H!(!ep.  Sometimes  it  Ix'j^ins  with  weakness  in  the  lindis,  a  sensation  of 
weariiuss  ami  sleepiness,  not  often  with  sens(»ry  symptoms.  The  paralysis 
is  usually  complete  within  the  first  twenty-f».ur  hours,  heginning  in  the 
legs,  to  which  in  rare  instaiu-es  it  is  conlined.  The  muscles  of  the  neck 
are  sometimes  involved,  and  occasionally  those  of  the  tongue  and  pharynx. 
The  cerel)ral  nerves  and  the  special  senses  are,  as  a  rule,  uninvolved.  Tlio 
attacks  are  afebrile,  sometimes  with  low  temperatures  and  slow  pidso. 
The  deep  reflexes  are  reduced,  sometimes  abolished,  and  the  skin  reflexes 
may  be  feeble.  One  of  the  most  renuirkable  features  is  the  extraordinary 
reduction  or  complete  abolition  of  the  faradic  excitability,  both  of  muscles 
and  of  lU'rves. 

Improvement  begins  sometimes  in  the  course  of  a  few  hours  or  after  a 
day  or  two,  and  the  paralysis  disap))ears  completely,  and  the  patient  is 
perfectly  well.  As  mentioned,  the  attacks  muy  recur  every  few  weeks,  in 
some  instances  even  daily;  more  commonly,  an  interval  of  one  or  two 
weeks  cla{)ses  between  the  attacks.  Goldflam  suggests  that  the  paralysis  is 
due  to  an  auto-intoxication,  and  that  the  poisonous  material  acts  ujuni  the 
nerve-endings  in  the  muscles.  He  has  made  experiments  with  the  urine 
of  a  case  which  showed  that  during  the  attacks  the  toxic  properties  of  this 
secretion  were  materially  int'reased.  From  the  recurring,  periodic  char- 
acter of  the  attacks  they  have  been  supposed  to  be  due  to  malaria,  but  of 
this  there  is  no  evidence. 


II.  Astasia  ;  Abasia. 

These  terms,  indicating  respectively  inability  to  stand  and  inability  to 
walk,  have  been  applied  by  Charcot  and  Blocq  to  diseased  conditions  char- 
acterized by  loss  of  the  2>ower  of  standing  or  of  walking  with  retention  of 
muscular  power,  coordination,  and  sensation.  lilocq's  definition  is  as  fol- 
lows:  "A  morbid  state  in  which  the  impossibility  of  standing  erect  and 
walking  normally  is  in  contrast  with  the  integrity  of  sensation,  of  muscu- 
lar strength,  and  of  the  coordination  of  the  other  movements  of  the  lower 
extremities."  The  condition  forms  a  symptom  group,  not  a  morbid  entity, 
and  is  probably  a  functional  neurosis.  Knapp  in  a  recent  paper  analyzes 
the  50  cases  reported  in  the  literature.  Twenty-five  of  these  were  in  men, 
25  in  women.  In  21  cases  hysteria  was  present;  in  3,  chorea;  in  2,  e[)i- 
Icpsy;  and  in  4,  intention  psychoses.  As  a  rule,  the  ])atients,  though  able 
to  move  the  feet  and  legs  perfectly  when  in  bed,  are  either  unable  to  walk 
properly  or  cannot  stand  at  all.     The  disturbances  have  been  very  varied, 


IIAYNAUD'S   niSKASK 


087 


luid  (lilTcront  forma  Imvc  hccii  rcco^jiiizcd.  Tlic  cotnuioncst,  lU'conliiiij  to 
Knnpp's  analysis  of  tlio  roconled  faM>rt,  is  the  paralytic,  in  wiiidi  tlic  l('f,'s 
give  out  as  tlip  patient  attempts  to  uiillx  and  "  hcnd  under  him  as  if  nuulc 
of  cotton."  "There  is  lU)  ri^^idity,  no  spasm,  no  iiu'o("irdiiiation.  In  heel, 
aittiiij;,  or  even  whilt^  suspended,  t!ie  muscular  st''enjrtli  is  round  to  he 
good."  Other  cases  are  associated  with  spasm  or  ataxia;  thus  tiiere  may 
he  Tnovement.s  whi(di  stilTen  the  legs  and  give  to  the  gait  u  somewhat  spas- 
tic character.  In  other  instances  there  .wo  Hudden  llexions  of  the  legs,  or 
oven  of  the  anus,  or  a  saltatory,  spring-like  spasm.  In  a  nuijority  of  the 
ciLses  it  is  a  nuinifestation  of  a  luairosis  allied  to  hysteria. 

The  ca.ses,  as  ii  rule,  recover,  partic-ularly  in  young  persons.  Ifcdapses 
iiro  not  uncommon.  The  rest  treatnu^nt  and  static  electricity  should  he 
employed. 


V.  VASO-MOTOR  AXD  TROPTIIC   DISORDERS. 


I.  RAYNAUD'S  DISEASE. 

Definition. — A  vascular  <lisorder,  j)rohal)ly  de[)endent  upon  vaso- 
motor iniluences,  (duiracterized  hy  tliree  grades  of  intensity:  (a)  Local 
.synco])e,  (/>)  local  asphyxia,  and  (c)  local  or  symmetrical  gaiiL'rcne. 

Loral  Siptnipp. — This  condition  is  sec^n  most  fre(piently  in  tlu;  extrem- 
ities, producing  the  condition  known  as  dead  fingers  or  dead  toes.  It  ir. 
analogor.s  to  that  produced  by  great  c(dd.  The  entire  hand  may  ho  af- 
fected with  the  fingers;  more  commoidy  only  one  or  more  of  the  finger.'*. 
This  feature  of  the  disease  rarely  occurs  alone,  l)ut  is  generally  associated 
with  local  asphyxia.  The  cojnmon  ficfiueuee  is  as  follows:  On  exposure  to 
slight  cold  or  in  consequence  of  some  cnu)tiomd  disturhauce  the  fingers 
hecome  white  and  cold,  or  l)oth  fingers  and  toes  arc  affected.  The  ))allor 
may  continue  for  an  iii(h>tlnit(>  time,  though  usually  not  more  tiian  an 
hour  or  so;  then  gradually  a  reaction  follows  and  the  fingers  get  burning 
hot  and  red.  This  does  not  necessarily  occur  in  all  the  finger.s  together ; 
one  finger  may  be  as  white  as  marble,  while  the  adjacent  ones  are  of 
a  deep  red  or  ])lum  color. 

Lunil  Asp/ii/.rin. — (-hill)Iains  form  the  mildest  grade  of  this  condifitm. 
It  usually  follows  the  local  syncope,  but  it  may  come  on  independently. 
The  fingers  aiul  toes  are  oftenest  affected,  next  in  order  the  oars ;  more 
rarely  portions  of  the  .skin  on  the  arms  and  legs.  During  an  attack  the 
fingers  alone,  sometimes  the  hands,  also  swell  and  become  iutensi  'y  con- 
gested. In  the  most  extreme  grade  the  fiugors  are  })erfectly  livid,  and 
the  capillary  circulation  is  almost  stagnant.  The  swelling  causes  stilT- 
noss  and  usually  ])aiu,  not  acute,  hut  due  to  the  tension  and  distention  of 
the  skin.     Sometimes  there  is  marked  anassthosiu.     Attacks  of  this  sort 


i 


988 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


P^I^P'^V 

may  recur  for  years,  and  bo  bniiifrlit  on  by  the  slightest  exposure  to  cold  or 
in  consequence  of  disturbances,  either  mental  or,  in  some  instances,  jfastric. 
Apart  from  this  unpleasant  symptom  tiie  j^'cneral  health  may  be  very  good. 
The  attacks  may  recur  only  at  long  intervals  or  during  the  winter  time. 

Loral  or  Si/>n/netric((/  (la)i(jrcnc. — 'IMie  mildest  grade  of  this  condition 
follows  the  local  as[)hyxia,  in  the  chronic  cases  of  which  small  necrotic 
areas  are  sometimes  seen  at  the  tips  of  i!ie  fingers.  Sometimes  the  jtads 
of  the  fingers  and  of  the  toes  are  quite  cicatricial  from  repeated  slight 
losses  of  this  kind.  So  also  when  the  cars  are  atfccted  there  may  be  super- 
ficial loss  of  substance-  at  the  edge.  The  severer  eases,  which  terminate 
in  extensive  gangrene,  are  fortunately  rare. 

In  an  attai.'k  tlu;  lociki  as[)hyxia  persists  in  the  fingers.  The  terminal 
phalanges,  or  perhaps  only  one  finger,  become  black,  cold,  and  insensi- 
ble. The  skin  begins  to  necrose  and  superfi(!ial  gangrenous  blebs  appear. 
(Gradually  a  line;  of  dcmarkation  show;  itst^lf  and  a  jiortion  of  one  or  more 
of  tlie  fini^ers  sloughs  avav.  The  resulting  loss  of  substance  is  much  less 
tlian  tlu*  appearaiice  of  the  haiul  or  foot  would  indicate,  and  a  condition 
which  looks  as  if  the  patient  would  lose  all  the  fingers  or  half  of  a  foot 
nuiy  result  perhaps  in  only  a  slight  superficial  h)ss  in  the  phalangcis.  In 
severer  cases  the  greater  portion  of  a  finger  or  the  tip  of  the  nose  may  be 
lost.  Occasionally  the  disease  is  not  confined  to  the  extremities,  but  afi^ects 
symmetrical  patches  on  the  limbs  or  trunk,  and  may  pass  on  to  rapid  gan- 
grene. These  severe  types  of  eases  occur  particularly  in  young  childr;  ti, 
and  death  may  result  within  three  or  four  days.  'IMie  attacks  are  usually 
very  painful,  and  the  motion  of  the  i)art  is  much  impaired.  In  some 
cases  numbness  and  tingling  persist  for  a  huig  time. 

There  are  remarkable  concomitant  symptoms  in  Ifayiuuurs  disease  to 
whicdi  a  good  deal  of  attention  has  been  paid  of  late  year  .  II;tMnoglo!'i- 
nuria  may  develop  during  an  attack,  or  may  take  the  place  of  an  outbreak. 
In  such  instances  the  alfection  is  usually  brought  on  I  y  cold  weather. 
In  a  case  reported  by  11.  T\I.  Thomas  from  my  clinic,  Haynaucrs  dis- 
ease occurred  for  three  successive  winters  and  always  in  association  will' 
liamioglobinuria.  The  attacks  were  sometimes  preceded  by  a  chill.  Sev- 
eral cases  of  the  kind  are  found  in  Harlow';  appendix  to  his  translation  of 
Raynaud's  paper  for  the  New  Sydenham  Society,  '"'he  onset  with  a  chill, 
as  in  the  case  just  mentioned,  Inis  doubtless  giv!.n  rise  to  the  idea  that  the 
disease  is  in  some  way  associated  with  ague.  (Jciebrtd  symptoms,  ])articu- 
larly  mental  torpor  and  transient  loss  of  consciorsness,  have  also  beer 
m)ticed  iu  sonui  cases.  Tl'o  case  just  mentioned  with  luTmoglobinuria 
had  epilepsy  with  the  attticks.  Exposure  on  a  cold  day  would  bring  on 
}  I  epileptic  seizure  with  the  local  asphyxia  and  bloody  uriuo.  Occasion- 
ally joint  alTections  develop,  particularly  anchylosis  and  th'.'kening  of  the 
l)halangeal  artic.dat  ions.  Southey  has  rejiorted  a  case  in  which  mania  de- 
veloped, and  Harlow  an  insti  nee  in  which  the  woman  had  delusions. 
Peripheral  neuritis  has  been  found  in  several  cuses. 


SM! 


ANGIO-NEUROTIC  (EDEMA. 


989 


The  patholor/i/  of  this  rcniarkablo  <lisoaso  is  still  obscure.  Raynaud 
suggested  that  the  loeal  syneope  was  produced  by  contraction  of  the  ves- 
sels, which  seems  likely.  1'he  asphyxia  is  dependent  upon  dilatation  of 
the  capillaries  and  small  veins,  probably  with  the  persistence  of  some  de- 
gree of  spasm  of  the  smalh'r  arteries.  There  are  two  totally  dill'erent  forms 
of  congestion,  which  may  be  shown  in  adjacent  fingers ;  one  may  be 
swollen,  of  a  vivid  red  color,  extremely  hot,  the  cai>illarii's  and  all  the  ves- 
sels fully  distended,  and  the  ana'Uiia  i)roduced  by  pressure  may  l)e  instanta- 
neously obliterated  ;  the  adjacent  linger  may  be  equally  awollen,  abso- 
lutely cyanotic,  stone  cold,  and  the  anannia  produced  by  pressure  takes  u 
long  time  to  disappear.  In  the  latter  ease  the  arterioles  arc  i)robably  still 
in  a  condition  of  spasm. 

Treatment. — In  many  cases  the  attacks  recur  for  years  uniidluenced 
by  treatment.  Mild  attacks  require  no  treatment.  In  the  severe"*  forms 
of  local  asphyxia,  if  in  the  feet,  the  patient  should  be  ke[)<^  in  bed  with 
the  legs  ehivated.  The  toes  should  be  wrapped  in  cotton-wool.  The  pain 
is  often  very  intense  and  nuiy  recpiire  morphia.  Carefully  applied,  i^ys- 
tematie  massage  of  the  extrendties  is  sometimes  of  benellt.  (ialvanism 
may  be  tried.  I'arlow  advises  immersijig  the  atfeeted  limb  in  salt  water 
and  placing  one  electrode  over  the  s])ine  and  the  other  in  the  water. 


ll 


i      P 


II.    ANGIO-NEU..OTIC  CEDEMA. 


Definition. — An  affection  characterized  by  the  occurrence  of  local 
(edematous  swellings,  more  or  less  limited  in  extent,  and  of  transient  du- 
ration. Severe  colic  is  sonu'times  associated  with  the  outbreak.  Tiiere  is 
a  marked  hereditary  disposition  in  the  disease.  'I'he  affection  has  been 
specially  studied  by  Quincke,  .lanneson,  J.  E.  (Jraham,  and  Matas. 

Symptoms. — Tiu'  o'dema  appears  suddenly  and  is  usually  circum- 
scribed. It  may  appear  in  the  face;  the  eyelid  is  a  (lommon  situation  ;  or 
it  may  involve  the  lips  or  cheek.  The  backs  of  the  hands,  the  legs,  or 
tiie  throat  may  be  attacked.  I  sually  the  coiidition  is  transient,  associated 
perhaps  with  slight  gastro-intestinal  distress,  and  the  alTcction  is  of  little 
monu^iit.  'I'here  may  be  ,i  remarkable  periodicity  in  the  outbreak  of  the 
(pdema.  In  Matas's  case  this  periodicity  was  very  striking;  the  attat^k 
ciine  on  every  day  at  eleven  or  twelve  o'clock.  The  disease  nuiy  bo  hered- 
itary through  many  generations.  In  the  fimily  whose  history  I  rejiorted, 
five  generations  had  been  a'lected,  including  tv\'nty-two  Tru'mbers.  The 
swellings  appear  in  various  parts ;  only  rarely  are  they  constant  in  oiu'  local- 
ity. The  hands,  fa(H>,  aiul  genitalia  are  the  parts  most  frequently  affected. 
Itching,  heat,  redness,  or,  in  some  instiinees,  urticaria  may  ])recede  the 
outbreak.  Sud«len  uidema  of  the  larynx  may  provt^  fatal.  Two  nu'm- 
bers  of  the  family  just  referred  to  died  of  this  complicati-^n.  In  one 
member  of   this  family,  whom  I  Haw   repeatedly  iu  attacks,  the  swell- 


m 


990 


DISEASP]S  OP  THE  NERVOUS  SYSTEM. 


in;j:a  oamo  on  in  difTerent  parts;  for  cxarnplo,  tlic  untler  lip  Avould  lie 
HW'olk'n  to  siinh  a  dof^reo  that  the  mouth  conhl  not  bo  oiKMied.  Tlio  hand., 
enlai'fije  siuhlcnly,  so  that  the  fingers  cam  ot  bo  bent.  The  attacks  recur 
every  three  or  four  weeks.  Ae(K)mpaiiying  them  are  usually  gastro- 
intestinal attacks,  severe  coli(%  ])ain,  nausea,  and  sometimes  vomitiuL'. 
The  eolie  is  of  great  intensity  and  usually  requires  nior]thia.  Arthriti- 
apparently  does  not  occur. 

The  disease  has  aflinities  with  urticaria,  the  giant  form  of  which  i;- 
prohaI)ly  the  same  disease.  There  is  a  form  of  severe  ]uirpura,  often  with 
urticarial  numifestations,  which  is  also  associated  with  marked  gastn.- 
intestinal  crises.  Quintike  regards  tiie  contlition  as  a  vaso-motor  neurosi> 
under  the  influence  of  which  the  permeability  of  the  vessels  is  suddenly 
increased. 

The  /rrrt/innii  is  very  unsatisfactory.  In  the  cases  associated  with 
annpmiaand  general  nervousjiess,  tonics,  particularly  large  doses  of  strych- 
nia, do  good  ;  but  too  often  the  disease  resists  all  treatment. 


&?"! 


III.    FACIAL  HEMI-ATROPHY. 

An  affection  characterized  by  progressive  wasting  of  the  bones  and 
soft  tissues  of  one  side  of  the  face.  The  atrophy  begins,  as  a  rule,  in 
childhood,  but  in  a  few  cases  has  not  come  on  until  middle  age.  It  begins 
dilfusely,  but  in  some  instances  has  started  at  oiu;  spctt  on  the  skin  and  has 
gradually  snread,  involving  at  first  the  subcutaneous  tissues,  then  the 
muscles  and  the  bones,  more  particularly  the  upper  jaw.  The  wasting  is 
sharply  limited  at  tlie  middle  line,  and  the  a}ii)earanee  of  the  patient  is 
very  reinarkablo,  the  face  looking  as  if  made  up  of  two  halves  from  ditTcr- 
eut  persons.  There  is  usually  change  in  the  color  of  the  skin  and  the 
hair  falls.  Owing  to  the  wasting  of  the  alveolar  processes  the  teeth  be- 
come loose  and  ultimately  fall  out.  The  wasting  involves  the  tissues  of 
the  orbit,  and  the  eye  on  thealfeeted  side  is  sunken.  In  a  majority  of  the 
cases  the  atrophy  has  been  confined  to  one  side  of  the  face,  l)ut  there  arc 
instances  on  record  in  which  the  disease  was  bilateral,  and  a  few  cases  in 
which  there  were  areas  of  atrophy  on  the  l)ack  and  on  the  arm  of  the 
same  side.  The  disease  is  rare.  Sachs  has  collected  07  cases  from  the 
literature. 

Two  autopsies  have  been  made.  In  Mendel's  case  there  was  the  terminal 
stage  of  an  interstitial  neuritis  in  all  the  bran<dies  of  the  trigeminus, 
from  its  origin  to  the  perii)hery,  most  marked  in  the  superior  nuixillarv 
braiu'h. 

In  Ilomen's  case,  which  came  on  rapidly  and  scarcely  belongs  to  tlie 
typical  form  of  the  disease,  a  tumor  was  found  pressing  upon  the  (Jiis- 
Bcrian  ganglion  and  the  trigeminus  nerve. 

The  disease  i.;  recognized  ut  a  glance.     The  facial  asymmetry  asso- 


ACROMEGALIA. 


991 


oiiitcd  with  congenital  wryneck  must  not  bo  confoundod  with  progrossivo 
fiicial  honii-atrophy.     Tim  precise  nature  of  the  disease  is  still  doubtful. 


IV.    ACROMEGALIA. 

Definition. — A  dystr()})hy  characterized  by  al)nornial  processes  of 
growtli,  cliicily  in  the  bones  of  the  face  and  extremities. 

The  term  was  introduced  by  Marie,  and  signifies  large  extremities. 

Etiology. — Nothing  definite  is  known  concerning  the  cause  of  the 
disease.  It  octnirs  rather  more  frequently  in  women.  Of  tlie  38  cases 
analyzed  in  the  monograph  of  Souza-Leite,  10  were  in  men  and  22  in 
women.  'JMie  disease  usually  begins  about  tiie  twenty-lil'tli  year,  though 
in  some  instances  as  late  as  the  fortieth.  Rheumatism,  syphilis,  and  the 
specific  fevers  have  preceded  the  development  of  the  disease,  but  probably 
have  no  special  connection  with  it.  In  this  country  five  or  six  cases  imve 
been  reported,  two  by  J.  E.  (Jraliam,  of  Toronto. 

Symptoms. — In  a  well-marked  (^ase  the  disease  i)resents  mo.st  char- 
acteristic features.  The  hands  and  feet  arc  greatly  enlarged,  but  are  not 
deformed,  and  can  be  used  freely.  The  hypertrophy  is  general,  involving 
all  the  tissues,  and  gives  a  curious  spade-like  character  to  tlu;  hands.  Tiie 
wrists  may  be  enlarged,  but  the  arms  are  rarely  alTected.  The  fei't  are 
involved  like  the  hands  and  arc  uniforndy  enlarged.  Thi^  big  toe  may  be 
much  larger  in  proportion.  The  nails  are  usually  broad  and  large.  The 
head  increases  in  volume,  but  not  as  much  in  proportion  as  the  face,  which 
becomes  nuicli  elongated  and  enlarged  in  conseciuenee  of  the  increase  in 
the  size  of  the  superior  aiul  inferior  maxillary  bones.  The  latter  in  par- 
ticular increases  greatly  in  size,  and  often  projects  below  the  uj)per  jaw. 
The  alveolar  processes  are  wiilcned  and  the  teeth  separated.  The  soft 
parts  also  increase  in  size,  and  the  nostrils  are  Lirgo  and  broad.  Tiu>  eye- 
lids are  sometimes  greatly  thickened,  and  the  ears  enormously  hy[)ertro- 
phied.  The  tongue  in  some  instances  l)ecomes  greatly  eidarged.  Late  in 
the  disease  the  spine  may  be  alTected  and  the  back  bowed — kypiiosis.  The 
bones  of  the  thorax  may  slowly  and  progressively  enlarge,  ^^'ith  lliis 
gradual  increase  in  size  the  skin  of  the  hands  and  face  may  appear  iu)nn'd. 
Sometimes  it  is  slightly  altered  in  color,  coarse,  or  llal)by,  but  it  has  not 
the  dry,  harsh  appearance  of  the  skin  in  myxo'dema.  The  nniscles  are 
sometimes  wasted.  Changes  in  the  thyroid  have  been  fo»ind,  but  arc 
not  constant.  The  gland  has  l)een  normal  in  some,  atrophitd  in 
(ttlu'rs,  and  in  a  third  group  of  cases  enlarged.  Hrb,  who  has  nuide 
an  elaborate  study  of  the  disease,  has  noticed  an  area  of  dulness  over 
the  nnuiubrium  stend,  which  he  thought  ))ossil)ly  duo  to  the  persist- 
ence or  eidargement  of  the  thymus.  Headache  is  not  uncommon.  Men- 
strual disturbance  may  occur  early,  and  there  iiuiy  be  suppression.  In 
some  instauccs  vision  has  been  involved,  owing  to  a  gradual  atrophy  of 


1    \ 


■'.    «* 


;«      !■ 


It. '3 


I, !. : 


992 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


i 


,.■(■■.. 


the  optic  nervo.  Tlic  disease  iruiy  persist  for  fifteen,  twenty,  or  nion^ 
years. 

The  juiflinlof/icctl  (inafniin/  lias  boon  studied  in  a  few  cases.  In  iuhli- 
tion  to  cnlar^'cnient  of  the  bones,  Mliicli  is  a  true  hypertrophy,  enormous 
enlar^'cnu'iit  of  the  hypophysis  (pituitary  body)  lias  been  found,  and  koihc 
liave  regarded  the  disease  as  associated  in  some  way  with  this.  Less  con- 
stant have  been  the  changes  in  the  thymus  and  in  the  thyroid.  In  souio 
instances  the  iierijiheral  nerves  have  been  involved.  The  most  exhausti\e 
anatomical  study  made  as  yet  is  that  published  by  Arnold,  of  lleidelberi,', 
on  the  ea  '.e  which  was  described  clinically  by  Friedreich  and  Erb. 

As  stated,  the  true  nature  of  the  disease  is  unknown,  ^larie  regards 
it  as  a  systemic  dystrophy,  analogous  to  myxanlcma  and  possibly  due  to 
the  morbid  condition  of  the  pituitary  body,  just  as  myxoedenui  is  associated 
with  disease  of  the  thyroid. 

Diagnosis. — The  disease  must  be  carefully  separated  from  the  osfcilis 
defdrniaiix  of  I'aget,  in  which  the  shafts  of  the  long  bones  arc  ehiclly  in- 
volved, and  in  the  head  the  bones  of  the  cranium,  but  not  those  of  the  face. 
Marie  states  that  in  Paget's  disease  the  face  is  triangular  with  the  base 
upward  ;  in  acromegalia  it  is  ovoid,  or  egg-shayicd,  with  the  large  end 
downward  ;  while  in  myxcrdema  it  is  round  and  full-moon  shaped.  The 
disease  must  not  be  confcninded  with  the  instances  of  congenital  or  pro 
gressivo  hypertrophy  of  a  single  member,  as  of  the  leg  or  arm,  the  so- 
called  giant  growth,  in  which  the  various  proportions  are  maintained. 

Lastly,  Marie  has  separated  from  acromegalia  a  group  of  cases  char- 
acterized l)y  hypertrophy  of  the  bones  of  the  extremities  and  of  the  shafts, 
producing  great  disability.  The  spine  is  also  affected  and  curvature  takes 
place.  The  fingers  are  characteristic.  The  terminal  phalanges  become 
bulbous,  enlarged,  and  the  nails  are  curved,  which  gives  the  ajjpearance  of 
the  so-,  ailed  llippocratic  linger,  a  very  differ.ent  condition  indeed  from  the 
flattened  terminal  phalanges  of  acromegalia.  Etiologically,  Marie  regards 
this  form  as  associated  in  some  way  with  pulmonary  troubles.  Thus,  for 
instance,  two  of  the  jiatients  had  ])urulent  pleurisy,  the  cases  of  Ewald 
and  of  Saundby  ha^l  new  growths  in  tlie  lungs,  and  others  presented 
chronic  bronchitis.  .Marie,  therefore,  terms  this  form  OKtcn-arlhroputhie 
pticuuiiqiic.  It  is  doubtful,  however,  as  Arnold  states  in  his  exhaustive 
study  of  I-'riedreich's  case,  whether  this  form  can  really  bo  separated  from 
acromegalia. 

The  treatment  does  not  appear  to  have  any  influence  upon  the  progress 
of  the  disease. 

Here  may  be  mentioned  a  remarkable  dystrophy,  mot  with  so  far  only 
in  women,  known  as  sdrnHldcti/Ic,  in  which  there  are  symmetrical  involve- 
ments of  the  fingers,  which  become  deformed,  shortened,  and  atrophied. 
The  skin  becomes  thickened,  of  a  waxy  color,  and  is  sometimes  pigmented. 
Bulla)  and  ulcerations  liave  been  met  with  in  some  instances,  and  a  groat 
deformity  of  the  nails.    The  disease  has  usually  followed  exposure,  and  the 


SCLERODEUMA. 


993 


patients  are  much  Avorso  durinf?  thu  uiiitcr  and  aro  curiously  sonpHivo  to 
cold.  'rii(>ro  may  be  chaiii^'cs  in  tliu  skin  of  tlio  foot,  hut  tho  doforuiity 
similar  to  that  wliich  o<'(;urrt  in  the  hand  lias  not  Itoon  noted.  Some  of  tliu 
cases  have  jiresentod  in  addition  dilTnso  Hclorodormatous  ohanijfcs  of  tho 
skin  of  otlior  parts.  An  admirahlo  dosiMujition  of  tho  diacapo  has  boon 
given  by  Ciordinior.* 


V.   SCLERODERMA. 

Defi.Ilitioil. — A  condition  of  localized  or  diffuse  induration  of  the 
skin. 

Two  forms  are  recognized,  the  localized  or  circumscribed,  which  cor- 
responds to  the  keloid  of  Addison  and  to  morphea,  and  tlie  dilTuse,  in 
which  larjre  areas  are  involved. 

In  the  cirrainscribi'd  form  tlu're  arc  patches,  ranj^niiir  fmm  a  few  cen- 
timetres in  diameter  to  the  size  of  the  hand  or  lartrer.  in  wbicli  the  skin 
has  a  waxy  or  dead-white  appearance  and  to  the  touch  is  bra\v?iy.  hard, 
and  inelastic.  Sometimes  there  is  a  j)reliininary  liypcra'tnia  of  the  skin, 
and  subserpiently  there  aro  chaiiijes  in  color,  either  areas  of  piiLrnu-ntation 
or  of  completeatro|;hy  of  the  piifment — leucodernni.  'V\w  sensory  chancres 
arc  rarely  marked.  The  secretion  of  sweat  is  diminished  or  entirely  abol- 
ished. The  disease  is  more  common  in  women  than  in  men,  and  is  situ- 
ated most  fre(|ucntly  about  the  breasts  and  neck,  soniotinu's  in  the  course 
of  the  nerves.  The  patches  may  develoj)  with  irroat  rapidity,  and  may  per- 
sist for  months  or  years;  sometimes  they  disappear  in  a  few  weeks. 

The  dijfti.se  form,  though  less  common,  is  more  serious.  Jt  develops 
first  in  the  extremities  or  in  liie  face,  and  the  patient  notices  that  the  skin 
is  unusually  hard  and  firm,  or  that  there  is  a  sense  of  stilfness  or  tension 
in  nnd\ing  accustomed  movc>ment.s.  (Jradually  a  (lill'iise,  l)rawny  indura- 
tion develops  and  the  skin  becomes  linn  and  hard,  and  so  united  to  tho 
Bubcutaneous  tissues  that  it  cannot  bi' ])ii'ked  u[»  or  pinched.  The  skin 
may  look  natural,  but  more  commonly  is  glossy,  drier  tiian  normal,  and 
unusually  smooth.  Of  44  cases,  in  "■24  the  first  appearances  wore  on  the 
arms,  in  i  on  the  legs,  in  1  on  both,  in  10  on  the  face  and  neck,  and  in  '-' 
on  the  trunk  (Dinkier).  The  disease  may  gradually  extend  and  involve 
the  skin  of  an  entire  limb;  in  rare  cases,  it  becomes  universal,  the  face 
is  expressionless,  tho  lips  cannot  be  moved,  mastication  is  impossible,  and 
it  becomes  extremely  dillioult  to  feed  tho  ])atient.  The  hands  bi'cttmo 
fixed,  the  fingers  immobile,  on  account  of  tiie  extreme  induration  of  tho 
skin  over  the  joints.  The  disease  is  chronic,  lasting  fi»r  many  months  or 
many  years.  There  are  instances  on  record  of  its  persistence  for  more 
than  twenty  years,     llecovery  niuy  occur,  or  tlie  disease  nuiy  he  arrested. 


m 


* 


'ill 


*  Aiucricuii  Journal  of  tlic  McJicul  Sciences,  .Iiinuary,  1889. 


994 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  patioiits  aro  apt  to  succumb  to  pulniomiry  complaints  or  to  nopliritis. 
I{houniati(?  troubles  liavc  been  noticed  in  some  instances;  in  others,  oiujo- 
curditis.  The  pathology  of  the  disease  is  unknown.  It  is  usually  rcpirdod 
as  a  tropho-iuHirosis,  ])rol)ably  dependent  upon  changes  in  the  arteries  of 
the  skin  leading  to  connective-tissue  overgrowtii. 

'i'he  })atients  re(iuiro  to  be  warndy  clad  and  to  be  guarded  against 
exposure,  as  they  are  particularly  sensitive  to  changes  in  the  weather. 
Frictions  with  oil,  and  galvanism  are  recommended. 


AINIIUM. 

Hero  a  brief  reference  may  be  made  to  the  remarkable  trophic  Iesi(jn 
described  by  Da  Silva  F.ima,  which  is  nu't  with  in  m-groes  in  Brazil,  Africa, 
India,  and  occasionally  in  the  Soutliern  States.  It  is  coidincd  to  the  toes, 
usually  the  little  toe,  and  begins  as  a  furrow  on  the  liiu'  of  the  digito- 
plantar  fold.  This  gradually  deepens,  the  end  of  the  toe  enlarges,  and, 
usually  without  inllammation  or  pain,  the  toe  falls  off.  The  process  may 
last  some  years,  ('ases  have  been  reported  in  this  country  by  Ilornaday, 
I'ittman,  F.  J.  Shepherd,  and  Morrison. 


f  I 


SECTION  IX. 


DISEASES  OF  THE  MUSCLES. 


I.   MYOSITIS. 

Definition. — Itifla,niniation  of  the  voluntary  muscles. 

A  prinuiry  myositis  occurs  as  an  acute  or  subacute  affection,  and  is 
probably  dependent  on  some  unknown  infectious  agent.  Several  cliarae- 
teristic  cases  have  been  described  of  late  years.  1'he  case  of  E.  Wagner 
may  \w  tjiken  as  a  typical  example.  A  tuberculous  but  well-built  woman 
entered  the  hospital,  complaining  of  stitfness  in  the  shoulders  and  a 
slight  (i)dema  of  the  back  of  the  hands  and  forearms.  There  was  panvs- 
thesia,  the  arms  became  swollen,  the  skin  tense,  and  the  mus(!les  felt 
doughy.  CJradually  the  thighs  became  affected.  The  disease  lasted  about 
three  months.  The  post-mortem  showed  slight  pulmonary  tuberculosis; 
all  the  muscles  except  the  glutei,  the  calf,  and  abdominal  muscles  were 
stiff  and  firm,  but  fragile,  and  there  were  serous  infiltration,  great  pro- 
liferation of  the  interstitial  tissue,  and  fatty  degeneration.  Similar  casea 
have  been  reported  by  rnverricht,  Hepp,  and  Jacoby  of  New  York.  In 
the  case  reported  l)y  .lacoby  the  muscles  were  firm,  hard,  and  tciuler,  and 
ttiero  was  slight  codema  of  the  skin  The  duration  of  the  cases  is  usually 
from  one  to  three  months,  though  there  are  instances  in  which  it  has  been 
longer  The  swelling  and  tenderness  of  the  muscles,  the  a>dema,  and  the 
pain  naturally  suggest  trichinosis,  and  indeed  Hepp  speaks  of  it  as  a 
})seudo-trichinosis.  The  nature  of  the  disease  is  unknown.  Senator's  case 
presented  marked  disorders  of  sensation,  and  there  is  a  question  whether 
tlie  peripheral  nerves  are  not  involved  with  the  muscles.  Wagner  suggests 
that  some  of  these  cases  wore  examples  of  acute  progressive  muscular  atro- 
])hy.  The  separation  from  trichinosis  can  be  made  only  by  removing  a 
portion  of  the  muscle.  There  are  septic  (!ases  in  which  a  diffuse,  purulent 
infiltration  of  the  muscles  of  different  regions  occurs.  Instances  have 
been  reported  in  which  this  luis  been  described  as  the  primary  affection, 
the  condition  of  the  muscles  even  passing  on  to  gangrene. 

A  remarkable  affection  is  myositis  ossificans  progressiva^  in  whicb 
portions  of  the  muscles  undergo  a  progressive  calcification. 

63  .  * 


i| 


.,]; 

ii 

'  m^' 

'■'•wi 

;i| 

■  i'. 

1 

1 

996 


DISEASES  OP  THE  MUSCLES. 


m 


II.    IDIOPATHIC  MUSCULAR  ATROPHY 

(I'rimary  Muscular  Dynliophij — L'rb), 

Deflnition. — Miistmlar  wasting',  with  or  without  iin  initial  hyjji'r- 
trophy,  bcfiinnitig  in  various  groups  of  nrisclos,  usually  progressive  in 
charai'tor,  and  dependent  on  primary  changes  in  the  niuseles  themselves. 
A  marked  hereditary  disposition  is  met  with  in  the  disease. 

iieforc  considering  the  primary  muscular  atrophies  it  may  be  well  to 
Hummarizc  ))riefly  the  chief  conditions  under  which  mu.scular  atrophy  oc- 
curs.    These  are : 

(1)  Acute  or  chronic  lesions  of  the  nuclei  of  the  motor  path,  which 
may  he  {a)  cortical,  as  a  direct  result  of  a  cerebral  lesion  ;  (b)  medul- 
lary, as  in  chronic  bulbar  paralysis ;  {c)  spinal,  either  aciute,  as  in  jmlio- 
Tnyelitis  of  children,  or  chronic,  as  in  the  progressive  muscular  atrophy  of 
the  simj)le  or  of  the  spastic  type. 

(2)  Neuritic  muscular  atrophy,  following  a  local  neuritis  duo  to  trauma, 
a  multiple  neuritis  duo  to  alcohol,  lead,  and  the  infectious  diseases.  In 
this  same  category  probably  may  be  placed  the  muscular  atrophies  associated 
with  joint-disease,  the  progressive  heini-atrophy  of  the  face,  and  the  atro- 
phy sometimes  found  in  cases  of  hysteria. 

(3)  Conditions  of  the  muscles  themselves — primary  muscular  atroj)hy. 
Eitiology. — The  most  important  factor  is  heredity.     JMany  members 

of  the  same  family  may  be  attacked  through  several  generations.  Males, 
as  a  rule,  are  more  frequently  affected  than  females.  The  disease  is  usu- 
ally transmitted  through  the  mother,  though  she  may  not  herself  be  the 
subject.  As  many  as  twenty  or  thirty  cases  have  been  described  in  five 
generations.  Isolated  cases,  however,  are  not  uncommon.  The  disease 
usually  sets  in  before  puberty,  but  may  be  as  late  as  the  twentieth  or 
twenty-fifth  year,  or  in  some  instances  even  later.  No  etiological  factors 
of  any  moment  are  known  other  than  heredity. 

Clinical  Forms. — Two  chief  types  may  bo  recognized:  (1)  With 
primary  hypertrophy,  the  psoudo-hypertrophic  muscular  paralysis;  and 
(JJ)  with  primary  atrophy. 

Pseiido-fu/perirophic  Mtiscular  Paralysis. — The  first  symptom  no- 
ticed is,  as  a  rule,  clumsiness  in  the  movements  of  the  child,  and  on  ex- 
amination certain  muscles  or  groups  of  muscles  seem  to  be  enlarged,  par- 
ticularly those  of  the  calves.  The  extensors  of  the  leg,  the  glutei,  the 
lumbar  muscles,  the  deltoid,  triceps,  and  infraspinatus,  are  the  next  most 
frequently  involved,  and  may  stand  out  with  great  prominence.  The  muscles 
of  the  neck,  face,  and  forearm  rarely  suffer.  Sometimes  only  a  portion  of 
a  muscle  is  involved.  With  this  liypertrophy  of  some  muscles  there  is 
wasting  of  others,  particularly  the  lower  portion  of  the  pectorals  and  tlie 
latissimus  dorsi.  The  attitude  when  standing  is  very  cluiracteristic.  The 
Ipgs  are  far  apart,  the  shoulders  thrown  back,  the  spine  is  greatly  curved, 
and  the  abdomen  protrudes.     The  gait  is  waddling  and  awkward.     In 


IDIOPATHIC  MUSCULAR  ATROPHY. 


997 


itrophy. 
lenibers 

Males, 

is  usu- 

1)0  the 

in  five 

disease 
tieth  or 

factors 

L)  With 
and 

torn  no- 
on ex- 
ted,  par- 
futei,  the 
L'xt  most 
I  muscles 
)rtion  of 
there  is 
and  the 
lie.     The 
curved, 

fard.     l?i 


Pitting  up  from  the  floor  the  position  assunuMl,  as  so  well  known  now 
through  (Jowers's  figures,  is  i)atliognomonic.  The  patient  first  turns  over 
in  the  all-fours  position  and  raises  the  trunk  with  his  arms;  tiic  hands  are 
then  mo\ed  along  the  ground  until  the  knees  arc  rcaclu'd  ;  then  with  otio 
hand  u])on  a  knee  he  lifts  himself  up,  grasps  the  other  knee,  and  gradu- 
ally pushes  himself  into  the  erect  posture,  as  it  has  been  expresst-d,  by 
clind)ing  up  his  legs.  The  striking  contrast  between  tiie  fceldcncss  of 
the  child  and  the  j)owerful-looking  i)seudo-hypertrophi('  muscles  is  very 
chara(;teristic. 

The  course  of  the  disease  is  slow,  but  j)rogressivc.  Wasting  proceeds 
and  finally  all  traces  of  the  enlarged  (condition  of  the  muscles  disappears. 
At  this  late  period  distortions  and  contractions  are  common. 

I'rimanj  Atrophic  Form. — Here,  too,  there  is  the  same  marked  tcMid- 
ency  to  involvement  of  ditferent  members  of  a  family.  Five  or  six  dif- 
ferent types  have  been  described,  but  it  seems  more  rational  to  group 
them  together  under  the  di^sigiuition  of  idiopathic  muscular  atropliy.  In 
all  of  the  cases  the  atrophy  begins,  as  a  rule,  before  the  twentieth  year. 
According  to  the  site  of  the  prinuiry  atrophy  ditferent  forms  have  been 
described.  In  the  juvenile  tt/j>e  of  Erb  the  affection  begins  a!)out  the 
fifteenth  or  the  twentieth  year  and  involves  the  muscles  of  tlie  upper 
arm  and  shoulder  and  the  gluteal  and  thigh  muscles.  In  the  facio- 
scapulo-humeral  type  of  Landcmzy  and  Dejerine  tiie  muscles  of  i\u>  face 
are  early  involved  with  those  of  scapulo-humcral  groups.  This  form  oc- 
curs usually  in  families,  and  the  onset  nuiy  be  delayed  until  the  twenti- 
eth or  thirtieth  year.  Leyden  describes  an  hereditari/  foriii,  beginning  in 
the  lower  extremities  and  back,  Avhich  may  be  associated  with  hyjuM'tropliy 
of  the  calves.  Another  type  has  been  described  by  Charcot  and  Tooth — 
the  peroneal  form;  but  there  is  still  some  doubt  whether  this  is  not  in 
reality  a  myelopathy  and  more  closely  related  to  chronic  polio-myelitis 
anterior.  In  this  form  the  atrophy  begins  in  the  muscles  of  the  legs, 
usually  in  the  extensors  of  the  great  toe,  and  afterwartl  in  the  common 
extensors  and  tlie  peroneal  groups.  The  cases  usually  Ix'gin  early,  and 
the  heredity  through  the  mother  has  been  traced  in  several  renuirkablo 
series,  particularly  that  of  Ilerringham's.  Fibrillary  contractions  ai\d 
the  reaction  of  degeneration  are  present.  Nerve  degeneration  has  been 
found  in  the  peripheral  parts,  and  ascending  degeneration  of  the  columns 
of  (loll. 

Morbid  Anatomy. — The  spinal  cord  and  peripheral  nerves  have 
been  found  normal  in  cases  of  pseudo-hypertrophic  muscular  paralysis  and 
in  the  forms  of  idiopathic  muscular  atrophy.  The  muscles  in  the  pseiulo- 
hypertrophic  condition  present  great  variations  in  the  size  of  the  muscle 
fibres,  some  of  which  may  be  hypertrophied  and  others  Avasted.  In  the 
early  stage  the  hjrpertrophy  of  the  fibres  may  be  very  })ronounced  and  the 
nuclei  of  the  sarcolemma  are  greatly  increased.  In  some  instances,  too, 
the  fibres  have  been  fissured  longitudinally.    At  a  later  stage  the  muscular 


i    I 


1     ! 


m 


098 


DISKASKS  OP  TIIK  MU.S(^LKS. 


fibrt'd  iirc  Wii.stcd  ntwl  liirgoly  ropliwed  hy  coiiiu'ctive  tissue  and  fat.  In 
tl)o  ])riniary  atrophic  form  wanting  of  tiio  libri's,  iiuTuuse  in  the  iiitorstitiul 
tissuo,  and  tlio  devclopinont  of  fat  arc  the  most  niarkod  features.  J'lxcept 
in  the  peroneal  typo,  about  which  there  is  atiil  doubt,  no  ulTectiou  of  the 
nerves  or  cord  has  been  deterniiiu'd. 

Diag^nosis. — Tiie  primary  myopathies  can  unually  be  readily  distin- 
guished from  the  eerel)ral,  myelopathic,  and  neuritic  forms. 

(a)  In  the  cerel)ral  atrophy  loss  of  j)ower  usually  precedes  the  atropliy, 
which  is  either  of  a  monople<;i(!  or  hemiplcgio  type. 

{/)}  In  the  myeloj)atliic  or  spinal  muscular  atrophy  the  distinctions 
are  clearly  marked.  J'n/io-ini/t'litis  antrrior  chrouini  bef,'ins  in  the  small 
muscles  of  the  hand,  a  situation  rarely  if  over  alTected  by  the  primary 
myopathies,  which  involve  first  those  of  the  calves,  the  trunk,  the  face,  or 
the  shoulder-girdle.  In  the  myelojiathic  atrophy  the  reaction  of  degeneru- 
tion  is  ])resent  and  iibrillary  twitchings  occur  in  both  the  atrophie«l  aiid 
non-atroi)hied  muscles.  In  many  cases  in  addition  to  the  wasting  in  the 
arms  there  is  a  spastic  condition  in  the  legs  and  increase  in  the  reflexes. 
The  myelopathic;  atrophies  come  on  late  in  life;  the  myopathic  forms  de- 
velop, as  a  rule,  early.  In  tin,'  primary  muscular  atntpliies  heredity  plays 
an  im|iortant  rnle,  which  in  the  myelopathic      ipiite  suljsidiary. 

(c)  In  the  neuritic  muscular  atrophies,  whether  due  to  lead  or  to 
trauma,  the  general  characters  and  the  mode  of  onset  are  distinctive.  In 
the  cases  of  multii)le  neuritis  seen  for  the  first  time  at  a  period  when  the 
wasting  is  marked  there  is  often  difticulty,  but  the  al)sence  of  family 
history  and  the  distribution  are  important  features.  Moreover,  the  })aral- 
ysis  is  out  of  proportion  to  the  atrophy.-  Sensory  symptoms  may  l)e 
present,  and  in  the  cases  in  which  tlie  legs  arc  chiefly  involved  there  is  usu- 
ally the  s/r/ipdf/c  gait  so  characteristic  of  peripheral  neuritis. 

The  outlook  in  the  jirimary  myopathies  is  bad.  The  wasting  pro- 
gre8S(!S  uniformly,  uninfluenced  by  treatment.  Erb  holds  that  by  elec- 
tricity and  massage  the  progress  is  occasionally  arrested.  The  genera! 
health  should  be  carefully  looked  after,  moderate  cvrcise  allowed,  fric- 
tions with  oil  applied  to  the  muscles,  and  when  the  ])atient  becomes 
bedfast,  as  is  inevitable  sooner  or  later,  care  should  be  taken  to  prevent 
contractures  in  awkward  positions. 


III.    THOMSEN'S  DISEASE;    MYOTONIA  CONGENITA. 

Definition. — An  hereditary  disease  characterized  by  tcmic  cramp  nf 
the  muscles  on  attempting  voluntary  movements.  The  disease  received  it- 
name  from  the  jdiysician  who  first  described  it,  in  whose  family  it  has 
existed  for  five  generations. 

Etiology. — All  the  typical  cases  have  occurred  in  family  groups ; 
a  few  isolated  instances  have  been  described  in  which  similar  symptom ■j 


'1 

lilt 


PAIIAMYOCLONUS   Ml'LTIPLKX. 


009 


have  boon  prcsont.  The  disease  is  nin^  in  tliis  eouiitry  ami  iti  Kn«:liiii(l ; 
it  Hocnis  more  coniiiio?!  in  (K-rinany  and  in  S<'anilinavia. 

Symptoms. — 'I'Ik*  disease  (ionics  on  in  ehildliood.  It  is  notioed  that 
on  aeeonnt  of  the  stilTness  tiie  children  are  not  al)le  to  tui\e  part  in  ordi- 
nary iraines.  'I'he  pcculiaritv  is  noticed  oidv  durin'' voluntary  nioven\ents. 
Tlie  contraction  wii  cli  tiie  patient  wills  is  slowly  accfuiiplislicd  ;  tlie 
relaxation  u  liich  the  patient  wills  is  also  slow.  'I'lic  contraction  often  per- 
sists for  a  little  time  after  he  has  dropped  an  object  which  he  has  picked 
up.  In  walk  in  <f,  the  start  is  dithcult;  one  leg  is  put  forward  slowly,  it 
halts  from  stilfness  for  a  second  or  two,  and  then  after  a  few  steps  the 
legs  become  limber  and  he  walks  without  any  ditlicult\.  The  muscles  of 
the  arms  and  legs  arc  those  usually  implicated ;  rarely  facial,  otnilar,  or 
laryngeal  muaelos.  Emotion  and  cold  aggravate  the  condition.  In  some 
instances  there  is  nu'Tital  weakness.  The  scnsatii>n  and  the  rellexes  are 
nornud.  The  condition  of  the  mus<'les  is  interesting.  The  patitMits  ap- 
pear and  are  museuliir,  anti  there  is  sometimes  a  definite  hypertrophy  of 
the  muscles.  The  fon^e  is  seaniely  proportionate  to  the  size.  Krb  has 
des(!ril)ed  a  characteristic  reaction  of  the  nerve  and  muscle  to  the  elec- 
trical currents — the  .so-called  myotoni(!  rea(!tion,  the  chief  feature  of  whicdi 
is  that  normally  the  contractions  caused  by  either  current  attain  their 
maximum  slowly  aiul  relax  slowly,  and  vermicular,  wave-like  contractions 
pass  from  the  cathode  to  the  anode. 

The  disease  is  iiu-urable,  but  it  may  b(<  arrested  ti>m))orarily.  The 
nature  of  the  atfcction  is  unknown.  There  is  an  extraordinary  incn-ase  in 
the  size  of  the  voluntary  fibres.  According  t(j  Hale  White,*  who  has 
recently  treated  the  subject  in  an  exhaustive  and  (;ritical  manner,  the 
fibres  may  be  more  than  double  the  width  of  those  of  the  normal  muscles. 
The  nuclei  and  the  interstitial  tissue  may  be  increased  and  sonu;  of  the 
fibres  contain  vatnioles.  No  post-mortem  has  been  made.  No  treatment 
for  the  condition  is  known. 


IV.    PARAMYOCLONUS   MULTIPLEX. 


An  affection,  described  by  Kriedrich,  characterized  by  chmic  contrac- 
tions, chiefly  of  the  muscles  of  the  extremities,  occurring  either  cDUstantly 
or  in  paroxysms. 

The  cases  have  usually  been  in  males  and  the  disease  has  followed 
'motional  disturbance,  fright,  or  straining.  The  contractions  are  usually 
bilateral  and  may  vary  from  fifty  to  one  hundred  and  fifty  in  the  minute. 
•Occasionally  tonic  spasms  occur.  It  is  not  accompanied  by  any  sensory 
or  motor  disturbances.  In  the  intervals  between  the  attacks  there  may  be 
tremors  of  the  muscles.     In  the  severe  spasms  the  movements  nuiy  be  very 


mm 


1000 


DISKASRH  OK  TIIK   MUSCIiKS. 


violent ;  tlio  body  Ih  toHHcd  about,  iiiul  it  iw  Hoiiictiitics  difficult  to  kcop  i]w 
jMitit'iit  in  lu'd.  In  a  case*  which  I  saw  at  tiic  Hicctn*  the  patient  was  per- 
fectly (piiet  so  lon;^  as  his  lej;s  wen!  tied  down  with  a  sheet,  hut  as  soon  as 
this  was  removed  tho  clonic;  spasms  occurred  in  the  legs  and  muscsles  of 
tho  hack  and  tossed  ti»c  body  about  in  the  bed  from  side  to  side.  The 
patient  uttered  a  curious  exjiiratory  grunt.  The  nature  of  the  disease  is 
unknown. 


■  r 


V  [ 


SECTION    X. 

TTIE   INTOXICATIONS,   SUN-STROKK, 

OBESITY. 


1.  ALCOHOLISM. 

(1)  Acute  Alcoholism. — When  a  liirj^c  f|uimtity  of  Jilcolxtl  is  tiikon,  its 
influi'iicu  oil  the  iicrvoius  systoin  is  iimiiifostLMi  in  miisciiiar  iin'ooniiim- 
tioii,  mentiil  distiirhaiiois  and,  finally,  narcosis.  The  individual  })rosont8  » 
flushod,  soniotiinos  sliffjitly  cyanosod  face,  a  fidl  pulse,  with  deep  but  rarely 
stertorous  respirations.  Tlu'  jjupils  are  dilated.  The  temperature  is  fre- 
(piei\tly  below  normal,  particularly  if  the  patient  has  been  exposed  to 
cold.  IVrlmps  the  lowest  reported  temperatures  have  been  in  eases  of  this 
sort.  An  instance  is  on  record  in  whieh  the  patient  on  admission  to  hos- 
pital had  a  temperature  of  'i-i°  C  (ea.  Tr>°  F.),  and  ten  hours  later  the 
temperature  had  not  risen  to  !tl°.  The  nnconseiousness  is  rarely  so  deep 
that  the  patient  cannot  be  roused  to  some  extent,  and  in  re]tly  to  tjuestions 
he  mutters  incoherently.  Muscular  twitchinj^s  may  occur,  but  rarely  con- 
vulsi(»ns.     The  breath  has  a  heavy  alcoholic  odor. 

'l"he  diaj^fnosis  is  not  diHieult,  yet  mistakes  are  frequently  made.  Per- 
sons are  sometinu's  broujjht  to  hospital  by  the  police  supp(»sed  to  bt^  drunk 
when  in  reality  they  are  dyin;?  from  ajioplexy.  Too  great  care  cannot  be 
exercised,  and  the  patient  should  receive  the  benefit  of  the  doubt.  In 
some  instances  the  mistake  has  arisen  from  the  fact  that  a  )>erson  who  has 
been  drinking  heavily  has  been  stricken  with  apoplexy.  In  this  condition 
the  coma  is  usually  deeper,  stertor  is  present,  and  there  may  be  evidence  of 
hemiplegia  in  the  greater  flaccidity  of  the  limbs  on  one  side.  The  subject 
has  already  been  considered  in  the  section  upon  ura;mic  coma. 

•('-i)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may 
be  taken  throughout  a  long  life  without  impairing  the  general  health. 

According  to  Payne,  the  poisonous  efTects  of  alcohol  are  manifested  (1) 
as  a  functional  poison,  as  in  acute  narcosis ;  ("2)  as  a  tissue  poison,  in  which 
its  efTects  are  seen  on  the  ]mrenchymatous  element:-),  jiaiticularly  epithe- 
lium and  nerve,  producing  a  slow  degeiieration,  an.l  on  the  blood-vessels, 
causing  thickening  and  ultimately  fibroid  changes ;  and  (;})  as  a  checker 


it  i 


!ii 


1002 


THE  INTOXICATIOXS,  SUN-STROKE,  OBESITY. 


K«  * 


of  tissue  oxidation,  since  the  alcoliol  is  consumed  in  place  of  the  fat.  This 
loads  to  fatty  changes  and  Konictinies  to  a  condition  of  geiu>ral  steatosis. 

'I'he  chief  effects  of  olironic  ah'ohol  poisoning  may  be  tlius  summa- 
rized : 

Nervovs  System. — Functioiuil  disturbance  is  common. — Unsttnuliness 
of  the  nuiscles  in  ])erf()rniiiig  any  action  is  a  constant  feature.  Tiie 
troinor  is  best  seen  in  the  hands  am'  in  the  t(,:igue.  The  mental  processes 
may  l»e  dull,  particularly  in  the  early  morning  hoi  iv,  and  the  ])atieiit 
is  unable  to  transact  any  business  uutd  he  has  had  his  accustonu'd  stimu- 
lant. Irritability  of  temper,  forgetfulness,  and  a  change  in  the  moral 
character  of  the  individual  gradually  come  on.  The  judgment  is  seri- 
ously impaired,  the  will  enfeebled,  and  in  \\w  final  stages  denu-ntia  nuiy 
supervene.  The  relation  of  chronic  ahtoholism  to  insanity  has  been  much 
di.scussed.  According  to  Savage,  of  IjtMHI  patients  admitted  to  the  lieth- 
lehem  Hospital,  13;' gave  drink  as  the  cause  of  their  insanity.  Chronic 
alcoholism  is  believed  by  many  to  bc(  one  of  the  special  causes  of  denu'ntia 
paralytica,  but  the  oninions  of  experts  on  this  (pu'stion  are  still  discordant. 
Savage  states  that  not  more  than  .seven  j)er  (u;nt  are  caused  by  al(;ohol 
alone.  In  numy  cases  it  is  certainly  one  of  the  imimrtant  elements  in  the 
strain  which  leads  to  this  breakdown. 

No  characteristic  (dianges  are  found  in  the  nervous  system.  TTiwmor- 
rhagic  paciiynuiningitis  is  iu)t  very  um'ommon.  ()[)acity  and  thickening 
of  ihe  pia-ar:ichiu)id  mend»ranes,  with  more  or  less  wasting  of  the  convo- 
lutions, gemu'ally  occur.  'I'he.sc?  are  in  no  way  j)ecnliar  to  chronic  alcohol- 
ism, but  are  found  in  old  persons  and  in  chronic  wasting  diseases.  In  the 
very  protracted  cases  there  may  be  chronic. encephalo-meningitis  with  ad- 
hesions of  the  nu'inbranes.  Wy  far  tin;  most  striking  elTect  of  alcohol  on 
the  nervous  system  is  the  proiluction  of  the  a'coholic  neuritis,  which  has 
already  been  con.'iidered. 

Dii/i'sfii'e  S//sft'in. — Catarrh  of  the  stomach  is  the  most  commo;:  symji- 
tom.  The  toi)er  has  a  furred  tongue,  heavy  breath,  and  in  the  mornitig  a 
.scwisation  of  sinking  at  the  stofnach  until  lie  h;is  his  dram,  'i'he  api)etite 
is  usually  impaired  an<l  the  bowels  are  constipated.  These  features  are 
associati'd  with  a  chronic  (tatarrh  of  the  stonuu-h. 

Alcohol  ])roduces  definite  changes  on  the  livr,  leading  to  the  various 
forms  of  cirrhosis  already  describi'd.  The  elTect  is  probably  a  primary 
degenerative  change  in  the  liver-cells,  although  many  good  (tbservers  still 
hold  that  the  poi.son  acts  first  upon  the  connective-tissue  eletnents.  It  is 
probable  that  a  special  vulnerability  of  the  liver-ccdls  is  lu'cessary  in  the 
etiology  of  alcoholi(!  cirrhosis.  There  arc  cases  in  which  comparatively 
moderate  driid\ing  for  a  few  years  has  been  followe(l  by  cirrhosis;  on  the 
other  hand,  the  livers  of  persons  who  hive  been  steady  drinkers  for  thirty 
or  forty  years  may  show  only  a  moderate  grade  of  sclerosis.  With  tiie  gas- 
tric; and  hepatic  disorders  the  facies  often  beconu's  very  characteristic;.  The 
venules  of  the  cheeks  and  nose  are  dilated ;  the  latter  becomes  eidarged, 


![i 


ALCOHOLISM. 


1003 


8yTn]v 

pputiU' 
iros  arc 

Iviiriinis 
triinan' 
■rs  stiil 
It  irf 
in  tlic 
|-jit,iYely 
oil  the 
tliirty 
Ue  pas- 

llarj-cil, 


red,  und  may  present  t)ie  coiulition  known  as  acne  rosnroa.     The  eyes  aro 
watery,  the  oonjiuu'tivtt'  hyperaMiiio  and  sometinies  bilo-tin<^oil. 

Kidnei/n. — Tlie  iiilhionce  of  clironie  ah-oholism  iipoii  tlicse  orpann  is 
h\  no  means  so  marked.  .\fc(irtiin>if  to  Dickinson  the  total  of  renal  dis- 
ease is  not  greater  in  the  drinking  class,  and  he  h.ohls  that  the  cITcct  of 
aleohol  on  tl»e  kidneys  has  been  mnch  overrated.  Formad  has  directed  at- 
tiMition  to  the  hwt  that  in  a  hirge  proportioii  o{  chronic  sdcoiiojics  the  kid- 
neys are  increased  in  size.  The  Cluy's  Hospital  statistics  support  tliis 
statement,  and  I'itt  notes  that  in  forty-three  per  cent  of  tiic  bodies  of  lianl 
drinkers  the  kidneys  were  liypertrofjhied  without  sliowing  niorl)id  change. 
Tiie  typical  granuhir  kidney  seems  to  result  indirectly  from  alcohol 
through  the  arterial  changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  observations  of  late  years  indicate  cicaiiy  that 
the  reverse  is  the  case  and  that  chronic  drinkers  are  much  more  liable  to  both 
acute  and  pulmonary  tuberculosis.  It  is  probably  altogether  a  (piestion  of 
altered  tissue-soil,  the  alcohol  lowering  the  vitality  and  t'liabling  the  bacilli 
mov"  readily  to  develop  and  grow. 

(3)  Delirium  Tremens  {mania  apntu)  is  really  oidy  an  incident  in  the 
history  of  chronic  alcoholism,  and  results  from  the  long-continued  action 
of  the  p»)ison  on  the  brain.  The  condition  was  first  accurately  described 
early  in  this  century  by  Sutton,  of  (Ireenwich,  who  had  numerous  oppor- 
trnities  for  studying  the  dilTerent  forms  among  the  sailors.  One  (>f  the 
most  thorough  and  careful  studies  of  the  disease  was  made  by  Ware,  of 
Boston.  A  :')ree  in  a  temperate  person,  no  matter  how  prolonged,  is  rare- 
ly if  ever  followed  by  delirium  tremens;  but  in  the  case  of  an  habitual 
drinker  a  temporary  excess  is  apt  to  bring  on  an  attack.  It  somclinu'S 
develops  in  (loiisequence  of  the  sudden  withdrawal  of  the  alcohol.  There 
are  circumstances  which  in  a  heavy  drinker  dcterriiinc,  sometimes  with 
abruptness,  the  onset  of  delirium.  Such  are  an  accident,  a  sudden  fright 
or  shock,  and  an  acute  inllammation,  jiarticularly  piu'umoiiia.  At  the 
outset  of  the  attack  the  patient  is  restless  and  ilcpresscd  ami  sleeps  badly, 
symiitoms  which  cause  him  to  take  .dcoliol  more  freely.  .After  a  day  or 
two  the  characteristic'  delirium  st^ts  in.  The  patient  talks  constantly  and 
incoherently;  he  is  iiicessantly  in  motion,  and  desires  to  go  out  and  attend 
to  some  imaginary  business.  Hallucinations  of  sight  and  hearing  develo|). 
He  sees  objects  in  the  room,  such  as  rats,  mice,  or  snakes,  and  fancies  that 
they  are  crawling  over  his  body,  'i'he  terror  inspired  by  these  imagiiuiry 
oltjects  is  great,  and  has  given  the  jiopular  name  "  horrors'"  to  the  disease. 
Till  patients  need  to  be  wj'lched  constantly,  for  in  their  delusions  they 
may  jump  out  of  the  window  or  esca|)e.  Auditory  hallucinations  are  not 
HO  common,  but  the  patient  may  complain  of  hearing  the  roar  of  animals 


or  the  threats 


Oi   imairmarv  enemies. 


Tl 


\ere  is  much  muscular  tremor 


the  tongue  is  cov(>red  with  a  thic^k  white  fur,  and  when  protruded  is  li'eiuu- 
lous.     The  pulse  is  soft,  rapid,  and  readily  compressed.     Then-  is  usually 


X     r 


1004 


THE  INTOXICATIONS,  SUN-STUOKE.   OBESITY. 


fever,  l)ut  tlio  tempenitiirc  rarely  registers  above  102°  or  103°.  In  fatal 
cases  it  may  be  bigber.  Insomnia  is  a  constant  feature.  On  tbe  tbird  or 
fourtb  tbiy  in  favorable  cases  tbe  restlessness  abates,  tbe  patient  sIiH'ps. 
and  improvement  gradually  sc^ts  in.  Tbe  tremor  persists  for  some  davi-, 
tbe  iiallucinations  giadually  disappear,  iind  tbe  appetiti;  retur'is.  In  more 
serious  cases  tbe  insomnia  j)ersists,  tbe  delirium  is  incessant,  ti<e  pulse 
becomes  more  fre(|uent  and  feeble,  tbe  tongue  dry,  tbe  prostration  ex- 
treme, and  deatb  takes  place  from  gradual  beart-failure. 

Diagnosis. — Tlu*  clinical  picture  of  tbe  diseiisi'  can  scarcely  be  con- 
founded uitli  any  otiier.  Cases  wilb  fever,  bowever,  may  he  mistaken  for 
meningitis.  \\\  far  tbe  most  common  error  is  to  overlook  some  local  dis- 
ease, sucb  as  pneumonia  or  erysipelas,  or  an  accident,  as  a  fractured  rih. 
wbicb  in  a  cbrfini(r  drinker  may  precipitate  an  attack  of  delirium  tremens. 
In  every  instance  a  careful  examination  sbould  be  made,  i)articularly  of 
tbe  lungs,  it  is  to  l)e  n-nu-ndu'rcd  tliat  in  tbe  severer  forms,  particidariv 
tbe  febrile  cases,  congestion  of  tbe  bases  of  tlic  lungs  is  by  no  nu>ans  un- 
common. Anotber  point  to  be  borne  in  mind  is  tbe  fact  tliat  pneumonia 
of  tbe  ajiex  is  apt  [o  be  accompanied  by  delirium  similar  to  iiituiiii  a 
jiofu. 

Prognosis.  —  Recovery  takes  jtlaee  in  a  large  proportion  of  I  be  cases 
in  private  i)ractice.  In  bospital  practice,  jiarticularly  in  the  large  cily 
bospitals  to  wbicb  tbe  dcliilitatcd  ])atients  are  taken,  tbe  deatb  rate  is 
bigiii'r.  (icrbard  slates  that  of  I. ••.'41  ca.'ies  admitted  to  tbe  IMiiladel])lii!i 
Hospital  r.'I  i)roved  fatal,  h'ecurrence  is  frecpient,  almost  indeed  tbe  rule, 
if  tbe  drinking  is  kept  up. 

Treatment. — Acute  alcobolism  rarely  rerpiires  any  special  measures, 
as  tbe  patient  slei'ps  (.(?  tbe  elVects  of  tbe  dchaucb.  In  tbe  case  of  pro- 
found alcobolic  coma  it  may  be  advisable  to  wasb  out  tbe  stomacli,  and  if 
collapse  svmptoms  occur  tbe  limbs  sbould  be  rublH-d  and  liot  applications 
made  to  tbe  body.  Sbould  convulsions  supervene,  cbloroform  may  !»• 
carefully  adndnistered.  In  tbe  acute,  violent  alcobolic  mania  tbe  bypo- 
dcrmic  injection  of  aponiorpbia,  one  eigbtli  or  one  sixth  (»f  a  grain,  i-- 
usually  very  elTcctual,  causing  nausea  and  vomiting,  and  ra{>id  disapj)ear- 
ance  of  tbe  numiacal  symptoms. 

Cbronic  alcobolism  is  a  contlition  very  dillicidt  to  treat,  and  once  full\ 
ostahlisbed  tbe  habit  is  rarely  abandoned.  Tbe  most  ohstinale  cases  an 
are  tbo.'^e  with  niarke(l  bcreditiiry  tendency.  \\'itlidra\val  of  tliealcctliol  is 
tbe  iirst  e.s,<cntial.  This  is  most  elTcctiiidly  accomplished  by  placing  tl  c 
patient  iii  an  institution,  in  wbicb  ho  can  lie  carefully  \vatche(|  during  th' 
trying  period  of  tbe  first  week  or  ten  drys  of  i:hstention.  The  absencr 
of  temptaiion  in  institution  life  is  of  special  advantage.  For  llie  slee|i 
lessness  the  hromiih's  or  hyo.scine  may  he  employed.  Quiniiu'  and  strycii 
nine  in  tonic  doses  nuiy  be  given.  Cocaine  or  tbe  lluid  extract  of  eoci 
has  been  recommended  as  a  substitute  for  alcohol,  but  it  is  not  of  una  ii 
service.     Prolonged  seclusion  in  a  suitable  institution  is  in  reality  theonl\ 


HI 


MORPHIA   HABIT. 


1005 


effectual  means  of  cure.     Wlien  the  licreditary  tendency  is  strongly  devel- 
oped a  lapse  into  the  drinkin<i;  habits  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  eonlined  to  bed  and  earc- 
fully  watehed  iiijrlit  and  day.  'i'he  danger  of  escape  in  these  oases  is  very 
great,  as  the  jjalient  imagines  himself  pursued  by  enemies  or  deniona. 
Klint  mentions  the  ease  of  a  man  who  escaped  in  his  night-clothes  and  ran 
barefooUnl  for  lifteen  miles  on  the  frozen  ground  Ix-fore  he  was  over- 
tiiken.  The  patient  should  not  be  strapiK'd  in  bed,  as  this  aggravates  the 
delirium;  sometinu's,  however,  it  may  \h'.  Tieeessjiry,  in  wiiicli  case  a  sheet, 
tied  across  the  l)e(l  may  be  sutlicient,  and  this  is  certainly  better  than  vio- 
lent restraint  by  three  or  four  men.  Aleohol  should  be  withdrawn  at 
once  utdess  the  pulse  is  feeble. 

DeliriuiM  tremens  is  a  disease  which,  in  a  large  majority  of  casc.s,  runs 
a  course  very  slightly  intlueiiced  by  medicine.  'The  indications  for  treat- 
ment are  to  procure  sleej)  and  to  support  the  strength.  In  mild  ca.ses  half 
»  drjichm  of  bromide  of  pot^kssium  combined  with  tiiK^ture  of  e^ipsieuni 
may  !>o  given  every  three  hours.  Chloral  is  often  of  great  service,  and  may 
be  given  without  hesitjition  unless  the  heart's  action  is  feeble,  (iood  re- 
sults sometimes  follow  the  hy[»()dermic  use  of  liyosciiie,  one  one-hundredth 
of  a  grain.  Ojiium  must  Ix;  used  cauti(Uisly.  A  s|»ecial  merit  of  Ware's 
work  Wits  the  ilenjonstration  that  on  a  rational  or  expectant  plan  of  treat- 
ment the  ])erccntag(!  of  recovery  was  greali-r  than  with  the  iudiscrimiuate 
use  of  sedativi's,  whii-h  had  been  in  vogue  for  many  years.  When  oi)iuin  '\>* 
indicatxMl  it  should  be  given  as  niorpliia,  hypodermicaliy.  The  elfect 
should  be  i-arefully  watched,  atul  if  after  three  or  f(»ur  (|uarter-grain  doses 
have  been  given  the  patient  is  still  restless  and  excited,  it  is  best  not  t(» 
push  it  fartlu'r.  When  fever  is  present  the  tran(|uillizing  eiTeet-*  of  a  cold 
douche  or  eold  bath  may  l»e  tried,  or  lht>  i-old  pack.  'l"he  lur^e  doses  of 
digitalis  fonnerly  employed  niv  not  advisable. 

("itrefnl  feeding  is  tlu^  most  imjKirtani  element  iji  the  treatnu'Ut  di 
thtse  cases.  Milk  and  coiieei  rateil  broths  should  Ih>  given  at  slated 
int^Tvals.  If  the  pulse  becomes  rapiil  ami  shows  signs  of  tlagiring  iiicoliol 
may  be  given  in  eouibiuatiun  with  the  ai'omutic  spirits  of  aiiuuuuiu. 


n.   MORPHIA    HABIT  {Morphiomauui     iliirphim'sm). 


This  habit  arises  from  t'.e  c(mstunt  us<»  of  n)<ir|>hia — taken  at  first,  a^^  n 
rule,  for  the  purpose  of  allnying  pain.  The  cmving  is  gradually  erigeu- 
dereil,  and  tlw"  habit  in  tliis  way  «e(|uired.  The  injm-ious  eire<'tK  vary 
very  much,  and  tn  the  Kast,  where  opium-smr>kingis  jis  common  as  tobacco- 
Hiuokiiig  with  us,  the  ill  elfeets  are,  aeeurdiiii;  to  good  observers,  nut  so 
striki'ig. 

The  habit  is  particularly  pwvalent  among  wfmuMi  and  physicians  who 
use  the  hyi)oderHiic  syringe  for  the  alleviation  of  jiain,  as  in  neuralgia  or 


;»iM 


m 


lOOG 


THE   INTOXICATfONS,  SUN-STROKE,  OBESITY. 


M 


8(!i!iti('ii.     'I'lie  acquisition  of  the  habit  as  a  pure  hixiiry  is  rare  in  this 
country. 

The  symptoms  at  first  are  sliglit,  and  moderate  (h»ses  may  bo  taken  for 
months  without  serious  injury  and  without  disturbance  of  health.  Tlierc 
are  exceptioual  instances  in  whit-li  for  a  ])eriod  of  years  excessive  doses 
luive  been  tai<eii  witliout  deterioration  of  tlie  mental  or  l)odily  functions. 
As  a  rule,  the  dose  necessary  to  obtain  the  desired  sensations  has  gradu- 
ally to  be  increased.  As  the  eiTects  wear  off  the  victim  experieiu^es  sensa- 
tions of  lassitiuhf  and  mental  depression,  accompanied  often  with  slight 
nausea  and  e])igastric  distress,  symptoms  which  are  relieved  l)y  another 
dose  of  the  drug.  The  coniirmed  opium-eater  presents  a  very  charac- 
teristic appearance.  There  is  a  sallowness  of  the  comjdexion  which  is 
almost  pathognomonic;,  and  he  becomes  emaciated,  gray,  and  prematurely 
aged.  He  is  restless,  irrital)le,  and  unable  to  renniin  quiet  for  any  ti?ne. 
Itching  is  a  common  symptom.  The  sleep  is  disturbed,  the  appetite  and 
(iigestion  are  deranged,  an  1  exeejjt  when  directly  under  the  inlluence  of 
the  drug  the  mental  condition  is  one  of  depression.  Occasionally  there 
are  pnd'use  sweats,  which  may  be  i)receded  by  chills.  The  pui)ils,  except 
wh'.'n  under  the  direct  inllucMce  of  the  drug,  are  dil.ited,  .sometimes  un- 
e(pial.  Persons  addictid  to  morphia  are  inveterate  liars,  and  no  reliance 
whatever  can  be  i)hiced  upon  their  statements.  In  many  instances  this  is 
not  confined  to  nuitters  relating  to  the  vice.  In  women  the  symptoms  nuiy 
be  associated  with  those  of  jtronoujiced  hysteria  or  neurasthenia.  The 
}»ractice  imiy  be  contiiuied  for  an  ii\de(inite  time,  usually  requiring  increase 
in  the  dose  until  ultimately  enormous  (pumtities  may  be  needed  to  obtain 
the  desired  effect.  Finally  a  condition  of  asthenia  is  induced,  in  which 
the  victim  takes  little  or  lu)  food  and  dies  from  the  extreme  bodily 
debility. 

The  freafinciif  of  the  morphia  habit  is,  extremely  difficult,  and  can 
rarely  be  successfully  carried  out  by  the  general  i)ractitioner.  Isolation, 
systematic  feeding,  and  gratlual  withdrawal  of  the  drug  are  the  essential 
elements.  As  a  rule,  the  patients  must  be  under  control  in  an  institution 
and  should  be  ii\  bed  for  the  first  ten  days.  It  is  best  in  a  majority  of 
cases  to  reduce  the  morphia  gradually.  The  diet  should  consist  of  beef- 
juices,  milk,  and  egg-white,  which  should  be  given  at  short  intervals.  The 
sulTerings  of  the  patients  are  usually  very  great,  mor^^  particularly  the  ab- 
dominal pjiins,  sonietimes  nausea  and  vomiting,  and  the  <listressing  rest- 
lessness. I'sually  within  a  week  or  ten  days  the  oj)ium  may  be  entirely 
withdrawn.  In  all  cases  the  pulse  should  be  carefully  watched  and,  if 
feeble,  stimulants  should  lie  given,  with  the  aromatic  s[)irits  of  ammoniii 
and  digitalis.  For  the  extreme  restlessness  a  hot  bath  is  serviceable.  The 
sleeplessui'ss  is  the  most  distres'^ing  syni])tom,  and  various  drugs  nuiy  ha\e 
to  be  resorted  to,  parti(!ularly  hyoscine  and  sulphonal  and  sometiiues,  if 


the  insomnia  persists 


morj 


)hia  itself. 


It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient 


LEAD-POISONIXO 


1007 


Ind  can 
(ilation, 
;sc'iiUal 
Jtutioii 
;)rity  of 
,f  boi't- 

It  ho  ab- 
l\if  ri'st- 
■iitircly 
and,  it' 


has  no  means  of  obtiiinin;::^  morpliia.  Evon  imdor  tlio  favorable  cireiiin- 
stanecs  of  seclusion  in  an  institution,  and  constant  watching  by  a  niglit  and 
a  day  nurse,  I  have  known  a  patient  to  practice  deception  for  a  period  of 
three  months.  After  an  apparent  cuire  the  ])atii'nls  are  only  too  apt  t<» 
lapse  into  tiie  habit. 

Tho  condition  is  one  which  has  boeomo  so  common,  and  is  so  niudi  on 
the  increase,  that  physicians  sliould  exercise  tho  utmost  caution  in  pre- 
scribing morphia,  particularly  to  fcMnah;  patients.  Tudcr  no  circumstaiu'cs 
whatever  should  a  patient  with  neuralgia  or  sciji'.lca  be  allowed  to  use  the 
hypodermic;  syringe,  and  it  is  uven  safer  not  to  intrust  this  dangerous 
instrnment  to  the  hands  of  the  nurse. 


III.    LEAD-POISONING   {Plumhivn;   Saturnism). 

Xitiolog*y. — 'I'he  disease  is  widespread,  ])articularly  in  lead-workers 
and  among  plund)ers,  oainters,  and  glaziers.  The  iiu^tal  is  introduce(| 
into  the  system  in  many  forms.  Miners  usually  esc^ape,  but  tho.se  engaged 
in  the  smelting  of  lead-ores  an;  often  attaciked.  Aninuds  in  the  neigld)or- 
hood  of  smelting  furmices  have  sulTered  with  the  disease,  and  even  tiie 
birds  that  feed  on  the  berries  in  the  neighborhood  nuiy  be  alTectcd.  Men 
engaged  in  'he  whiti'-lead  factories  are  particularly  prone  to  plumbism. 
Accidental  contamination  may  come  in  many  ways;  most  commoidy  by 
drinking  water  wiiich  hrs  passed  thrcugh  lead  pipes  or  been  stored  in 
lead-lined  cisterns.  Wines  and  cider  which  contain  acids  quickly  become 
contaminated  in  contact  with  lead.  If  was  the  frerpu'iicy  of  colit-  in  cer- 
tain of  the  cider  districts  of  Devonshire  which  gave  the  name  Devonshire 
colic,  as  the  freciueney  of  it  in  Poitou  gave  tlie  name  rolini  Puionum. 
Among  the  innnmerable  sources  of  accidental  contamination  may  be  nu-n- 
tioned  milk,  various  sorts  of  beverages',  liair  dyes,  false  teeth,  and  thread. 
A  serious  outbreak  of  lead-poisoning,  wiiicli  was  investigated  by  I)iivid  D. 
Stewart,  occurre<l  ri'cently  in  IMiiladelphia,  owing  to  tlie  disgraceful  adul- 
teration of  a  baking-powder  with  chronuite  of  lead,  which  was  used  to  give 
a  yellow  tint  to  the  cakes.     licad  given  medicinally  rarely  produces  poi.son- 

/Vll  ages  are  attacked,  but  J.  J.  i'utnam  states  that  children  arc  rela- 
tively !''S3  liable.  The  largest  iuind)er  of  castis  oecnir  between  thirty  and 
tort-.  According  to  Oliver,  from  whoso  recent  (lulstonian  lectures  I  here 
quoic,  fetjudes  are  more  susceptible  than  males.  He  states  that  they  an^ 
much  more  ((uickly  brought  under  its  inlluencc,  and  in  a  recent  epidemic 
in  whi(.'h  a  tliousand  cases  were  involved  the  proportion  of  females  to 
m  ■  3s  was  four  to  one. 

The  lead  gains  entrance  to  the  system  through  the  lungs,  tli(>  digestive 
organs,  or  the  skin.  Poisoning  may  follow  tlie  use  of  cosmetics  contain- 
ing lead.     Through  the  lungs  it  is  freely  absorbed.     The  chief  channel, 


\  \ 


1008 


TIIK   INTOXICATIONS,  SUN-STUOKK,  onKSITY, 


uccordiiiif  to  Oliver,  is  tlio  dii^cstivo  systciii.  It  is  rapidly  rliininutcd  by 
the  kidneys  and  skin,  and  is  present  iti  the  urine  of  lead-workers.  The 
dusceptibility  is  reniarkal)ly  varied.  The  symptoms  may  be  manifest  with 
u  montii  of  exposure.  On  the  other  hand,  Taiu|uerel  (des  IManches)  met 
with  a  case  in  a  man  who  had  been  a  lead-worker  for  fifty-two  years. 

Morbid  Anatomy.— Small  <|uantilies  of  leatl  occur  in  the  body  in 
liealth.  .1.  .1.  I'utnam's  reports  sl\ow  that  of  l.")0  persons  not  presciiiting 
Bymjitoms  of  lead-poi.soning  truces  of  lead  occurred  in  the  urine  of  ;i5  per 
cent. 

In  chronic  poisoniiiL,'  leail  is  found  in  the  various  or;xaiis.  'I'he  alTected 
muscles  are  yellow,  fatty,  and  libroid.  The  nerves  present  the  features  of 
a  peripheral  de<;ener;itive  neuritis,  'i'he  cord  and  the  nerve-roots  are,  as  a 
rule,  uninvolved.  In  the  primary  atrophic  form  the  <(aii<,dion  cells  of  tl>c 
anterior  horns  ar»>  probably  inv(»lved.  in  thi'  acute  fatal  cases  there  may 
be  the  most  intense  enlero-colitis. 

Clinical  Forms. — Anif)'  J'oisuniiHf. — We  do  not  refer  here  to  the 
aecidental  or  suicidal  cases,  which  present  vomitin;,',  pain  in  the  abdomen, 
aiul  collapse  .symptoms.  In  workers  in  lead  then*  are  several  nuinifesta- 
tion.s  which  follow  a  short  time  after  exposure  and  set  in  acutely.  'I'here 
may  be,  in  the  first  place,  a  ra|tidly  devi'lopinj^  aiuemia.  Acute  neuritis  has 
been  descrilu'd,  and  convul^ioi,i.s,  epilepsy,  and  a  delirium,  wliiidi  may  be, 
as  Stephen  Mackenzit;  has  noted,  not  unlike  that  produced  by  alcohol, 
'i'hcre  are  al.so  casi-s  in  which  the  <;astro-intestinal  symptoms  are  most 
intense^  and  rapidly  prove  fatal,  '{'here  was  admitted  under  my  care  in  the 
I'hihuhilphia  Hospital  a  painter,  aifjed  fifty,  sufferin;:;  with  anaMiiia  and 
Hovcro  abdominal  pain,  which  had  lasted  about  a  week.  He  had  \omiting, 
constipation  at  first,  afterward  severe  diarrluea  and  mela-na,  with  distention 
ami  tenderness  of  the  abdomen.  There  were  albumen  and  lube-casts  in  the 
urine.  The  temperature  was  usually  subnormal.  Death  occurred  at  the 
end  of  the  second  week.  There  was  fouiul  t!ve  most  inten.se  entero-colitis 
with  luemorrhages  and  exudation.  The.se  acute  forms  develop  more  fre- 
(pu'iitly  in  j)ersons  recently  exp.osed,  and,  according  to  Mackenzie,  arc  more 
frecjuent  in  winter  than  in  summer. 

( '/iron ic poison iiif/  presents  the  following  symptoms: 

{(i)  Ancemia,  the  so-called  saturnine  catdiexia,  which  may  be  profound. 
.\s  a  rule,  however,  the  corpuscles  do  not  sink  below  .'>()  per  cent. 

(/»)  /line  line  on  gums,  which  is  a  valuable  indication,  but  not  invari- 
ably present.  'I'wo  lines  must  be  distinguished:  one,  at  the  margin  be- 
tween the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  mouth  and  cleansing  the  teeth.  The  otlrtT  is  the  well-known 
ehara(!tcristic  blue-bla-k  line  at  the  margin  of  the  gum.  The  color  is  not 
nnil'orm,  but  being  in  the  papilla'  o'  ihe  gums  the  line  is,  as  seen  with  a 
magnifying-glas-i,  \nWrrn\A4't\.  'IMic  lead  is  absorl>ed  and  converted  in  the 
tisaties  into  a  bla<  k  sulphide  by  the  actioji  of  sulphuretted  hydrogen  from 
the  tartar  of  the  teeth.     Tlu'  line  may  form  rajiidly  after  exposure  and 


m 


rofound. 

)t  invari- 
ir;j;in  be- 
iiovcd  by 
ll-kiiown 
(ill-  irt  iittt 
ji\  with  rt 
li'il  ill  the 
Im'ii  from 
isiire  ami 


LKAD-l*OISONlN(}. 


1000 


disappear  within  a  fow  weeks,  or  luuy  persist  for  miiiiy  montlis.  I'liilip- 
8()ii  has  noted  tlio  occurrence  of  a  blaclc  line  in  miners,  due  to  the  deposition 
of  carljon. 

'riio  most  important  symptoms  of  chronic  lcad-poisonin,<r  are  colii-, 
lt'ad-|)alsy,  and  the  encei)lialopatiiy.  Of  these?,  tlie  colic  is  the  most  frc- 
(picnt.  Of  'raH(|iiercl's  cases,  there  were  l,'i\'i  of  colic,  1(»1  of  paralysis, 
and  ','i  of  encephaloi)athy. 

{(•)  Culio  is  tiie  most  common  symptom  of  chronic  lcad-poisonin<,'.  It 
is  often  precetled  by  gastric  or  intestinal  symptoms,  particularly  constipa- 
tion. The  i)ain  is  over  till' \vlii>le  al)domen.  The  colic  is  usually  parox- 
ysmal, like  true  colic,  and  is  relieved  by  pressure.  There  is  often,  in  addi- 
tion, ln'tween  the  paroxy.-nis  a  ilull,  heavy  pain.  There  may  be  vomitinj,'. 
During  the  attack,  as  Uiegcl  noted,  \\w  pulse  is  increased  in  tension  and 
the  lu-art's  action  is  retarded.     The  pupils  are  usually  uncfpial  (Oliver). 

{(I)  livad-iutlsji. — This  is  rarely  a  primary  manifestation,  'i'he  onset 
may  I)e  acute,  suhacute,  or  clironic.  It  usually  develops  without  fever. 
In  its  distril)ution  it  nuiy  l)e  partial,  limited  to  a  muscle  or  to  certain  nnis- 
<?le  groups,  or  generalized,  involving  in  a  short  time  the  muscles  of  the 
extremities  and  the  trunk.  Madame  Dejerine-Klumpke  recogiuzes  the 
following  lonilized /onus  : 

(1)  Anti-l)rachial  type,  paralysis  of  the  extensors  of  the  lingers  and  of 
the  wrist.  In  this  the  nnisculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.     The  supinator  longus  usually  escapes. 

{•i)  Brachial  type,  which  involves  the  deltoid,  the  biceps,  the  brachi- 
alis  anticus,  and  the  supinator  longus,  rarely  the  pectorals.  The  atrophy 
is  of  the  scai)ulo-humeral  form.  It  s  bilateral,  ivnd  sometimes  follows  the 
first  form,  but  it  may  be  primary. 

(;})  The  Aran-Duchenne  type,  in  whi(di  the  snudl  muscles  of  the  hand 
ami  of  the  themir  and  hypothenar  emineiu-es  are  involved.  It  produces  a 
paralysis  closely  re.send)ling  that  of  the  early  stage  of  poJ/o-mi/rli/is  diife- 
rior  clininica.  The  atvophy  is  marked,  and  may  be  the  first  manifestation 
of  the  Iead-])alsy.  Mobius  has  shown  that  this  form  is  particularly  de- 
veloped in  tailors. 

(4)  The  peroneal  type.  Ac(;ording  to  Tan(|uerel,  the  lower  lind)s  are 
involved  in  the  proportion  of  thirteen  to  one  hundred  of  the  up|ter  limhs. 
The  lateral  peroneal  mu.si'les,  the  extensor  communis  of  the  tot's,  and  the 
extensor  pro})rius  of  the  big  toe  are  involved,  producing  the  stcppaye. 
gait. 

(.'))  Laryngeal  form.  Adductor  |iaralysis  lias  been  noted  by  Morell 
Mackenzie  and  others  in  lead-palsy. 

Generalized  I'alnies. — There  may  be  a  slow,  chronic  paialysis,  gradu- 
ally involving  the  extreuuties,  beginning  with  the  classical  jiicture  of 
wrist-drop.  More  frequently  there  is  a  rapid  gciu>rali/.ation,  i)ro(iucing 
complete  paralysis  in  all  tin;  muscles  of  the  parts  in  a  few  days.  It  may 
pursue  a  course  like  an  ascending  paralysis,  associatet)  with  rapid  wasting 


I  .,1  '} 
■     -11 

ij 


tWH 


m 

■  if  1 ' 


111 


III 


1010 


TIIK  INTOXICATIONS,  SUN-STROKK,   OKKSITY. 


of  ull  four  limbs.  Siu-h  chsch,  however,  aro  very  riire.  DoiiUi  lias  oc- 
curred hy  involvenuuit  of  tJu*  (liaplini,<,'m.  Oliver  reports  a  ruse  of  IMiilip- 
son's  in  whieli  corupleto  paralysis  supervened.  Dejeriiie-Khunpke  also 
recofjfiiizes  a  febrilo  form  of  general  ])aralysis  in  lead-poisoning,  which 
nuiy  clo.sely  re.send»l(i  the  subacute  spinal  paralysis  of  Ducheiiiie. 

There  is  also  a  primary  saturnitu;  muscular  atrophy  in  which  tlic 
weak lu'ss  and  wasting  comi!  on  together  and  develop  proportioiuitely.  It 
iH  this  form,  according  to  (Jowers,  which  most  frequently  as.^umes  the 
Aran-Duchennc!  type. 

'I'he  electrical  reactions  are  tho.se  (»f  lesions  of  the  lower  motor  seg- 
ment, and  have  been  described  under  lesions  of  the  nerves.  The  degen- 
erative reaction  in  its  dilferont  gnules  may  be  present,  de])ending  upon  the 
severity  of  the  disease. 

I'sually  with  the  onset  of  the  paralysis  there  aro  pains  in  the  legs  and 
joints,  the  so-called  saturnine  arthralgias.  As  a  rule,  however,  sensation 
is  unatfected  and  the  sen.sory  nerves  ar(>  not  involved. 

(e)  'Vho  cerebral  symptoms  are  numerous.  0\){\v  neuritis  or  neuro- 
retinitis  may  develop.  Hysterical  symptoms  occasionally  occur  in  girls. 
Kpile|)sy  is  not  uncommon,  and  in  tits  develoi)ing  in  the  adult  the  possi- 
bility of  Icail-poisoning  should  always  be  considered.  An  acute  delirium 
nniy  occur  with  hallucinations.  The  patients  may  have  trance-like  at- 
Uicks,  which  follow  or  alternate  with  convulsions.  A  few  cases  of  lead 
encephalopathy  tinally  drift  int(»  lunatic;  asylums.  'J'remor  is  one  of  the 
commonest  manifestatioJis  of  lead-poLsoning. 

( /')  Arii'rio-siJvrosis. —  iiCad-workers  are  notoriou.sly  subject  to  arte- 
rio-sclerosis  with  contracted  kidneys  and  hyj)ertrophy  of  the  heart.  The 
cases  usually  show  distinct  gouty  deposits,  particularly  in  the  big-toe 
joint;  but  in  this  country  acute  gout  in  lead-workers  is  rare.  According 
to  Sir  William  Huberts,  the  lead  fav(»rs  the  precipitation  of  the  crystalline 
urates  of  the  tissues.  Halfe  has  shown  that  lead  diminishes  the  alkalinity 
of  the  blood,  and  so  les.sens  the  solubility  of  the  uric  acid. 

Prognosis.  — In  the  minor  manifestations  of  lead-poisoning  this  is 
good.  According  to  (Jowers,  the  outlook  is  bad  in  the  primary  atroplii<' 
form  of  paralysis.  Convulsions  are,  as  a  rule,  serious,  and  the  mental 
symptoms  which  sucoood  may  be  permanent.  Oci-asionally  the  wrist-drop 
persists. 

Treatment.  —  Projthylactic  measures  should  be  taken  at  all  lead- 
works,  but  unless  employes  arc  careful  poisoning  is  apt  to  occur  even 
under  the  most  favorable  coiiditions.  Cleanliness  of  the  hands  and  of  the 
tinger-nails,  fre(|uent  bathing,  and  the  use  of  respirators  when  ntx'essary, 
should  be  insisted  u|)on.  When  the  lead  is  in  the  system,  the  iodide  ol' 
])otassiuin  should  lie  given  in  from  five-  to  ten-grain  doses  three  times  a 
day.  For  the  colic,  local  applii'ations  and,  if  severe,  morphia  nuiy  be  us((l 
An  occasional  morning  purge  of  .sulphate  of  magnesia  may  be  given.  For 
the  ana'mia  iron  should  be  used.     In  the  very  acute  cases  it  is  well  not 


ARSENICAL  POISONINO. 


mil 


to  give  the  iodidi',  as,  iiocordinj;  to  some  writorH,  the  lihcnition  of  tht-  Ifiul 
whieli  hiiH  been  (Icposiled  in  the  tissues  may  ineivuse  the  severity  of  the 
Hympioms.  For  tliu  local  palsies  massage  and  the  eoiistaJit  ciirrciit  sliotdd 
be  used. 


this  is 
|tn)|ihif 

I  mental 
[st-drop 

II  Icad- 
lir  even 
|l  of  tlie 

•cssary. 
Idide  of 

times  a 
Iw.  used- 

I'ell  not 


IV.    ARSENICAL  POISONING. 

Acute  poisoiiiini  by  arsenic  is  common,  i)articularly  by  Paris  green  mid 
such  mixtures  as  "  Hougli  on  Ifats,"  which  are  used  to  destroy  vermin 
and  insects.  The  chief  symptoms  are  intense  ])ain  in  liie  stonuich,  vomit- 
ing, and,  later,  colic,  with  diarrho>aand  tenesmus;  oecasioiuilly  the  synip- 
totns  are  those  of  collapse.  If  recovery  takes  ])lace,  ])aralysis  may  follow. 
The  treatment  should  be  similar  t<t  that  of  other  irritant  poisons  -rapid 
removal  with  the  stomach  pump,  the  promotion  of  vomiting,  anW  the  use 
of  milk  and  eggs.  If  the  poison  has  been  takt-n  in  solution,  dialyzed 
iron  may  bo  used  in  large  doses  of  from  six  to  eight  drachms. 

('fn'o)ii('  Arscnli'id  l\)isi>inu;f. — Arsenic  is  used  extensively  in  tlie 
arts,  parti(^ularly  in  the  numufaeture  of  colored  j)apers,  artiticial  (lowers, 
and  in  many  of  the  fabrics  employed  as  clothing.  The  glazeil  green  and 
red  papers  used  in  kindergartens  also  contain  arseiiii-.  It  is  jirescnt  also 
in  many  wall-papers  and  carpets.  Much  attention  has  been  jiaid  to  this 
(piestion  of  late  years,  as  instances  of  poisoning  have  been  thought  to  de- 
peiul  upon  wall-papers  and  other  household  fabrics.  According  to  .1.  ,), 
I'utiuim,  the  greatest  danger  is  from  the  dust  blown  oif  by  currents  of  air 
or  detached  by  the  brush.  It  is  thought,  too,  that  possibly  sonu'  V(»latile 
comj)oun(l  of  arsenic!  may  be  formed.  Arsenic  is  eliminated  in  all  the 
secretions,  and  has  been  found  in  the  milk.  .1.  .1.  Putnam,  it  should  be  re- 
mendiered,  has  shown  that  it  is  not  uncommon  to  liiid  traces  of  arsenic  in 
the  urine  of  many  persons  in  ai)parent  health.  The  elfects  of  moderate 
(piantities  of  arsenic  are  n(<t  infrequently  seen  in  medical  practice.  In 
chorea  and  in  pernicious  ana'mia,  steadily  increasing  doses  are  often  givi-n 
until  the  patient  takes  from  fifteen  to  twenty  dro))s  of  Fowler's  solution 
three  times  a  day.  Flushing  and  hypera-mia  of  the  skin,  pudiness  of  the 
eyelids  or  above  the  eyebrows,  nausea,  vomiting,  and  diarrhoa  arc  the 
most  common  symjitoms.  Hedness  and  sonu'time>.  bleeding  of  the  gums 
and  salivation  occur.  In  the  j)rotracted  administration  of  arsenic  patients 
may  complain  (tf  numbness  and  tingling  of  the  lingers.  In  the  large 
nund)er  of  patients  to  whom  1  have  adnunistered  arsenic,  often  in  doses 
which  might  be  termed  exce.ssive,  I  have  seen  only  one  case  in  which 
numbness  and  tingling  were  marked.  Pigmentation  of  the  skin  I  have 
seen  on  several  occasions. 

In  the  slow  poi.soning  by  the  ab.sorption  of  arsenic  in  minute  do.ses,  as 
from  -wall-paper  and  fabrics,  the  syinptoms  are  varied.  .I..1.  Putnam  groups 
them  into  the  cases  in  which  the  symptoms  mainly  concern  the  general 
nutrition  without  signs  of  local  irritation ;  those  in  which  the  symi)toms 


,  :;  1 


i 


""""*  -■    ■■—rt 


nMUHwi 

rt   ■ 

t 

1 

1012 


THE  INTOXICATIONS,  SUN-STIIOKK,  OHKSITY. 


aro  due  to  lrritiiti(»ii  (tf  tlio  coujunftivip,  mouMi,  or  pimryiix ;  thoso  witli 
syniptonis  poiiitiiif^  to  tluMlifjcstivo  tnict;  cases  with  iimrkiMl  ihtvouh 
jtlu'iiouu'iiii ;  1111(1  those  in  which  the  nutrition  of  houw  Kpccial  [uirt  (if  the 
hody  irt  involved.  'The  uiost  ('((riinKin  Kyiuptonis  are  those  (d'  auieiiiiu 
and  (U'l)ility,  perhaps  with  sli<jht  irritation  of  the  mucous  niendtraiu',  and 
iiuinhness  and  tinj^iiu;;.  How  far  tiu'se  syinptoinH  arc  to  he  attributed  to 
the  small  (pumtities  (d'  arseidc  al)S(»rhe(l  from  wall-pa|)ers  and  fabrics  is  hy 
»(>mv  considered  doulilful.  That  children  and  adults  uuiy  take  with  ini- 
jiuiMty  larfi(f  doses  for  mouths  without  iiupleasuut  efTects,  and  the  fact  of 
the  {gradual  estaldishment  of  a  toleration  whi(di  emddes  Styrian  j)easants 
to  take  as  uiueh  as  eight  grains  of  arseuious  aeid  in  a  day,  speak  Htrong'y 
against  it. 

Arxfiiini!  jxtrali/sis  has  the  same  characteristics  as  lead-|>alsy,  hut  the] 
higs  are  more  aifecletl  than  the  arms,  ])arti(ndarly  the  extensors  and  pero- 
neal group,  so  that  the  patient  lias  the  eharaeteristic  nffji/niyc  gait  of 
peripheral  ueuriti.s. 

The  electrical  reaction  in  the  muscles  luay  be  disturbed  l)efore  any 
loss  of  ]»ower,  and  when  the  patient  is  asked  to  extend  the  wrist  fully  aud 
to  spread  the  fingers  slight  weakness  nuiy  bo  detected  early. 


V.     PTOMAINE   POISONING. 


MS 


In  the  bacterial  decomposition  of  animal  matters  chemical  compounds 
are  formed,  the  putrefa(rtive  alkaloids,  known  as  ])tojnaines  and  toxiiu's. 
some  of  which  are  highly  poisonous.  They  differ  extraordinarily  in  their 
chemical  charact(M's  and  physiological  effects.  Some  only  are  )»oisonous, 
and  these  Hrieger  has  designated  as  toxines.  "^riie  specill(!  acti(»n  of  the 
micro-organisms  in  disease  is  now  attributed  in  large  ])art  to  the  forma- 
tion of  these  bodies,  and  the  whole  (piestion  of  immunity  aiul  protection 
is  now  being  worked  out  in  this  direction,  a  special  stimidus  having  been 
given  of  late  in  the  discovery  by  llankin  of  the  so-called  defensive  alka- 
loids (see  under  ])neunu»nia). 

Our  interest  here  is  in  the  effe(^ts  of  these  jmisons  when  taken  Avith 
foods.* 

It  is  (juit(i  jiossibh^  that  the  leiicomaiiu\s,  the  basi(!  substiinces  formed 
in  the  living  l)ody,  may  under  certain  circumstances  be  capable  of  causing 
disease.  Products  also  of  the  biu-terial  decomposition  in  the  intestitu's 
niiiy  be  absorbed  and  act  as  poisons.  Our  knowledge  on  these  points  is  as 
yet  scanty  and  uncertain.  A  sugg(»stivo  chapter  (XIII)  upon  the  subject 
is  to  be  found  in  the  work  of  Vaughan  and  Novy. 

*  For  (I  full  (lisc'ussioii  of  the  whole  subject  the  student  is  referred  to  the  Manuii! 
upon  Ptomaines  and  Lcuconiaines,  by  Vaughan  and  Novy,  secontl  edition,  Philadclphiii. 
1801. 


PTOMAINK   POISON  I  NO. 


1013 


with 

[  tli<- 
u'liiiii 
'.  untl 
ii'd  to 
1  is  by 
Lli  ini- 
[uct  of 
•iisauls 
,rou}:!'y 

but  Uu'l 
(I  pero- 
jruit  of 

'ore  any 
ully  aiul 


)mpoun>ls 

(I  loxiiu's. 
y  in  thi'ir 
)oisonous, 
oil  of  tho 
le  fonna- 
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vinjj;  hi't-n 
sivc  alka- 

[i\i>H\  wiU» 

^,f  causinir 

intc'stiiH's 

[)()ints  is  i>^ 

fclio  subjoii 


the  "Mantui! 


Amonjr  tli(!  more  coriinion  forms  iirc  the  fi)ll(»\vinf(  : 

(1)  Meat  Poisoning. — Cuhi'S  Imvo  usuully  folldwcd  tlio  outin;,'  of  smi- 
siigea  or  jmrk-pie  or  hcad-clu'ese,  and  also  occasionally  hccf,  vcal,  and  mut- 
ton. Sausaj^(*  j»ois(iuiii;r,  which  is  known  by  the  name*  of  hdlnlistn  or 
n/ tan/ ids  is,  has  louj^  been  rccoi^ni/cd,  and  there  have  been  numeroiis  out- 
breaks, particularly  in  parts  of  (Jerniany.  Similar  attacks  have  bi'cn  pnn 
diuied  by  hum  an<l  l)y  head-cheese,  'i'ho  preciso  nature  of  the  poison  in 
these  cases  has  not  yet  been  determiiu'd.  Other  outbreaks  have  fnlldwed 
the  eatin<j  <»f  beef  and  veal.  In  the  nuijority  of  these  cases  the  nu-at  has 
tiiulcrj^one  decomposition,  thou;^h  the  ehan^'c  may  not  have  been  evident 
to  the  taste.  The  symptoms  (»f  meat  poisoninj^  are  those  of  acute  jjastro- 
intestimd  irritation.  Hallard's  description  of  the  Wellbeck  eases,  (pioted 
by  V'au^han,  holds  pxtd  for  a  majority  of  them  : 

"  A  p(U*iod  of  incubation  preceded  the  illiu'ss.  In  ')!  cases  where  this 
could  be  accurately  determinetl,  it  was  twelve  hours  or  less  in  5  cases;  be- 
twcten  twelve  ami  tliirty-six  hours  in  ;]4  cases;  between  thirty-six  and 
forty-eij,'lit  hours  in  8  eases;  and  later  than  this  in  only  4  cases.  In  many 
cases  the  first  definite  symptoms  occurred  suddenly,  and  evidently  unex- 
pe;'todly,  but  in  some  eases  there  were  observed  durinj^  the  incubation 
more  or  less  feeling  of  lanjjfuor  and  ill-health,  loss  of  appetite,  nausea,  or 
fugitive,  fjripinj^  pains  in  the  belly.  In  about  a  third  of  the  ci^.ses  the  first 
definite  .symptom  was  a  sense  of  chilliiu'ss,  usually  with  ri<,'ors,  or  trem- 
blinji^,  in  oiu'  (!ase  accompanied  by  dyspneea;  in  a  few  cases  it  was  <;iddi- 
noss  with  faintiu'ss,  sometimes  accompanied  by  a  cold  sweat  and  tottcrinj?; 
in  others  the  first  symptom  was  headache  or  pain  somewh(>re  in  the  trunk 
of  the  body — e.  p.,  in  the  chest,  back,  between  the  shoulders,  or  in  the  ab- 
domen, to  which  part  the  pain,  wherever  it  mi<rht  huvi^  connnenced,  snbse- 
(piently  extended.  In  one  case  the  first  symptom  noticed  was  a  difficulty 
in  .swallowing.  In  two  ca.ses  it  was  intense  thirst.  Hut  however  the  attack 
may  luivo  (sonunenced,  it  wius  usually  not  long  before  pain  in  the  ubdotnen, 
diarrh(i>a,  ami  vomiting  came  on,  diarrho'a  being  (»f  more  certain  occur- 
rence than  vomiting.  The  pain  in  several  cases  cdiumenced  in  the  chest 
or  between  the  shoulders,  and  extended  first  to  the  ui»pcr  and  then  to  the 
lower  i)art  of  the  abdomen.  It  was  usually  very  severe  iiuleed,  (piickly 
producing  jirostnition  or  faintness,  with  cold  sweats.  It  was  variously  de- 
scriluMl  as  crampy,  burning,  tearing,  etc.  The  diarrlneal  (li<;charges  wen^ 
in  sonu!  (rases  (|uite  unrestrainable, and  (where  a  description  of  them  could 
be  obtained)  were  said  to  have  been  exceedingly  olTcnsive  and  usually  of  a 
<lark  color.  Must  tilm*  weakness  was  an  early  and  very  remarkable  symp- 
tom in  nearly  all  the  ases,  and  in  numy  it  was  so  great  that  the  patient 
(M)uld  oidy  stall  I  by  holding  on  to  something.  Ile-idache,  sonuitimes 
severe,  was  a  conuj'jii  and  early  symptom  ;  and  in  most  cases  thenr  was 
tldrst,  often  intense  and  most  distressing.  The  tongue,  when  ob.stn'vcd, 
was  described  usnnlly  as  thickly  coated  with  a  brown,  velvety  fur,  l)ut  red 
at  the  tip  and  edges.     In  the  early  stage  the  skin  was  often  cold  to  tho 


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Photografjhic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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1014 


THE  INTOXICATIONS,  SUN-STROKE,  OBESITY. 


toucli,  but  afterward  fever  set  in,  the  temperature  rising  in  somi'  Cases  to 
101°,  103°,  and  104°  F.  In  a  few  severe  cases,  where  the  skin  wa,s  actually 
cold,  the  patient  complained  of  heat,  insisted  on  throwing  off  tlie  hod- 
clothes,  and  was  very  restless.  The  pulse  in  the  height  of  the  illness  l)t>- 
came  quick,  counting  in  some  cases  100  to  1^8.  The  above  were  the 
symptoms  most  frequently  noted.  Other  symptoms  occurred,  however, 
some  in  a  few  cases,  and  some  only  in  solitary  cases.  These  I  now  pro- 
ceed to  enumerate.  Excessive  sweating,  cramps  in  the  legs,  or  in  both 
legs  and  arms,  convulsive  flexion  of  the  hands  or  fingers,  muscular  twit(!ii- 
ings  of  the  face,  shoulders,  or  hands,  aching  pain  in  the  shoulders,  joints, 
or  extremities,  a  sense  of  stiffness  of  the  joints,  prickling  or  tingling  or 
numbness  of  the  hands  lasting  far  into  convalescence  in  some  cases,  a 
sense  of  general  compression  of  the  skin,  drowsiness,  hallucinations,  im- 
perfection of  vision,  and  intolerance  of  light.  In  three  cases  (one  that  of 
a  medical  man)  there  Avas  observed  yellowness  of  the  skin,  either  general 
or  confined  to  the  face  and  eyes.  In  one  case,  at  a  late  stage  of  the  ill- 
ness, there  was  some  pulmoiuiry  congestion  and  an  attack  of  what  was  re- 
garded as  gout.  In  the  fatul  cases  death  was  preceded  by  collapse  liki^ 
that  of  cholera,  coldness  of  the  surface,  pinched  features,  and  blueness  of 
the  fingers  and  toes  aiid  around  the  sunken  eyes.  The  debility  of  conva- 
lescence Wiuj  in  nearly  all  cases  protracted  to  several  weeks. 

"  The  mildest  cases  were  characterized  usually  by  little  remarkable 
beyond  the  following  synijitoms,  viz.,  abdominal  pains,  vomiting,  diar- 
rhoia,  thirst,  headache,  and  muscular  weakness,  any  one  or  two  of  which 
might  be  absent," 

Many  instances  are  on  record  of  poissoning  by  canned  goods,  particu- 
larly meat.  Some  of  these,  according  to  John  G.  Johnson,  have  been  cases 
of  corrosive  poisoning  from  muriate  of  zinc  and  muriate  of  tin  used  as  an 
amalgum,  but  poisonous  effects  identical  with  those  just  described  have 
followed  the  use  of  canned  meats. 

Certain  game  birds,  particularly  the  grouse,  are  stated  to  be  poisonous, 
in  special  districts  and  at  certain  seasons  of  the  year. 

(2)  Poisoning  by  Milk  Products. — Poisoning  by  cheese  has  long  been 
known.  In  ]\Iichigan,  in  1883  and  1881,  there  were  nearly  300  cases  of 
cheese  poisoning,  and  from  pieces  of  the  cheese  Vaughan  separated  a  sub- 
stance Avhich  he  called  tyrotoxicon  Since  that  date  other  outbreaks  hnvo 
been  rei)orted.  Apparently  to  this  poison  also  are  due  the  outbreaks  fol- 
lowing the  use  of  milk,  several  of  which  are  reported  in  the  manual  by 
Vaughan  and  No\y.  Still  more  numerous  of  late  years  have  been  the 
cases  due  to  poisonous  ice-cream,  in  Avhich  also  the  tyrotoxicon  has  been 
found. 

The  symptoms  are  those  of  acun!  gastro-intcstinal  irritation,  and  are 
similar  to  those  already  detailed  by  Ballard. 

(3)  Poisoning  by  Shell-flsh  and  Fish. — Perhaps  tho  most  serious  form 
of  ichthysmus,  as  the  disease  is  called,  is  that  produced  by  the  mussel, 


,  jti'-Tr'S'r-K-r*^ 


rVff 


GRAIN   POISONING. 


1015 


many  epidemics  of  which  have  been  studied  of  late,  more  particuhirly  an 
outbreak  at  Wilhelmshaven.  Brieger  lias  separated  a  poison  which  he  has 
called  mytilotoxin.  It  has  been  shown  that  this  exists  chiefly  in  the  liver 
of  the  mussel.  It  does  not  yet  appear  to  be  settled  whether  there  is  a  spe- 
cial poisonous  variety  or  whether  the  mussel  only  becomes  toxic;  unde; 
certain  conditions.  The  latter  seems  to  be  the  most  probable  view,  s;^ 
Schmidtmann  found  that  the  non-poisonous  mussels  soon  became  toxic; 
when  placed  in  the  Wilhelmshaven  bay,  while  those  from  the  bay  soon 
lost  their  toxic  properties  when  j)laced  in  the  open  sea. 

The  symptoms  of  mussel  poisonijig  follow  the  eating  of  cither  raw  or 
cooked  mussels.  The  8ynii)toms  are  those  of  an  acute  poisoning  with  pro- 
found action  on  the  nervous  system,  and  without  gastro-intestinal  symp- 
toms. There  are  numbness  and  coldness,  no  fever,  dilated  pupils,  rapid 
pulse,  and  death  occurs  sometimes  within  two  hours  with  collapse  symp- 
toms. 

Poisoning  occasionally  follows  the  eating  of  oysters  which  are  stale  or 
decomposed.  The  symptoms  are  usually  gastro-intestinal.  Certain  fish 
also  cause  poisoning,  more  particularly  the  salted  sturgeon  used  in  parts 
of  Russia,  which  hji.s  sometimes  proved  fatal  to  large  numbers  of  jx'rsons. 
In  the  middle  parts  of  Europe  the  barb  is  stated  to  be  sometimes  poison- 
ous, producing  the  so-called  '•'■harhoi  cholera.''''  In  China  and  Japan  vari- 
ous species  of  the  tetrodon  are  also  toxic,  sometimes  proving  fatal  within 
an  hour,  with  symptoms  of  intense  disturbance  of  the  nervous  system. 
Several  other  poisonous  forms  are  known,  which  produce  symptoms  de- 
scribed as  ichthysmus  paralyticus. 


^1 

■■'i 

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;  1 

;;| 

*  1 

A 

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1 

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1 

VI.   GRAIN   POISONING. 


(1)  Ergotism. — The  prolonged  use  of  meal  made  from  grains  contam- 
inated with  the  ergot  fungus  {claviceps  purpurea)  causes  a  series  of  symp- 
toms knoivn  as  ergotism,  epidemics  of  which  have  prevailed  in  different 
parts  of  Europe.  Two  forms  of  this  chronic  ergotism  are  described — the 
gangrenous  and  the  convulsive  or  spasmodic.  In  the  former,  mortification 
affects  the  extremities — usually  the  toes  and  fingers,  less  commonly  the  ears 
and  nose.  Preceding  the  onset  of  the  gangrene  there  are  usually  anaes- 
thesia, tingling,  pains,  spasmodic  movements  of  the  muscles,  and  gradiud 
blood  stasis  in  certain  vuscular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodromal 
stage  of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness, 
headache,  and  tingling  sensations  in  different  parts  of  the  body,  perha{)8 
accompanied  with  slight  fever,  spasmodic  symptoms  develop,  ])roducing 
cramps  in  the  muscles  and  contractures.  The  arms  are  flexed  and  the 
legs  and  toes  extended.  T  hese  spasms  may  last  from  a  few  hours  to  many 
days  and  relapses  are  frequent.     In  severer  cfises  epilepsy  develops  and  the 


1016 


THE   INTOXICATIONS,  SUN  STROKE,  OBESITY. 


patient  may  die  in  convulsions.  ]\rental  symptoms  are  common,  mani- 
fested sometimes  in  a  preliminary  delirium,  but  more  commonly,  in  the 
chronic  poisoning,  as  melancholia  or  dementia.  Posterior  spinal  eclerosis 
occurs  in  chronic  ergotism.  In  the  interesting  group  of  29  cases  studied  by 
Tuczek  and  Siemens,  nine  died  at  various  jjcriods  after  the  infection,  and 
four  post-mortems  showed  degeneration  of  the  posterior  columns.  A  con- 
dition similar  to  tabes  dorsalis  is  gradually  produced  by  this  slow  degen- 
eration in  the  spinal  cord. 

(3)  Lathyrism  {LupinosiH). — An  affection  produced  by  the  use  of  meal 
from  varieties  of  vetches,  chiefly  the  Luthyrus  sativus  and  L.  cieera. 
The  grain  is  popularly  known  as  the  chick-pea.  The  grains  are  usually 
powdered  and  mixed  with  the  meal  from  other  cereals  in  the  preparation 
of  bread.  As  early  as  the  seventeenth  century  it  was  noticed  that  the  use 
of  flour  with  which  the  seeds  of  the  Lathyrus  were  mixed  caused  stiffness 
of  the  legs.  The  subject  did  not,  however,  attract  much  attention  until 
the  studies  of  James  Irving,  in  India,  who  between  1859  and  18G8  pub- 
lished several  important  communications,  describing  a  form  of  spastic 
j)araplcgia  affecting  large  numbers  of  the  inhabitants  in  certain  regions  of 
India  and  due  to  the  use  of  meal  made  from  the  Lathyrus  seeds.  It  also 
produces  a  spastic  paraplegia  in  animals.  The  Italian  observers  describe 
a  similar  form  of  paraplegia,  and  it  has  been  observed  in  Algiers  by  the 
French  physicians.  The  condition  is  that  of  a  spastic  paralysis,  involving 
chiefly  the  legs,  which  may  proceed  to  complete  paraplegia.  The  arms 
are  rarely,  if  ever,  aifected.  It  is  evidently  a  slow  sclerosis  induced  under 
the  influence  of  this  toxic  agent.  The  precise  anatomical  condition,  so 
far  as  I  can  a- 'ortain,  has  not  yet  been  determined. 

(3)  Pellagra. — This  is  a  nutritional  disturbance  due  to  the  use  of  altered 
maize.  The  disease  occurs  extensively  in  parts  of  Italy,  in  the  south  of 
France,  and  in  Spain.  It  has  not  been  observed  in  this  country.  It  pre- 
vails extensively  among  the  poorer  classes,  particularly  in  the  country  dis- 
tricts, and  appears  to  be  associated  in  some  way  with  the  use  of  naize 
which  (according  to  most  authorities)  is  fermented  or  diseased.  In  the 
early  stage  the  symptoms  are  indefinite,  characterized  by  debility,  pains  in 
*the  spine,  insomnia,  digestive  disturbances,  more  rarely  diarrhu>a.  The 
first  clear  manifestation  of  the  disease  is  the  pellagral  erythema,  which  al- 
most invariably  appears  in  the  spring.  This  is  followed  by  desiccation 
and  exfoliation  of  the  e|)idermis,  which  becomes  very  rough  and  dry,  and 
occasionally  crusts  form,  beneath  which  there  is  suppuration.  With  these 
cutaneous  manifestations  there  are  digestive  troubles — salivation,  dyspv^psia, 
and  diarrhoea — which  may  be  of  a  dysenteric  nature.  After  lasting  for  a 
few  months  improvement  occurs  in  the  milder  cases  and  convalescence  is 
gradually  established.  In  the  more  severe  and  chronic  forms  there  arc 
pronounced  nervous  symptoms — headache,  backache,  spasms,  and  finally 
paralysis  and  mental  disturbance.  The  paralytic  condition  affects  tlut 
legs  and  leads  gradually  to  paraplegia.     The  mental  manifestations,  which 


- 


SUNSTROKE. 


1017 


are  rarely  met  with  until  the  third  or  fourth  attack,  are  mehvncholia  or 
suicidal  mania.  Finally,  there  may  be  a  condition  of  the  most  pronounced 
cachexia. 

The  anatomical  changes  are  indefinite.  Chronic  degenerative  changes 
have  been  found,  particularly  fatty  degeneration  and  a  peculiar  jiigmenta- 
ti(m  in  the  viscera.  The  measures  to  be  employed  are  cliange  in  diet,  re- 
moval from  the  infected  district,  and,  as  a  prophylaxis,  proper  preserva- 
tion of  the  maize.* 


VII.  SUNSTROKE 

{Heat  Exl'f'stion  ;    Insolation  ;    Thermic  Fever ;    Heat-stroke  ;    Coup  de   Soleit). 

Definition. — A  condition  produced  by  exposure  to  excessive  heat. 

It  is  one  of  the  oldest  of  recognized  diseases ;  two  instances  are  men- 
tioned in  the  Bible.  It  was  long  confounded  with  apoplexy.  The  Anglo- 
Indian  surgeons  gave  admirable  descriptions  of  it.  In  this  country  the 
most  important  contributions  have  come  from  the  New  York  Hospital  and 
the  Pennsylvania  Hospital ;  from  the  former,  the  studies  of  Swift  and 
Darrach,  from  the  latter,  the  papers  of  Gerhard,  George  B.  "Wood,  the 
elder  Pepper,  and  Levick.  In  New  Orleaas,  Bennett  Dowler  studied  the 
disease  aiul  recognized  the  difference  between  heat  exhaustion  and  sun- 
stroke. Very  little  has  been  added  to  our  knowledge  of  the  disease  sin(.„ 
the  publication  of  a  monograph  by  H.  C.  Wood.  Two  forms  are  recog- 
nized, heat  exhaustion  and  heat-stroke. 

Heat  Exhaustion. — Prolonged  exposure  to  high  temperatures,  particu- 
larly when  combined  with  physical  exertion,  is  liable  to  be  followed  by 
extreme  prostration,  collapse,  restlessness,  and  in  severe  cases  by  delirium. 
The  surface  is  usually  cool,  the  pulse  small  and  rapid,  and  the  temperature 
may  be  subnormal — as  low  as  95°  or  96°.  The  individual  need  not  neces- 
sarily be  exposed  to  the  direct  rays  of  the  sun,  but  the  condition  may 
come  on  when  working  in  close,  confined  rooms  during  midsummer.  It 
may  also  follow  exposure  to  great  artificial  heat ;  thus  the  stokers  in  the 
Atlantic  steamships  sometimes  succumb  to  the  effect  of  the  great  heat  in 
the  engine  rooms. 

Sunstroke  or  Thermic  Fever. — The  cases  are  chiefly  found  in  persons 
who,  while  working  very  hard,  are  exposed  to  the  sun.  Soldiers  on  the 
march  with  their  heavy  accoutrements  are  particularly  liable  to  attack. 
In  the  larTCr  cities  of  this  country  the  cases  are  almost  exclusively  <  m- 
fined  to  workmen  who  are  much  exposed  and,  at  the  same  time,  have 
been  drinking  beer  and  whisky. 

Morbid  Anatomy  and  Pathology.— i^fV/or  mortis  occurs  early. 
Putrefactive  changes  develop  with  great  rapidity.    The  venous  engorge- 


*  The  most  elaborate  discussion  of  the  subject  is  by  Jules  Aniould  in  the  Diotioa- 
naire  Encyclopedique  des  Sciences  Medicales,  tome  xxii,  1886. 


mm  i 


i 

"M 


1 1 


■A 


1018 


THE  INTOXICATIONS,  SUN-STROKE,  OBESITY. 


ment  is  extreme,  particularly  in  the  cerobrum.  The  left  ventricle  is  con- 
tracted (Wood),  and  the  right  chamber  dilated.  The  b'ood  is  usually 
fluid  ;  the  lungs  are  intensely  congested.  Parenchymatous  changes  occur 
in  tiie  liver  and  kidneys. 

According  to  Wood,  "  heat  exhaustion  with  lowered  temperature 
represents  a  sudden  vaso-motor  palsy,  i.  e.,  a  condition  in  which  the  exist- 
ing effect  of  the  heat  paralyzes  the  centre  in  the  medulla."  On  the  other 
hand,  thermic  fever  is  held  to  be  due  to  piivalysis  under  the  influence  of 
the  extreme  external  heat  of  tiie  centre  in  the  medull  i  which  regulates 
the  disposition  of  the  bodily  heat.  Owing  to  this  disturbance,  more  heat 
is  produced  and  less  given  off  than  normally. 

Symptoms. — The  patient  may  be  struck  down  and  die  within  an 
hour  with  sym])toms  of  heart  failure,  dyspnani,  and  coma.  This  form, 
sometimes  known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  graphi- 
cally described  by  Parkes.  Death  indeed  nuiy  be  almost  instantaneous,  the 
vicitims  falling  as  if  struck  upon  the  head.  The  usual  form  in  this  lati- 
tude comes  on  during  exposure,  with  pain  in  the  head,  dizziness,  a  feel- 
ing of  oppression,  and  sometimes  nausea  and  vomiting.  Visual  disturb- 
ances are  common,  and  a  patient  may  have  colored  vision.  ])iarrha?a 
or  frequent  micturition  may  supervene.  Insensibility  follows,  which  may 
be  transient  or  which  deepens  into  a  profound  coma.  The  patients  are 
usually  admitted  to  hospital  in  an  unconscious  state,  with  the  face  flushed, 
the  skin  pungent,  the  pulse  rapid  and  full,  and  the  temperature  ranging 
from  107°  to  110°,  or  even  higher.  F.  A.  Packard  states  that  of  the  31  cases 
admitted  to  the  Pennsylvania  Hospital  in  the  summer  of  1887,  in  a  ma- 
jority of  them  the  temperature  was  between  110°  and  111°.  In  one  case 
the  temperature  was  112°.  The  breathing  is  labored  and  deep,  sometimes 
stertorous.  Usually  there  is  complete  relaxation  of  the  muscles,  but 
twitchings.  Jactitation,  or  very  rarely  convulsions  may  occur.  The  pupils 
may  at  flrst  be  dilated,  but  by  the  time  the  cases  are  admitted  to  hospital 
they  are  (in  a  majority)  extremely  contracted.  Petechife  may  be  i)resent 
upon  the  skin.  In  the  fatal  cases  the  coma  deepens,  the  cardiac  pulsa- 
tions become  more  rapid  and  feeble,  the  breathing  becomes  hurried  and 
shallow  and  of  the  Cheyne-Stokes  type.  The  fatal  termination  may 
occur  within  twenty-four  or  thirty-six  hours.  Favorable  indications  are 
the  recovery  of  consciousness  and  a  fall  in  the  fever.  The  recovery  in 
these  cases  may  be  complete.  In  other  instances  there  are  remarkable 
after-effects,  the  most  constant  of  which  is  a  permanent  inability  to  bear 
high  temperatures.  Such  patients  become  very  uneasy  when  the  ther- 
mometer reaches  80°  F.  in  the  shade.  An  extraordinary  instance  came 
under  my  notice  in  Avhich  the  patient  was  subsequently  so  sensitive 
to  temperatures  in  the  neighborhood  of  75°  F.  that  at  such  times  he  lived 
comfortably  only  in  the  cellar,  and  finally  sought  refuge  in  Alaska.  .  Loss 
of  the  power  of  mentsil  concentration  and  failure  of  memory  are  more 
constant  and  very  troublesome  sequelas.     Such  patients  are  always  worse 


OBESITY. 


1019 


in  the  hot  weather.  Occasionally  convulsions  and  marked  mental  distuvb- 
ance  may  develop.  II.  C.  Wood  states  that  in  a  case  of  tliis  kind  chronic 
meningitis  was  found. 

Guiteras  has  called  attention  to  a  form  of  fever  occurring  in  the  South, 
known  in  Florida  as  "Florida  fever,"  in  the  Carolinas  as  "country  fever," 
and  in  tropical  countries  nsijievre  infldinmalture  'i'he  ciu^cs  last  for  a  vari- 
able time,  and  are  mistjiken  for  malaria  or  typhoid ;  but  he  believes  them 
to  be  entirely  distinct  and  due  to  a  })rolonge(l  action  of  the  high  teni})(!ra- 
tures.     lie  has  called  the  condition  a  "  continued  thermic  fever." 

The  diagnosis  of  neat  exhaustion  from  thermic  fever  is  readily  made, 
as  the  difference  between  the  two  conditions  is  striking.  "  In  solar  ex- 
haustion the  skin  is  moist,  pale,  and  cool ;  the  breathii\g  is  easy  though 
hurried ;  the  pulse  is  small  and  soft ;  the  vital  forces  fall  into  a  temporary 
collapse;  the  senses  remain  entire"  (Dowler) ;  whereas  in  sunstroke  or 
heat  apoplexy  there  is  usually  unconsciousness  and  ])yrexia. 

The  mode  of  onset,  together  with  the  circumstances  under  which  it 
occurs  and  the  high  temperature,  ]iennits  thermic  fever  to  be  readily  dif- 
ferentiated from  apoplexy,  ant], coma  from  other  conditions. 

Treatment. — In  heat  exhaustion  stimulants  should  be  given  freely, 
and  if  the  temperature  is  below  normal  the  hot  bath  should  be  used 
Ammonia  may  be  given  if  necessary.  In  thermic  fever  the  indications 
are  to  reduce  the  temperature  as  rapidly  as  possible.  This  nuiy  be  done 
by  placing  the  patient  in  a  bath  at  70°.  Rubbing  the  body  with  ice  was 
practised  at  the  New  York  Ilospitid  by  Darrach  in  1857,  and  is  an  excel- 
lent procedure  to  lower  the  temperature  rapidly.  Ice-water  enemata  may 
also  be  employed.  At  the  Pennsylvania  Hospifcil  in  the  summer  of  1887 
the  ice-pack  was  used  with  great  advantage.  Of  31  cases  only  13  died, 
a  result  probably  as  sjitisfactory  jis  can  be  obtainefl,  considering  that  many 
of  the  patients  are  almost  moribund  when  brought  to  haspitiil.  It  should 
be  compared  with  Swift's  statistics,  in  which  of  150  cases  78  died.  In  the 
cases  in  which  the  symptoms  are  those  of  intense  asphyxia,  and  in  which 
death  may  take  place  in  a  few  minutes,  free  bleeding  should  be  ])nictised, 
a  procedure  which  saved  Weir  Mitchell  when  a  young  man.  Of  other  rem- 
edies, the  antipyretics  have  been  employed,  and  may  bo  given  when  thci'e 
is  any  special  objection  to  hydrotherapy,  for  which,  however,  they  cannot 
be  substituted. 

Vm.    OBESITY. 


Corpulence,  an  excessive  development  of  the  bodily  fat,  is  a  condition 
for  which  the  physician  is  frequently  consulted,  and  for  which  much  may 
be  done  by  a  judicious  arrangement  of  the  diet.  The  tendency  to  polysarcia 
or  obesity  is  often  hereditary,  and  is  particularly  a})t  to  be  manifest  after 
the  middle  period  of  life.  It  may,  however,  bo  seen  early,  and  in  this 
country  it  is  not  very  uncommon  in  young  girls  and  young  boys. 


pin 


m 


1020 


THE  INTOXICATIONS,  SUN-STROKE,   OBESITY. 


!!■ 


¥^\ 


A  very  importiint  factor  is  overeaf-iiifj,  a  vice  wliich  is  more  preva- 
lent and  only  a  little  behind  overdrinking?  in  its  disastrous  elTects.  A 
majority  of  pe'-sons  over  forty  years  of  a^^;  habitually  eat  too  much.  In 
8t>ine  of  the  most  aggravated  cases  of  obesity,  howcvi-r,  this  plays  no  part, 
and  the  unfortunate  victim  may  be  a  notoriously  siiudl  eater.  A  second 
element  is  lack  of  proper  exercise ;  a  third  less  important  factor  is  the  tak- 
ing largely  of  alcoholic  beverages,  particularly  beer. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  which 
were  so  loi\g  blamed,  are  not  at  fault,  since  they  are  themselves  converted 
into  water  and  carbon  dioxide.  On  account,  however,  of  the  facility  with 
v/hich  they  are  utilized  for  the  purjjoses  of  oxidation  the  albuminous  ele- 
ments of  the  food  are  less  readily  oxidized,  not  so  fully  decomposed,  and 
the  fat  ia  in  reality  separated  from  them.  So,  too,  the  fats  themselves  are 
not  so  prone  to  cause  obesity  as  the  carbohydrates,  being  less  readily  ox- 
idized and  interfering  less  with  the  complete  metabolism  of  the  albumi- 
nous elements. 

Many  plans  are  now  advised  for  the  reduction  of  fat,  the  most  impor- 
tant of  which  are  those  of  Banting,  Ebstein,  and  Oertel.  In  the  Banting 
method  the  amount  of  food  is  I'educed,  the  liquids  are  restricted,  and  the 
fats  and  carbohydrates  excluded. 

Ebstein  recommends  the  use  of  fat  and  the  rapid  exclusion  of  the  carbo- 
hydrates.    The  following  is  an  examjile  of  his  dietary : 

Breakfast  (0  A.  m.  in  summer,  7.30  A.  M.  in  winter). — White  bread, 
well  toasted  (rather  less  than  two  ounces)  and  well  covered  with  butter. 
Tea,  without  milk  or  sugar,  eight  or  nine  ounces. 

Dinner,  2  p.  M. — Soup  made  with  beef-marrow.  Fat  meat,  with  fat 
sauce,  four  to  five  ounces.  A  moderate  quantity  of  asparagus,  si^inach, 
cabbage,  peas,  and  beans.  Two  or  three  glasses  of  light  white  wine. 
After  the  meal,  a  large  cup  of  tea  without  milk  or  sugar. 

Slipper,  at  7.30  p.  m. — An  egg,  a  little  roast  meat,  with  fat.  About 
an  ounce  of  bread,  well  covered  with  butter.  A  large  cup  of  tea,  without 
milk  or  sugar. 

Oertel's  method  has  already  been  considered  in  connection  with  the 
treatment  of  fatty  heart,  and  is  combined  with  systematic  bodily  exercise. 
It  is  particularly  adapted  for  stout  persons  with  weak  heart. 

The  so-called  Schweninger  cure  is  in  reality  Oertel's,  with  the  sole 
modification  of  the  forbidding  of  any  fluid  at  meals.  Liquids  must  be 
taken  more  than  two  hours  after  the  food. 

Yeo,  after  a  full  consideration  of  the  various  methods,  gives  the  follow- 
ing useful  summary : 

"  The  albuminates  in  the  form  of  animal  food  should  be  strictly  lim- 
ited. Farinaceous  and  all  starchy  foods  should  be  reduced  to  a  mininuim. 
Sugar  should  be  entirely  prohibited.  A  moderate  amount  of  fats,  for  the 
reasons  given  by  Ebstein,  should  be  allowed. 

"  Only  a  small  quantity  of  fluid  should  be  permitted  at  meals,  but 


I!. 

1: 


OBESITY. 


1021 


enough  sliould  be  allowed  to  aid  in  the  solution  and  digestion  of  the  food. 
Hot  water  or  warm  aroinatii;  beverages  may  be  taken  freely  Ix'twecn  meals 
or  at  the  end  of  the  digestive  j)rocess,  especially  in  gouty  cases,  on  account 
of  their  eliminative  action. 

"No  beer,  porter,  or  sweet  wines  of  any  kind  to  be  taken;  no  spirit, 
except  in  very  small  qu.  itity.  It  should  be  generally  recognized  that  the 
use  of  alcohol  is  one  of  the  most  common  provocatives  of  obesity.  A 
little  Ilock,  still  Moselle,  or  light  claret,  with  some  alkaline  table  water  is 
all  that  should  be  allowed.  'J'he  beneficial  effects  of  such  diet  will  be  aided 
by  abundant  exercise  on  foot  and  by  the  free  use  of  saline  purgatives,  so 
that  we  may  insuue  a  complete  daily  unloading  of  the  intestinal  canal. 

"  It  is  only  necessary  to  mention  a  few  other  details.  Of  animal  foods, 
all  kinds  of  lean  meat  may  be  taken,  poultry,  game,  fish  (eels,  salmon, 
and  mackerel  are  best  avoided),  eggs. 

"  Meat  should  not  be  taken  more  thai>  once  a  day,  and  not  more  than 
six  ounces  of  cooked  meat  at  a  time.  Two  lightly  boiled  or  poached  eggs 
may  be  taken  at  one  other  meal,  or  a  little  grilled  fish. 

"  Bread  should  be  toasted  in  thin  slices  and  completely,  not  browned  on 
the  surface  merely. 

"  Hard  captain's  biscuits  may  also  be  taken. 

"  Soups  should  be  avoided,  except  a  few  tablespoonfuls  of  clear  soup. 

"  Milk  should  be  avoided,  unless  skimmed  and  taken  as  the  chief  article 
of  diet.  All  milk  and  farinaceous  puddings  and  pastry  of  all  kinds  are 
forbidden.     Fresb  vegetables  and  fruit  are  permitted. 

''  It  is  important  to  bear  in  mind  that  the  actual  quantity  of  food  per- 
mitted must  have  a  due  relation  to  the  physical  development  of  the  indi- 
vidual, and  that  what  would  be  adequate  in  one  case  might  be  altogether 
inadequate  in  the  case  of  another  person  of  larger  physique."  * 

*  A  System  of  Therapeutics,  vol.  i,  edited  by  II.  A.  Hare,  Philadelphia,  1891. 


■a 
i 


follow- 

tly  lim- 

himum. 

for  the 


lis,  but 


o  to 


rl 


SECTION   XI. 
DISEASES  DUE  TO  ANIMAL  PARASITES. 


I.    PSOROSPERMIASIS. 

Undku  this  term  are  embraced  several  ulTeetions  produced  by  the  sjio- 
rozoH,  These  parasites  be]on^in<if  to  tlie  lowest  division  of  the  protozoji, 
are  also  known  as  psorosperms  and  gregarinidiB.  They  are  extraordinarily 
abundant  in  the  invertebrates,  and  are  not  uncommon  in  the  higher  mam- 
mals. The  entire  group  of  blood  parasites,  hivmatozoa,  which  live  within 
the  corpuscles,  are  closely  related  to  them.  Psorosperms  are,  as  a  rule, 
parasites  of  the  cells — ct/tozoa.  The  commonest  and  most  suitable  variety 
for  study  is  the  coccidinin  oviforme  of  the  rabbit,  which  })roduces  a  dis- 
ease of  the  liver  in  which  the  organ  is  studded  throughout  with  whitish 
nodules,  ranging  in  size  from  a  pin's  head  to  a  split  pea.  On  section  each 
nodule  is  seen  to  be  a  dilated  portion  of  a  bile  duct ;  the  walls  are  lined 
with  epithelium  in  the  interior  of  which  are  multitudes  of  ovoid  bodies — 
the  coccidia.  Another  very  common  forni  occurs  in  the  muscles  of  the 
pig,  the  so-called  Rainey's  tube,  which  is  an  ovoid  body  within  the  sar- 
colemma  containing  a  number  of  small,  si(!kle-shaped,  unicellular  organ- 
isms. 

These  bodies  probably  play  a  more  important  role  in  human  pathology 
than  has  hitherto  been  thought.  The  cases  reported  may  be  grouped  un- 
der the  following  divisions :  internal  and  external. 

(1)  Internal  Psorospermiasis. — In  a  majority  of  the  cases  of  this  group 
the  psorosperms  liave  been  found  in  the  liver,  producing  a  disease  similar 
to  that  which  occurs  in  rabbits.  In  Guebler's  case  there  were  tumors 
which  could  be  felt  in  the  liver  during  life,  and  they  were  determined  by 
Leuckart  to  be  due  to  coccidia.  In  W.  B.  Haddon's  case  the  patient  was 
admitted  to  8t.  Thomas's  Hospital  with  slight  fever,  drowsiness,  and  grad- 
ual unconsciousness ;  death  occurred  on  the  fourteenth  day  of  observa- 
tion. Whitish  neoplasms  were  found  upon  the  peritonaBum,  omentum,  and 
on  the  layers  of  the  pericardium ;  and  a  few  were  found  in  the  liver,  spleen, 
and  kidneys.  A  somewhat  similar  case,  though  more  remarkable,  as  it  ran 
a  very  acute  course,  is  reported  by  Silcott.  A  woman,  aged  fifty-three, 
admitted  to  St.  Mary's  Hospital,  was  thought  to  be  suffering  from  typhoid 


wmmsmm 


«ii-M»«iArmi 


PSOROSPKRMIASIS. 


1023 


fovor.  She  had  had  a  chill  kIx  wooks  hoforo  admission.  Thoro  was  fever 
of  an  iMterniittcnt  type,  slight  diarrhd'a,  nausea,  tenderness  ov(!r  the  liver 
and  spleen,  and  a  dry  tongue;  death  occurred  from  heart-failun^  'i'he 
liver  waa  enlarged,  weighed  eighty-three  ounces,  antl  in  its  substance  there 
were  caseous  foci,  around  eacdi  of  whicli  was  a  ring  of  congestion.  The 
spleen  weighed  sixteen  ounces  aiul  contained  similar  bodies.  'Die  ileum 
presented  six  papule-like  elevations.  The  nnisses  rcsendjlcd  tuhercU'S, 
but  on  examination  coccidia  were  found. 

The  parasites  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  been  recorded  by  Bhmd  Sutton  aiul  l*aul  Kve.  In  the  case 
reported  by  Kve  the  syinptoms  were  htematuria  aTid  freciuent  micturition, 
and  deatli  took  phico  on  the  seventeenth  day.  The  nodules  throughout 
the  pelvis  and  ureters  have  been  regarded  as  mucous  cysts.  In  a  case 
reported  by  Joseph  (jritKths  the  tunujrs  in  the  ureter  caused  liydrone- 
phrosis. 

(2)  Cutaneous  Psorospermiasis. — '{")  J'^dlicnlar. — This  rcmarkal)lo 
skin-disease  was  originally  described  by  J.  C.  White,  under  the  name  of 
keratosis  folUcnhtris.  Darier,  of  Paris,  has  shown  that  tiiis  is  really  a 
parasitic  affection.  The  lesions  are  chiefly  on  the  face,  the  flanks,  and  the 
inguinal  regions.  It  is  at  first  papular,  surmounted  by  a  grayish  crust,  dry 
and  hard.  'J'he  lesions  finally  become  confluent,  and  form  a  series  of 
irregulai  elevations  giving  a  rasp-Hke  feeling  to  the  touch. 

Microscopical  examination  shows  that  in  these  papillomatous  growths 
tliere  are  numerous  organisms  corresponding  to  psorosperms.  At  the  St. 
Louis  Hospital,  in  Paris,  Darier  was  kind  enough  to  show  me  the  cases  and 
the  specimens  from  them.  No  one  accustomed  to  the  appearance  of 
psorosperms  as  seen  in  the  lower  animals  could  question  the  truly  para- 
sitic nature  of  these  bodies.  A  case  of  the  disease  has  been  reported  iu 
this  country  by  A.  R.  llobinson. 

{b)  Pagefs  Disease  of  the  Nipple. — In  this  affection,  formerly  regarded 
as  an  eczema,  psorosperms  are  constantly  present,  as  shown  by  Darier, 
A.  B.  Alacallum,  and  others.  They  are  readily  demonstrated,  without  any 
special  preparation,  and  here,  too,  of  the  nature  of  the  bodies  there  can  be 
no  question. 

In  molluscum  contagiosum  and  in  epithelioma  many  observers  liave 
noted  the  presence  of  bodies  which  lie  in  and  between  the  epithelial  cells 
and  have  some  resemblance  to  psorosperms.  The  bodies  are  readily  seen 
in  sections  of  epithelioma,  but  they  lack  the  sharply  defined  characters  of 
the  coccidia  which  are  present  in  Paget's  disease  and  iu  White's  keratosis. 


\ 


11 


!li! 


r 


I' 


1024 


DISKASES  DUK  TO  ANIMAL  TAIlASlTKa 


II.  DISTOMIASIS. 


Sf'vorul  forms  of  tn^niiitodes  or  Hiikes  iiru  juiriusitic  in  mun,  uud  when 
in  niiniluTs  may  nuiHo  HcrioiiH  (liHoiiHo. 

(1)  Lircr  Fluh'K. — 'V\w  followiiif?  viirictios  of  flukt's  Imvc*  boon  f(»u)i(l : 
Thvdi.s/oiiia  //rjxi/icum,  ii  very  coninioii  piinisito  iji  riiiiiiiiants,  wliicli  lias  a 
Icnj^'tli  of  from  twenty-  'i^'lit  to  thirty-two  millimetres.  The  dislonin 
lan(ro/(i(u)ii,  a  much  si  laller  form,  from  eight  to  ten  millimetres  in  length, 
wliich  is  also  very  common  in  slicep  uud  cutth',  I'he  lUdomn  crufisum, 
tlui  largest  form,  measuring  from  four  to  eight  centimetres  in  length. 
One  or  two  otlier  less  imj)ortant  forms  have  occasionally  been  met  with. 
The  studies  of  the  .Japaiuvsc  jihysieians  iiave  brought  to  light  the  interest- 
ing fa(!t  that  there  is  a  distoma  widely  endemic!  in  certain  ])rovinces  in 
that  country.  Two  forms  have  been  described,  the  distoma  endemicnm 
ami  tho  di'yfonia  prriiicioffitDi^  al)out  which  there  is  still  a  doubt  whether 
they  are  different  species  or  not.  The  studies  of  Ijima  indicate  that  they 
are  ])robal)ly  the  same.  Accordiiig  to  Baelz,  fully  twenty  i)er  cent  of  the 
inhal)itants  of  certain  provinces  are  affected. 

The  flukes  occupy  the  bile-])assage8  and  the  upper  portion  of  the 
small  intestine.  W.  oji  in  large  numbers  they  may  cause  serious  and 
fatal  disease  of  the  liver,  usually  with  ascites  aiul  jaundice.  The  liver 
nuiy  be  enormously  oidarged ;  in  Kichner's  case  it  weighed  eleven  ])0UTul8. 
The  flukes  may  cause  a  chronic  cholangitis,  leading  to  great  thickening 
or  even  calcification  of  tlie  walls  of  the  bile-duct. 

The  endemic  fluke  disease  of  Japan  is  characterized  by  enlargement  of 
the  liver,  emaciation,  diarrhani,  and  frecpiently  ascites. 

(2)  The  Blood  Fluke;  Bilharzia  Hmmitobia. — This  trematode  is 
found  in  Egypt,  southern  Africa,  and  Arabia,  aiul  is  the  cause  in  these 
countries  of  the  endemic  hiBmaturia.  The  female  is  about  two  centi- 
metres in  length,  cylindrical,  filiform,  and  about  '07  millimetre  in  di- 
ameter. The  parasite  lives  in  the  venous  system,  particularly  in  the  por- 
tal vein,  aiul  in  the  veins  of  the  spleen,  bladder,  kidneys,  and  mesentery. 
According  to  liilharz,  at  least  fifty  i)er  cent  of  the  lower  classes  in  Egypt 
are  infected  with  it.  It  is  not  yet  known  how  the  parasite  gains  entrance 
to  the  body.  In  all  ju-obability  it  is  by  drinking  impure  water  contain- 
ing the  embryos. 

The  symptoms  are  due  to  changes  in  the  mucous  membrane  of  the 
urinary  organs  caused  by  the  presence  of  the  parasites  in  the  blood-ves- 
sels of  these  parts.  Hasmaturia  is  the  first  and  most  constant  symptom, 
leading  gradually  to  anaemia.  There  is  generally  pain  during  micturi- 
tion. The  blood  is  not  constant  in  the  urine.  The  ova  of  the  Bilharzia 
are  readily  seen  under  a  microscope  with  a  low  power.  They  are  ovoid  in 
shape,  translucent,  with  a  small  spike  at  one  end.  The  embryo  can  be 
readily  seen. 

The  disease  is  rarely  fatal ;  a  great  majority  of  the  cases  recover.    Chil- 


DISEASKS  CAUSED   BY  NE:.lATOnES. 


1025 


(Iren  are  mnro  comnioiily  nttiu^ked  tliim  grown  porsons,  and  tho  ilint^iwo 
of  ton  (lisu|t|)c'iir8  by  tl»o  time  of  puhorty. 

(;})  lironrliiiil  Fhikr;  fUsfiinui  Iiiti;/fri :  Parasifir  lfiniinp/i/si'.9. — 
In  ])artM  of  Cliiiiii,  .liipaii,  mill  Kormosa  tlioro  is  an  cpidcinic  disease,  do- 
Hcribed  by  Kinjjer  and  Manson,  characterized  by  a(taci\s  of  cou^di  and 
liiemoptysis  associated  with  tlio  prusouco  of  u  Buiull  iluko  in  tho  broncliial 
tubes. 


III.    DISEASES  CAUSED   BY   NEMATODES. 

1.    ASCAUIASIS. 

(ft)  Aurnris  hnnhriroidi's,  tlie  most  common  human  parasite,  is  fouiul 
chietly  in  chihiren.  'I'he  fenuilf!  is  from  seven  to  twelve  indies  in  len;,fth, 
the  male  from  four  to  eij^lit  inches.  'I'he  worm  is  cylindrical,  pointed  at 
both  ends,  and  has  a  yellowish-brown  sometimes  a  slightly  reddish  coh)r. 
Four  longitudinal  bands  can  be  seen,  and  it  is  striated  transvers(?ly.  Tho 
ova,  wbich  are  sometimes  found  in  largo  numbers  in  tho  fieees,  are  small, 
brownish-red  in  color,  elliptic}'',  and  have  n  very  thick  covering.  'I'hey 
measure  '075  millimetre  in  length  and  -058  millimetre  in  width.  They 
develop  outside  tho  body,  but  the  life  history  is  not  known.  The  para- 
site occupies  the  upper  portion  (/f  the  small  intestine.  I'sually  not  more 
than  one  or  two  are  present,  but  occasionally  they  occur  in  enornu)us 
numbers.  The  migrations  are  peculiar.  They  may  pass  into  the  stom- 
ach, from  which  they  may  bo  ejected  by  vomiting,  or  they  may  crawl  up 
tho  oesophagus  and  enter  the  pharynx,  from  which  they  may  bo  with- 
drawn. A  child,  under  my  care  In  the  small-pox  dejiartment  of  the  (Jen- 
eral  Hospital,  during  convalescence,  withdrew  in  this  way  nujre  than 
thirty  round  worms  within  a  few  weeks.  In  other  instances  tho  worm 
passes  into  the  larynx,  and  has  been  known  to  cause  fatal  asphyxia,  or 
passing  into  the  trachea,  to  cause  gangrene  of  the  lung.  I'hey  may 
pass  into  the  P^ustachian  tube  and  appear  at  the  external  meatus.  The 
most  serious  migration  is  into  the  bile-duct.  There  is  a  specimen  in  the 
Wistar-Horner  Museum  of  the  University  of  Pennsylvania  in  which  not 
only  the  common  duct,  but  also  tho  main  branches  throughout  the  liver 
are  enormously  distended  and  packed  with  numerous  round  worms.  The 
bowel  may  be  perforated  by  them  and  peritonitis  result. 

The  symptoms  are  not  definite.  When  a  few  are  present  tiiey  may  be 
passed  without  causing  disturbance.  In  children  there  are  irritjitive 
symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  tho  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions. 
These  symptoms  may  be  marked  in  very  nervous  children. 

Treatment. — Santonin  can  be  given,  mixed  with  sugar,  in  doses  of 
from  one  to  three  grains  for  a  child  and  three  to  five  grains  for  an  adult, 
followed  by  a  calomel  or  a  saline  purge.    The  dose  may  be  given  for 


1026 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


as 
1. 


I 


three  or  four  days.  An  unpleasant  consequence  wliich  sometimes  follows 
tlie  administration  of  this  drug  is  xanthojjsia  or  yellow  vision. 

(b)  Oxyuris  Vermicularis  [Thread-worm ;  Fin-worm). — This  com- 
mon parasite  occui)ies  the  rectum  and  colou.  The  male  measures  about 
four  millimetres  in  length,  the  female  about  ten  millimetres.  They  pro- 
duce great  irritation  and  itching,  particularly  at  night,  symptc^ms  which 
become  intensely  aggravated  by  tlie  noctui'ual  migration  of  the  parasites. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  auiemia.  Though  most 
common  in  children  the  parAsite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  faices.  Infection  i)robahly  takes 
place  through  the  water  or  jiossibly  through  salads,  such  as  lettuces  and 
cresses.  A  person  the  subject  of  the  worms  })asses  ova  in  large  numbers 
in  the  faeces,  and  the  possibility  of  reinfection  must  be  scrupulously 
guarded  against. 

T'he  treatment  is  simple,  though  occasionally  there  are  instances  in 
which  all  forms  of  medication  are  resisted.  A  case  is  mentioned  of  a  gen- 
tleman, aged  forty,  who  had  siill'ered  from  childhood  and  had  failed 
to  obtain  any  benefit  from  prolonged  treatment  by  many  helminthologists. 
Santonin  may  be  used  in  small  doses,  and  mild  purgatives,  particularly 
rhubarb.  Large  injections  containing  carbolic  acid,  vinegar,  quassia,  aloes, 
or  turpentine  nuiy  be  employed.  In  children  the  use  of  cold  injections  of 
strong  salt  and  water  is  usually  efficacious.  They  should  be  re})eated  for 
at  least  ten  days.  In  giving  the  injection  care  should  be  taken  to  have 
the  hips  well  elevated  so  that  the  fluid  can  be  retained  as  long  as  possible. 
For  the  intense  itching  and  irritation  at  night  vaseline  may  be  freely 
used  or  belladonna  ointment. 

II.   Trichiniasis. 

The  trichina  spiralis  in  its  adult  condition  lives  in  the  small  intestine. 
The  disease  is  produced  by  the  embryos,  which  pass  from  the  intestines 
and.  reach  the  voluntary  muscles,  where  they  finally  become  encapsulated 
— muscle  trichiuic.  It  is  in  the  migration  of  the  embryos  that  the  group 
of  symptoms  known  as  trichiniasis  is  produced. 

Description  of  t/ie  Pants i/es. — (a)  Adulter  intestinal  form.  The  fe- 
male measures  from  three  to  four  millimetres;  the  male,  1"5  nnllimetre, 
and  has  two  little  projections  from  the  hinder  end. 

(b)  The  embryo  or  muscle  trichina  is  from  0-0  to  one  millimetre  in 
length  and  lies  coiled  in  an  ovoid  capsule,  which  is  at  first  translucent,  but 
subsequently  opaque  and  infiltrated  with  lime  salts.  The  worm  presents  a 
pointed  head  and  a  somewhat  rounded  tail. 

When  flesh  containing  the  trichina^  is  eaten  by  man  or  by  any  ani- 
mal in  which  the  development  can  take  place,  the  capsules  are  digested 
and  the  trichinae  set  free.     They  pass  into  the  small  intestine,  and  about 


DISEASES  CAUSED   BY  NEMATODES. 


1027 


the  third  day  attain  thoir  full  growth  and  become  sexually  mature.  \'ir- 
chow's  experiments  have  shown  that  on  the  sixth  or  seventh  day  the  em- 
bryos an  fully  developed.  The  young  produced  by  each  female  tricliiua 
have  b(.cu  estimated  at  several  hundred.  Loiikart  thinks  that  various 
broods  are  developed  in  succession,  and  that  as  many  as  a  thousand 
emI)ryos  may  be  produced  by  a  single  worm.  The  time  from  the  inges- 
tion of  the  ilesh  containing  the  muscle  trichinae  lo  the  development  of  the 
brood  <jf  cml)ryos  in  tlie  intestines  is  from  seven  to  nine  days.  As  soon 
as  born  the  embryo  trichime  leave  the  intestines ;  wandering  through  the 
peritonanim  and  the  connective  tissues,  probably  through  the  mesentery 
and  retroperitoneal  tis.sues — some  hold  by  means  of  the  blood  current — 
they  finally  reach  the  muscles,  which  constitute  "  the  scat  of  election." 
After  a  preliminary  migration  in  the  intermuscular  connective  tissue  they 
penetrate  the  primitive  muscle  fibres,  and  in  about  two  weeks  develop  into 
tlie  full-grown  nuiscle  form.  In  this  process  an  interstitial  myositis  is  ex- 
citeil  and  gradually  an  ovoid  capsule  develoj)s  about  the  2)arasite.  Two, 
occasionally  three  or  four,  worms  may  be  seen  within  a  single  capsule. 
This  process  of  encapsulation  has  been  estimated  to  taivo  about  six  weeks. 
Within  the  muscles  the  parasites  do  not  und(>rgo  further  development. 
Gradually  the  capsule  becomes  thicker,  and  ultimately  lime  salts  are 
dcpo.^ited  witliin  it.  'I'his  clninge  may  take  })la('e  in  num  within  four  or 
live  months.  In  the  hog  it  may  be  deferreil  for  many  years.  The  cah 
cification  renders  the  cyst  visible,  and  since  first  seen  by  Tiedemann,  in 
18:2:?,  and  Hilton,  in  183:^,  these  small,  opaque,  oat-shaped  bodies  have  been 
familiar  objects  to  demonstrators  of  normal  ami  morl)id  anatomy.  The 
tricliinre  may  live  within  the  muscles  for  an  indefinite  period.  They  have 
been  found  alive  aiul  capaljle  of  developing  as  late  as  twenty  or  even 
twenty-five  years  after  their  entrance  into  the  system.  In  nuiny  in- 
stances, however,  the  worms  are  completely  calcified.  Tlie  trichina  occurs 
in  swine,  in  the  rat,  occasionally  in  mice  and  cats  ;  it  has  been  f(mnd  also 
in  the  fox  and  a  few  other  animals.  The  ])arasite  was  first  found  in  the 
hog  by  the  late  Joseph  Leidy.  Experimentally,  guinea-])igs  and  rabbits 
are  readily  infected  by  feeding  fli-'m  with  muscle  containing  the  larval 
form.  Dogs  are  infected  with  v.ifiiculty;  cats  more  readily.  Experi- 
mentally, animals  sometimes  die  of  the  disease  if  largo  numbers  of  the 
parasites  have  been  eaten.  In  the  hog  the  trichimv,  like  the  cysticerci, 
cause  few  if  any  symptoms.  An  ani  nud  the  muscles  of  which  are  swarm- 
ing with  living  trichina)  may  be  well  nourished  and  healthy-looking.  An 
important  point  also  is  the  fact  that  in  the  hog  the  capsule  does  not  readi- 
ly become  calcified,  so  that  the  parasites  are  not  visible  as  in  the  human 
muscles.  For  a  long  time  the  trichina  was  looked  upon  as  a  pathological 
curiosity,  but  in  1800  Zenker  discoA'ored  in  a  girl  in  the  Dresden  IIos})ital 
who  had  symptoms  of  typhoid  fever  both  the  intestinal  aiul  the  muscle 
forms  of  the  trichiuie,  since  which  time  the  disease  has  been  thoroughly 
studied. 

65 


if 


1028 


DISEASES  DUE  TO  ANIJIAL  PARASITES. 


Man  is  infected  by  eating  the  flesh  of  trichinous  hogs.  The  inoitlence 
of  the  disease  in  swine  varies  much  in  diirerent  ccjimtries.  In  Germany, 
Avhere  a  thorough  and  systematic  microscopic  examination  of  all  switio 
flesh  is  mad",  the  proportion  of  trichinous  hogs  is  abimt  I  in  l,8r)2.  At 
the  Herlin  al)attoir,  where  the  microscopic  examination  is  conducted  by  a 
stall  of  over  eighty  men  and  women,  two  portions  are  taken  from  the  ab- 
dominal nniscles,  from  the  diaphragm,  and  from  the  intercostal  muscles, 
and  one  piece  from  the  muscles  of  the  larynx  and  tongue.  A  special  com- 
pressor is  used  to  flatten  the  fragments  of  the  muscle,  aiul  the  examination 
is  made  with  a  magnifying  power  of  from  seventy  to  one  huiulrt'd  diameters. 
During  the  three  years  ending  in  1885  there  were  G03  trichinous  hogs  de- 
tected, a  ratio  of  1  to  1,292.  Statistics  arc  not  available  in  England.  In 
the  United  States  systematic  inspection  is  unknown,  and  the  statistics  are 
by  no  means  extensive  enough.  "•Taking  all  the  examinations  of  Amer- 
ican pork  thus  far  made,  both  at  home  and  abroad,  and  we  have  a  total  of 
298,782,  in  which  trichina;  were  found  0,280  times,  being  2"1  per  cent,  or 
1  to  48"  (Salmon,  1884). 

In  1883,  in  conjunction  with  A.  W.  Clement,  I  examined  1,000  hogs 
at  the  Montreal  abattoir,  and  found  only  4  infected.  1'here  is  no  reason 
to  believe  that  the  liog  of  this  country  is  less  liable  to  trichina  than  the 
Gernum  animal. 

Modes  of  Iiifccfion. — The  danger  of  infection  depends  entirely  upon 
the  mode  of  i)re})aration  of  the  flesh.  Thorough  cooking,  so  that  all  parts 
of  the  meat  reach  the  lioiling  point,  destroys  the  parasites ;  but  in  large 
joints  the  central  portions  are  often  not  raised  to  this  temperature.  '^Phe 
frequency  of  the  disease  in  different  countries  depends  largely  upon  the 
hfibits  of  the  people  in  the  preparation  of  pork.  In  Xorth  Germany, 
Avhere  raw  ham  and  wurst  are  freely  eaten,  the  greatest  number  of  cases  have 
occurred.  In  South  Gernumv,  France,  and  England  cases  are  rare.  In 
this  country  the  greatest  number  of  persons  .attacked  have  been  Germans. 
Salting  and  smoking  the  flesh  are  not  always  sufficient,  and  the  Havre  ex- 
periments showed  that  animals  are  readily  infected  when  fed  with  portions 
of  the  pickled  or  the  smoked  meat  as  prepared  in  this  country.  Garl 
Friinkel,  however,  states  that  the  experiments  on  this  point  have  been 
negative,  and  that  it  is  very  doubtful  if  any  cases  of  trichiniasis  in  Ger- 
many have  b*en  caused  by  American  pork. 

Frequcncii  of  IiifectioH. — The  dissecting-room  and  post-mortem  statis- 
tics show  that  from  one  half  to  two  per  cent  of  all  bodies  contain  trichina'. 
Of  1,000  consecutive  autopsies  of  which  I  have  notes  the  trichinae  were 
present  in  6  instances.  I  have,  in  addition,  seen  them  in  two  dissecting- 
room  cases  and  in  two  l)odies  at  the  Philadel])hia  Hospital. 

The  disease  often  occurs  in  epidemics,  a  large  number  of  persons  being 
infected  from  a  single  source.  Among  the  best  known  of  these  outbreaks 
are  the  Iledersleben,  in  which  there  wore  337  persons  affected,  and  th(! 
Emersleben,  in  which  there  were  250  persons  attacked.     The  extensive 


DISEASES  CAUSED  BY  NEMATODES. 


1029 


ontbroaks  of  this  sort  have  been,  with  few  excjeptions,  in  North  Germany. 
Alfred  Mann,  after  .i  careful  search,  at  my  request,  of  the  literature  in  the 
Surgeon-Generars  library,  finds  records  of  -t.-jO  ciises  in  this  country.  The 
two  largest  groups  of  cases  were  at  Astoria,  Ore.,  reported  by  Kinney,  15 
(!ases  and  one  death ;  and  at  St.  Paul,  Minn.,  reported  by  Persons  and 
Andrews,  15  cases  and  three  deaths. 

Symptoms. — The  ingestion  of  trichinous  tlesh  is  not  necessarily 
followed  by  the  disease.  When  a  limited  number  are  eaten  only  a  few  em- 
bryos pass  to  the  muscles  and  may  cause  no  symptoms.  AV ell-characterized 
cases  pi'esent  a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  meat  there  are 
signs  of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appe- 
tite, vomiting,  and  sometimes  diarrhoea.  The  preliminary  sym})toms,  how- 
ever, are  by  no  means  constant,  and  in  some  of  the  large  ei)iilemics  casos 
have  been  observed  in  which  they  have  been  absent.  In  other  cases  the 
gastro-intestinal  features  have  been  marked  from  the  outset,  and  the  attack 
has  resembled  cholera  nostras.  Pains  in  different  parts  of  the  body,  gen- 
eral debility,  and  weakness  have  been  noted  in  some  of  the  epidemics. 

The  invasion  r^ymptoms  develop  between  tlie  seventh  and  the  tenth  day, 
sometimes  not  until  the  cjul  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases  Cliills  are  not  common.  The  thermo  neter  may  register 
103°  or  104°,  and  the  fever  is  usually  remittent  or  intermiitent.  Tlie  mi- 
gration of  the  parasites  in  the  muscles  excites  a  more  or  less  intense  myo- 
sitis, which  is  characterized  by  pain  on  pressure  and  movement,  and  by 
swelling  and  tension  of  the  muscles.  The  limbs  are  placed  in  the  jiosi- 
tions  in  which  the  muscles  are  in  least  tension.  The  involvement  of  the 
muscles  of  mastication  and  of  the  larynx  may  cause  difficulty  in  chewing 
and  swallowing.  In  severe  cases  the  involvement  of  the  dia})hragm  and 
intercostal  muscles  may  lead  to  intense  dyspmca,  which  sometimes  proves 
fatal.  Oedema,  a  feature  of  great  importance,  may  be  early  in  the  face. 
Later  it  develops  in  the  extrer.iities  when  the  swelling  and  stiffness  of  the 
muscles  arc  at  their  height.  Profuse  sweats,  tingling  and  itching  of  the 
skin,  and  in  some  instances  urticaria,  have  been  described.  The  general 
nutrition  is  much  disturbed  and  the  patient  becomes  emaciated  and  often 
uniemic,  particularly  in  the  protracted  cases.  The  patellar  tendon  reflex 
may  be  absent.  The  patients  are  usually  conscious,  except  in  cases  of  very 
intense  infection,  in  which  the  delirium,  dry  tongue,  and  tremors  give  a 
j)icture  similar  to  typhoid  fever.  In  addition  to  the  dyspnam,  present  in 
the  severer  cases,  there  may  be  bronchitis,  and  in  the  fatal  cases  })neu- 
monia  or  pleurisy.  In  some  epidemics  polyuria  has  been  a  commor  symp- 
tom.    Albuminuria  is  frequent. 

The  intensity  aiul  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  established  for 
six  or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the 


n  •  \' 


:k:   :i 


1030 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


muscular  strength.  One  ciise  in  the  Iledersloben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  Ilederslebon  epidemic  the  greatest  mortality 
occurred  in  the  f(nirth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
died  in  the  second  week  with  severe  choleraic  symptoms. 

The  mortality  has  ranged  in  different  outbreaks  from  one  or  two  per 
cent  to  thirty  per  cent.  In  the  Iledersleben  epidemic  101  persons  died. 
Among  the  450  oases  reported  in  this  country  there  were  122  deaths. 

The  cma torn ical  cJi (1)1  f/es  are  chiefly  in  the  voluntary  muscles.  In  the 
early  stages  they  look  normal,  but  in  the  fourth  or  fifth  week  grayish- 
white  areas  appear  in  which  the  muscle  fibres  arc  extensively  degenerated 
and  in  the  neighborhood  of  the  trichina;  there  is  an  acute  interstitial 
myositis.  Cohnheim  has  described  a  fatty  degeneration  of  the  liver  and 
enlargement  of  the  mesetiteric  glands.  At  the  time  of  death  in  the 
fourth  or  fifth  week  or  later  the  adult  trichina3  are  still  found  in  the  in- 
testines. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  which 
has  been  eaten  and  the  number  of  trichina^  which  mature  in  the  intestines. 
In  children  the  outlook  is  more  favorable.  Early  diarrhanx  and  moderately 
intense  gastro-intestinal  symptoms  are,  as  a  rule,  more  favorable  than  con- 
stipation. 

Diagnosis. — This  is  perfectly  clear  when  a  large  number  of  persons 
are  infected  at  once  and  the  parasites  have  been  found  in  the  ham  or  sau- 
sages. The  worms  may  be  discovered  in  the  stools.  The  stools  should  be 
spread  on  a  glass  plate  or  black  background  and  examined  with  a  low- 
1)0 wer  lens,  Avhen  the  trichina;  are  seen  as.small,  glistening,  silvery  threads. 
In  doubtful  cases  the  diagnosis  may  be  made  by  the  removal  of  a  small 
fragment  of  muscle.  A  special  harpoon  has  been  devised  for  this  purpose 
by' means  of  which  a  small  portion  of  the  biceps  or  of  the  pectoral  muscle 
may  be  readily  removed.  Under  cocaine. anaesthesia  an  incision  may  be 
made  and  a  small  fragment  removed.  The  disease  may  be  mistaken  for 
acute  rheumatism,  particularly  as  the  pains  are  so  severe  on  movement, 
but  there  is  no  special  swelling  of  the  joints.  The  tenderness  is  in  the 
muscles  both  on  ])ressure  and  on  movement.  The  intensity  of  the  gastro- 
intestinal symptoms  in  some  cases  has  led  to  the  diagnosis  of  cholera. 
Many  of  the  former  epidemics  were  doubtless  described  as  ty])hoid  fevt/, 
which  the  severer  cases,  owing  to  the  prolonged  fever,  the  sweats,  the  de- 
lirium, dry  tongue,  and  gastro-intestinal  symptoms,  somewhat  resemble. 
The  pains  in  the  muscles,  swelling,  oedema,  and  shortness  of  breath  are  the 
most  important  diagnostic  points.  Under  acute  myositis  reference  has 
already  been  made  to  the  cases  which  closely  resemble  trichiniasis.  The 
epidemic  in  1879  on  board  the  training  ship  Cornwall  presented  symp- 
toms similar  to  those  of  trichiniasis.  One  patient  died.  Two  months  after 
burial  the  body  was  examined,  and  living  and  dead  nematode  worms  were 
found  which,  as  Bastiau  showed,  were  not  the  trichina,  but  a  rhabditis. 


DISEASES  CAUSED  BY   NEMATODES. 


1031 


persons 
1  or  sau- 
loulil  be 
1  a  low- 
» reads, 
a  small 
lurpose 
muscle 
may  be 
vcn  for 
)vemcnt, 
is  in  the 
gastro- 
cholera.. 
,d  levc.-, 
the  de- 
esemble. 
are  tbo 
ince  has 
The 
d  symp- 
ths  after 
•rns  were 
Ihabditis. 


1 


IS. 


Tliey  were  probably  not  parasitic,  but  entered  the  body  of  the  cadet  after 
burial. 

Prophylaxis. — It  is  not  definitely  known  how  swine  become  dis- 
eased. It  has  been  thought  tin  c  they  are  infected  from  ruts  about  slaugli- 
ter-houses,  but  it  is  just  as  reasonable  to  believe  that  the  rats  are  infected 
by  eating  portions  of  the  trichinous  flesii  of  swine.  The  swine  sliould,  as 
far  as  possible,  be  grain-fed,  and  not,  as  is  so  common,  allowed  to  eat  olfal. 
The  most  satisfactory  prophylaxis  is  the  complete  cooking  of  pork  and 
sausages,  and  to  this  custom  in  England,  France,  South  Germany,  and 
particularly  in  this  country,  immunity  is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty- 
six  hours  that  a  large  number  of  persons  have  eaten  infected  meat,  tlie 
indications  are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  Purga- 
tives of  rhubarb  and  senna  may  be  given,  or  an  occasional  dose  of  calomel, 
(jlycerin  has  been  recommeiuled  in  large  doses  in  order  that  by  passing 
into  the  intestines  it  may  by  its  hygroscopic  i)roperties  destroy  the  worm. 
Male-fern,  kamala,  santonin,  and  thymol  have  all  been  recommended  in 
this  stage.  There  is  no  doubt  that  diarrhcca  in  the  first  week  or  ten  days 
of  the  infection  is  distinctly  favorable.  The  indications  in  the  stage  of  in- 
vasion are  to  relieve  the  pains,  to  secure  sleep,  and  to  support  the  patient's 
strength.  There  are  no  medicines  which  have  any  iutlueuco  upon  the 
embryos  in  their  migration  through  the  muscles. 

III.  Anchylostomiasis. 

The  dochmius  or  strongyhis  duodenaUs,  "ho  known  as  the  sclerostomum 
or  anchylustomum  dtiodviude  is  the  only  strongyle  harmful  to  man.  It 
belongs  to  tlie  same  family  as  the  stroHf/ylus  armalus,  whicl:  causes  tlio 
verminous  aneurism  in  the  horse.  The  pai'asites  live  in  the  upper  por- 
tion of  tlie  small  intestine,  cliiolly  in  the  jejunum.  They  are  easily  seen, 
the  male  having  a  length  of  froai  six  to  ten  millimetres,  and  the  female 
from  ten  to  eighteen  millimetre--i.  'I'lie  mouth  is  provided  with  a  scries  of 
tooth-like  hooks,  by  mcaus  of  which  the  parasite  attaches  itself  to  tlio 
mucous  membrane.  The'  male  has  a  prominent  expiinsion  or  bursa  at  the 
tail  end.  Tlie  existence  of  the  parasite  has  long  been  known,  but  it  was 
not  thought  to  be  pathogenic  until  CI  riesinger  demonstrated  its  association 
with  the  Egyptian  chlorosis.  It  has  also  been  shown  to  be  the  cause  of 
tlie  anannia  to  which  miners  and  brick-makers  are  subject.  Throughout 
Euro])e  the  disease  has  been  widely  spread  by  the  employment  of  Italian 
and  Polish  laborers.  In  certain  Italian  provinces  it  is  extremely  preva- 
lent and  serious.  It  occurs  in  India  and  in  Brazil,  and  has  been  described 
in  Jamaica  (Straclian).  DoUey  states  that  the  parasite  was  described  many 
years  ago  by  i)hysicians  in  the  Southern  States,  but  no  recent  observations 
upon  the  disease  have  been  made  in  this  country. 

Symptoms. — 'The    parasites  withdraw   blood   by   suction,  and   tho 


[I 


1032 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


8yni]itoms  result  from  this  slow  depletion.  In  the  early  stage  there  may 
only  be  gastric  or  gastro-intestiiial  distiirhanoe,  but  if  tlie  parasites  are 
present  in  large  numbers  anaemia  is  gradually  produced  and  constitutes 
the  characteristic  feature  of  the  disease.  The  Egyj)tian  chlorosis,  brick- 
maker's  anaemia,  tuii.'i  ijiamiia,  miner's  cachexia,  and  mountain  aiui3mia 
are  due  to  this  cause,  i  ae  clinicjal  course  is  variable.  In  some  instances 
the  ana?mia  develops  acutely  and  reaches  a  high  grade  within  a  short  tinui, 
causing  great  shortness  of  breath  and  o'lh-nui.  There  is  serious  disturb- 
ance of  nutrition,  sometimes  diarrhu'a  and  colicky  pains ;  but  the  most 
j)ronounced  symptom  is  tlie  pallor  and  the  associated  phenomena  of 
chronic  amemia.  The  lesions  of  the  intestines  are  those  of  chronic 
catarrh,  and  small  haemorrhages  occur  in  the  mucosa.  Dilatation  and 
hypertrophy  of  the  heart  have  been  found  in  many  cases. 

The  diagnosis  is  not  difiicult.  The  ova,  which  are  a])undant  in  the 
stools,  are  oval,  about  '05  millimetre  in  length,  and  possess  a  thin, 
transparent  shell.  There  is  no  operculum,  as  in  the  ovum  of  the  oxyuris, 
and  the  yolk  is  unscgmented.  The  larvtis  develop  in  moist  earth  and 
readily  get  into  the  drinking  water,  through  which  infection  occurs. 

The  systematic  use  of  latrines  and  the  boiling  of  all  water  used  for 
di'inking  purposes  are  the  important  prophylactic  measures.  The  treat- 
ment should  be  directed  to  the  destruction  of  the  parasites  in  the  intes- 
tine, which  may  be  effected  by  the  nude  fern  or  by  thymol,  which  Sonsino 
recommends  highly.  It  is  given  in  capsules  of  half  a  drachm  every  hour 
for  four  doses.     A  purgative  is  not  necessary. 


IV.    FiLAIlI-ASIS. 

Under  this  term  may  bo  considered  the  morbid  conditions  Induced  by 
thofilaj'ia  sanguinis  hominis,  or  ihofilaria  Bancrofti,  the  name  employed 
to  designate  the  adult  worm,  which  was  discovered  by  Bancroft,  of  Bris- 
bane. In  the  adult  form  the  worm  lives  in  the  lymphatics.  The  female 
is  thus  described  by  Patrick  Manson,  whose  studies  on  this  parasite  have 
been  so  important :  "  A  long,  slender,  hair-like  animal  quite  three  inches 
in  length  but  only  one  one  hundredth  inch  in  breadth,  of  an  opaline  ap- 
pearance, looking,  as  it  lies  in  the  tissues,  like  a  delicate  thread  of  catgut 
animated  and  wriggling.  A  narrow  alimentary  canal  runs  from  the  sim- 
ple club-like  head  to  within  a  short  distance  of  the  tail,  the  remainder  of 
the  body  being  almost  entirely  occupied  by  the  reproductive  organs.  The 
vagina  opens  about  one  twenty-fifth  of  an  inch  from  the  head ;  it  is  very 
short,  and  bifurcates  into  two  uterine  horns,  which,  stuffed  with  embryos 
in  all  stages  of  development,  run  backward  nearly  to  the  tail."  The  male 
worm  is  much  smaller  and  has  only  occasionally  been  found.  The  female 
produces  an  extraordinary  number  of  embryos,  which  enter  the  blood 
current  through  the  lymphatics.  Each  embryo  is  within  its  shell,  which 
is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the  movements. 


DISEASES  CAUSED  BY  NEMATODES. 


1033 


0  may 
es  avo 
titutc3 
briek- 
mvniia 
dances 
t  time, 
isturb- 
e  most 
icna  of 
ehroiiio 
on  and 

t  in  the 
a  tliin, 
oxynvis, 
rth   and 

rs. 

nscd  for 
'lie  treat- 
;be  intes- 

1  Sonsino 


iduced  by 
employed 
1,  of  Bi-is- 
|ie  feinale 
site  liave 
•eo  inclics 
.inline  ap- 
of  catgut 
[i  the  sim- 
lainder  of 
ins.     The 
it  is  very 
embryos 
The  male 
'he  female 
|the  blood 
ell,  which 
lovcments. 


They  are  about  the  ninetieth  part  of  an  inch  in  length  and  the  diameter 
of  a  red  blood-corpuscle  in  thickness,  so  that  tliey  readily  pass  through  the 
capillaries.  They  move  with  the  greatest  activity  and  form  very  striking 
and  real' ily  recognized  objects  in  a  blood-drop  under  the  micro-scope.  A 
remarkal)le  feature  is  the  periodicity  in  the  occurrence  of  the  emhryos  in 
the  blood.  In  the  daytime  they  are  almost  or  entirely  alwent,  whereas  at 
night,  in  typical  cases,  they  are  present  in  large  numbers.  If,  however, 
as  Stephen  Mackenzie  has  shown,  the  patient,  reversing  his  hal)its,  slee})s 
during  the  day,  the  periodicity  is  reversed.  The  further  development  of 
the  embryos  appears  to  be  associated  with  the  mos(|uito,  wliii-h  at  night 
sucks  the  blood  and  in  this  way  frees  them  from  tlie  body.  Some  slight 
development  takes  place  within  the  body  of  the  moGcputo,  and  it  is  prob- 
able that  the  embryos  are  set  free  in  the  water  after  the  death  of  the  host. 
The  further  development  is  not  known,  but  it  is  prol)ably  in  drinking 
water.  The  filari;i3  inay  be  present  in  the  body  without  causing  any  symp- 
toms. In  animals  blood  fllarife  are  very  common  aiul  rarely  cause  incon- 
venieiice.  It  is  oidy  Avhen  the  adult  worms  or  the  ova  l)lock  the  lymph  chan- 
nels that  certain  definite  sympton\s  occur.  ]\Ianson  .suggests  that  it  is  the 
ova  (prematurely  discharged),  which  are  considerably  shorter  and  thicker 
than  the  full-grown  embryos,  which  block  the  lym})h  cliannels  and  pro- 
duce the  conditions  of  htematochyluria,  elephantiasis,  and  lymph-scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  aiul  sub- 
tropical countries,  (luiteras  has  shown  that  tlic  disease  prevails  exten- 
sively in  the  Southern  States,  and  since  his  paper  a])peared  ef>ntributions 
have  been  made  by  ^latas,  of  Xew  Orleans,  Mastiu,  of  Mobile,  and  De 
Saussure,  of  Charleston. 

The  effects  produced  may  be  described  under  the  above-mentioned 
conditions. 

(a)  Hcematochyluria. — Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time  to 
time  passes  urine  of  an  opaque  white,  milky  appearance,  or  bloody,  or  a 
chylous  iluid  which  on  settling  shows  a  slightly  reddish  clot.  The  urine 
may  be  normal  in  rpuintity  or  increased.  The  condition  is  usually  inter- 
mittent, and  the  patient  may  pass  normal  urine  for  weeks  or  montlis  at  a 
time.  Microscopically,  the  chylous  urine  contains  minute  molecular  fat 
granules,  usually  red  blood-corpuscles  in  various  amounts.  It  was  in 
urine  of  this  kind  that  Wucherer,  of  Bahia,  first  detecited  the  filarian  em- 
bryos. It  is  remarkable  for  how  long  the  condition  may  persist  without 
serious  impairment  of  the  health.  A  patient,  sent  to  me  by  Dawson,  of 
Charleston,  has  had  hajmatochyluria  intermittently  for  eighteen  years. 
The  only  inconvenience  has  been  in  the  passage  of  the  blood-clots  which 
collect  in  the  bladder.  At  times  he  has  also  uneasy  sensations  in  the  lum- 
bar region.  The  embryos  are  present  in  his  blood  at  night  in  large  num- 
bers. Chyluria  is  not  always  due  to  the  filaria.  The  nonrparasitic  form 
of  the  disease  has  already  been  considered. 


I 


1034 


DISEASES  DUE  TO  ANIMAL  PARASITES, 


Opportunities  for  studying?  tlio  anatomiciil  condition  of  those  ca^os 
rarely  occur.  In  the  case  doscril)ed  by  Stoplu'n  ]\Iackenzie  the  renal  and 
peritoneal  lymph  j)lexuses  wen;  enormously  eidarged,  extending  from  the 
diaphragm  to  tho  pelvis.  The  thoracic  duct  above  the  diaphragm  was 
impervious. 

{/))  Li/inpli-scrotum  and  certain  forms  of  elephdntiasin  are  sometimes 
caused  by  the  filaria.  In  the  former  the  tissues  of  the  scrotum  are  eiu)r- 
mously  thickened  and  the  disteiuled  lymph-vessels  may  bo  plainly  seen. 
A  clear,  sometimes  a  turbid,  fluid  follows  puncture  of  tho  skin.  The 
parasites  are  not  always  to  bo  found.  I  have  examined  two  typical  cases 
Avithout  fliuling  lilaria  in  the  exuded  fluids  or  in  the  blood  |it  night.  So 
also  the  majority  of  cases  of  elephantiasis  which  occur  in  this  country  are 
non-parasitic.  In  China  it  is  stated  that  the  parasites  occur  in  all  these 
cases.* 

V.   Dracontiasis  {Guinea-worm  Disease). 

The  Filaria  or  Draciincuhis  mcdincnsis  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  East  Indies.  In  the  United  States  cases  occasion- 
ally occur.  Jarvis  reports  a  case  in  a  post  chaplain  who  had  lived  at  Fort- 
ress Monroe,  Va.,  for  thirty  years.  Van  Ilarlingen's  patient,  a  num  aged 
forty-seven,  had  never  lived  out  of  Philadelphia,  so  that  the  worm  must 
be  included  among  the  parasites  of  this  country.  A  majority  of  the  cases 
reported  in  American  journals  have  been  imported. 

Only  the  female  is  known.  It  develops  in  the  subcntancous  and  inter- 
muscular connective  tissues  and  produces  vesicles  and  abscesses.  In  the 
large  majority  of  the  cases  the  parasite  is  found  in  the  leg.  Of  181  cases, 
in  l^'l  the  worm  was  found  in  the  feet,  33  times  in  the  leg,  and  11  tinu>s  in 
the  thigh.  The  worm  is  usually  solitary,  though  there  are  cases  on  record 
in  which  six  or  more  have  been  present.  It  is  cylindrical  in  form,  about 
two  millimetres  in  diameter,  and  from  fifty  to  eighty  contimeti'os  in  length. 

The  worm  gains  entrance  to  the  system  through  the  stomach,  not 
through  the  skin,  as  was  formerly  supposed.  It  is  probable  that  both 
male  aiul  female  are  ingested ;  but  the  former  dies  and  is  discharged, 
while  the  latter  after  impregnation  penetrates  the  intestine  and  attains  its 
full  development  in  the  subcutaneous  tissues,  whore  it  may  remain  quies- 
cent for  a  long  time  and  can  be  felt  beneath  the  skin  like  a  bundle  of 
string.  Suppuration  is  after  a  time  excited,  and  when  tho  abscesses  are 
opened  or  burst  the  worm  appears  and  is  sometimes  discharged  entire.  The 
worm  contains  an  enormous  number  of  living  embryos,  which  escape  into 
the  water  and  develop  in  the  cyclops — a  small  crustacean — and  it  seems 
likely  that  man  is  infected  by  drinking  the  water  containing  these  devel- 
oped larvae. 

*  For  full  consiilerntioii  of  tlie  subject  of  conijciutiil  occlusion  and  dilatation  of 
lymph  channels,  see  work  on  tiiis  subject  by  Samuel  C.  Buscy,  New  York,  1878. 


DISEASES  CAUSED  BY  NEMATODES. 


1035 


The  frmtmont  consists  in  promoting  tlio  suppunition,  and  when  the 
worm  is  scon  the  common  procwluro  is  to  roll  it  round  u  portion  of  smooth 
wood,  and  in  this  way  prevent  tlie  retra(?tion,  and  each  day  wind  a  little 
moro  until  the  entire  worm  is  wiliulrawn.  It  is  stated  that  special  care 
must  he  taken  to  prevent  tearing  of  the  worm,  as  disastrous  consecpiencos 
sometimes  follow,  probably  froiu  the  irritation  caused  by  the  migration 
of  the  embryos.  It  is  stated  that  the  leaves  of  the  plant  called  amarptiltre 
are  almost  a  specific  in  the  disease.  Asafo'tida  in  full  doses  is  said  to  kill 
the  worm.  . 

VI.  Other  Nematodes. 

{a)  Among  less  important  filarian  worms  parasitic  in  man  the  follow- 
ing may  be  mentioned :  filario,  loa,  wlii(;h  is  a  cylindrical  worm  of  about 
three  centimetres  in  length  and  whose  habitat  is  beneath  the  conjunctiva. 
It  has  been  found  on  the  West  African  coast,  in  Brazil,  and  in  *'ie  West 
Indies.  Filaria  Iciitis,  which  has  been  found  in  a  cataract.  Three  speci- 
mens have  been  fouiul  together.  Filaria  Inbinlis,  which  has  been  found 
in  a  pustule  in  the  npper  lip  Filaria  Iioininis  oris,  which  was  described 
by  Leidy,  from  the  mouth  of  a  ('liild.  Filaria  hronchialis,  which  has  been 
found  occasionally  in  the  trachea  and  bronchi.  This  jiarasite  has  been 
seen  in  a  few  cases  in  the  bronchioles  and  in  the  lungs.  There  is  no  evi- 
dence that  it  ever  produces  an  extensive  verminous  bronchitis  similar  to 
that  which  I  have  described  in  dogs.  Filaria  imilis,  of  which  Bowlby 
has  described  two  cases.  liv  one  case  with  haematnria  female  worms  Avere 
found  in  the  portal  vein,  ami  the  ova  were  present  in  the  thickened 
bladder  wall  and  in  the  ureters. 

(b)  Trichoccphalus  Dixpar  {Whip-worm). — This  parasite  is  not  infre- 
quently found  in  the  civcum  and  large  intestine  of  man.  It  measures  from 
four  to  five  centimetres  in  length,  the  male  being  somewhat  shorter  than 
the  female  The  worm  is  readily  recognized  by  the  remarkable  ditrerence 
between  the  anterior  and  posterior  portions.  The  former,  which  is  at  least 
three  fifths  of  the  body,  is  extremely  thin  and  hair-like  in  contrast  to  the 
thick  hinder  portion  of  the  body,  which  in  the  female  is  conical  and 
pointed,  and  in  the  male  more  obtuse  and  nsually  rolled  like  a  spring. 
The  ova  are,  oval,  lemon-shaped,  -0.5  millimetre  in  length,  and  each  is 
provided  with  a  button-like  projection. 

The  number  of  the  worms  found  is  variable,  as  many  as  a  thousand 
having  been  counted.  It  is  a  widely  spread  jiarasite.  In  parts  of  Europe 
it  occurs  in  from  ton  to  thirty  per  cent  of  all  bodies  examined,  but  in  this 
country  it  is  not  so  common.  The  trichocephalns  rarely  causes  symptoms. 
It  lias  been  thought  by  certain  physicians  in  the  East  to  ha  the  cause  of 
beri-beri  Several  cases  have  been  reported  recently  in  which  profound 
anaemia  has  occurred  in  connection  with  this  parasite,  usually  with  diar- 
rhoea. Enormous  numbers  may  occur,  as  in  Iludolphi's  case,  without  pro- 
ducing any  symptoms. 


III 


1030 


DISEASES  T)UK  TO  ANIMAL   I'AUASITES. 


The  (liiignosis  is  readily  inudo  by  tlie  cxaniiniition  of  tlic  fa>ccs,  which 
coiitiiiii,  .s(Hiictiriio,s  in  great  abuiulance,  the  characteristic  himon-slmpod, 
hard,  dark-))ro\vii  ('f?f,'s. 

(r)  A'ltxtroiiiji/lKs  (liyas. — 'i'hi.s  eiioniioiis  iioinatodo,  tiie  mali'  of  which 
measures  about  a  foot  in  k'tigtli  and  tlic  female  about  tliree  feet,  «)ccurH  in 
very  many  animals  and  has  occasionally  been  met  witli  in  man.  It  ia 
usually  found  in  the  renal  rejrion  and  niav  entirely  destroy  the  kidney. 

{(I)  JiliabdoiiCDUi  Iith'stiiKtle. — Under  this  name  are  now  inchukul  the 
small  nematode  worms  found  in  the  fa-ccs  and  formerly  described  as  an- 
giiillula  stercoraUs  and  angnilluhi  inlestinalis.  This  parasite  occurs 
abundantly  in  the  stools  of  the  endemic  diarrha'a  of  hot  countries,  and  has 
been  si)ecially  described  by  the  French  in  the  diarrluea  of  Cochin-China. 
It  occurs  also  in  Brazil,  and  has  been  found  in  Italy  in  connection  with 
the  anchylostoma  in  cases  of  miner's  anscmia.  It  is  stated  that  the  worms 
occupy  all  parts  of  the  intestines,  and  have  even  been  found  in  the  biliary 
and  pancreatic  ducts.  It  is  only  when  they  are  in  very  large  numbers 
that  they  2'roduce  severe  diarrluea  and  ananuia. 

Acanthocephala  {Thorn-hvadcd  W'oniis). — The  echuiorJif/ncJius  (jigas  is 
a  common  parasite  in  the  intestine  of  the  hog  and  attains  a  largo  size. 
The  larvae  develo}!  in  cockchafer  grubs.  Lambl  found  a  small  echino- 
rhynclius  in  the  intestine  of  a  boy.  Welch's  specimen,  which  Avas  fouiul 
encysted  in  the  intestine  of  a  soldier  at  Netley,  is  stated  by  Cobbold  prob- 
ably not  to  have  been  an  ecliinorhgnclms.  Itecently  a  case  of  echinorhyn- 
chus  moniliformis  has  been  described  in  Italy  by  (Jrassi  and  Calandruccio. 


IV.   DISEASES   CAUSED   BY   CESTODES 

{Tape-tvonns ;  Hydatid  Disease). 

Man  harbors  the  adult  parasites  iu  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 


T.  IxTESTiXAL  Cestodes;  Tape-worm.s. 

(a)  Tmnia  solium,  or  pork  tape-worm.  This  is  not  a  common  form  in 
this  country.  It  is  much  more  frequent  in  parts  of  Europe  and  Asia. 
When  mature  it  is  from  six  to  twelve  feet  in  length.  The  head  is  small, 
round,  not  so  large  as  the  head  of  a  pin,  and  provided  with  four  sucking 
disks  and  a  double  row  of  booklets ;  hence  it  is  called,  in  contradistinction 
to  the  other  form  in  man,  the  armed  tape-worm.  To  the  head  succeeds  a 
narrow,  thread-like  neck,  then  the  segments,  or  proglottides,  as  they  are 
called.  The  segments  possess  both  male  and  female  generative  organs, 
and  about  the  four  hundred  and  fiftieth  become  mature  and  contain  ripo 
ova.  The  worm  attains  its  full  growth  in  from  three  to  three  and  a  half 
months,  after  which  time  the  segments  are  continuously  shed  and  appear 


niSKASES  f;AUS?]D   BY  CESTODKS. 


1037 


forms 


form  in 
Asia, 
small, 
lucking 
linction 
Iceeds  a 
biey  are 
I  organs, 
fiin  ripe 
a  half 
appear 


ill  tho  stools.  T\w  sc^fiiK'iils  aro  about  ono  ccntiiuctro  in  Kmi<?11i  and  from 
Ki'VtMi  to  eight  milliiuoircs  in  broadth.  I'ressud  botweini  gla.ss  platos  tlio 
ovarian  rosotto  ia  seen  as  a  (.'cutral  stem  with  about  twolvo  or  fifti-on  latiTul 
branclu's.  Tlicro  are  man y  thousands  of  ova  in  oacli  ripo  segment,  and 
cacih  ovum  consists  of  a  linn  siicll,  inside  of  which  is  a  little  cinl)ryo,  pro- 
vided witJi  six  h(jol\lets.  Tlie  segments  are  eonlinuoiisly  passed,  and  if 
the  ova  are  to  attain  further  deveh)pment  they  must  l)e  taken  into  tlio 
stomacli,  either  of  a  ])ig,  or  of  imin  inmself  The  egg-stiells  are  digested, 
the  six-hooked  end)ryos  become  free,  and  jiassing  from  the  stonuu'li  readi 
various  parts  of  tlie  body  (the  liver,  muscles,  brain,  or  eye),  where  they 
develop  into  the  larva;  or  cysticerci.  A  hog  under  these  circumstances  is 
said  to  bo  measlcd,  and  tho  cysticerci  are  spoken  of  as  measles  or  blad- 
der worms. 

Tho  f(vni(i  solium  received  its  name  because  it  was  thought  to  exist  as  a 
solitary  parasite  in  the  bowel,  but  two  or  three,  or  even  more  worms  may 
occur. 

(b)  T'.enia  m()inat(t  or  mcdiocancllata — tho  unarmed  or  beef  tape-worm. 
This  is  a  longer  ami  larger  parasite  than  the  Icpnia  .so/iinn.  It  is  certainly 
the  common  tape-worm  of  this  country.  Of  scores  of  .specimens  which  I 
liave  examined,  almost  all  were  of  this  variety.  According  to  IJerenger- 
Feraud  it  has  spread  rapidly  in  western  Europe,  owing  ])robal)Iy  to  tho 
importation  of  beef  and  live  stock  from  the  Mediterranean  basin.  It  nuiy 
attain  a  length  of  fifteen  or  twenty  feet,  or  more.  The  head  is  large  in 
comparison  to  the  tcPHia  koUudi,  and  measures  over  two  millimetres  in 
breadth.  It  is  square-shaped  and  provided  with  four  large  sucking  disks, 
but  there  are  no  booklets.  Tho  ripe  segments  are  from  seventeen  to 
eighteen  millimetres  in  Icngtli,  and  from  eight  to  ten  millimetres  in 
breadth.  The  ovarian  rosette  consists  of  a  central  stem  with  from  seven- 
teen to  eighteen  lateral  brandies,  which  are  given  off  more  dichotomously 
than  in  the  tcenia  solium.  Tho  ova  are  somewhat  larger,  and  the  shell  is 
tliicker,  but  the  two  forms  can  scai'cely  be  distinguished  by  their  ova. 
The  ripe  segments  aro  passed  as  in  tho  ta?nia  solium,  and  aro  ingested  by 
cattle,  in  the  flesh  or  organs  of  which  the  oggs  develop  into  tho  bladder 
worms  or  cysticerci.  Whether  they  develop  in  man  or  not  is  uncertain. 
No  instance  of  the  cysticercus  of  the  tdinia  saginata  has,  so  far  as  I  know, 
been  reported  in  man. 

Of  other  forms  of  tape-worm  may  be  mentioned  : 

(c)  Tcenia  eUiptica  {twnia  cneumerina).  A  small  parasite  very  com- 
mon in  the  dog  and  occasionally  found  in  man,  and  the  larva)  of  which  de- 
velop in  the  louse  of  the  dog. 

{d)  Taniia  flavo-pundata.  A  small  cestode  was  found  in  the  intes- 
tine of  a  child  in  Boston,  and  has  since  been  met  with  in  one  or  two 
cases. 

(e)  Tmnia  nana  and  the  tatnia  Madagascar iensis  have  been  found  only 
once  or  twice. 


^    J 


ill 


w 


1038 


DISKASES  DUK  TO  ANIMAI.  PARASlTKS. 


if 


a 


(/)  /iof/iri<irrp/ifthtK  hifits.  A  coHtodo  worm  fdiiiid  only  in  (vrlain 
(listrictH  bonloriiijf  on  the  Hiiltic  Sou  and  in  parts  of  Swit/A'riand.  So  fur 
us  I  Jviiow  it  has  jiot  bocii  found  in  this  country  I'Xccpt  in  a  fi-w  imported 
cases.  The  j)arasite  is  liir;,'e  and  h)n;,',  nieasiiriiij?  from  twenty-live  to 
thirty  feet  or  more.  Its  head  is  ditTerenl  from  Miut  of  the  ta'iiia,  as  it 
jK)ssessea  two  hitoral  ffrooves  or  j)its  and  has  no  liooklets.  The  hirviB 
develop  in  the  peritona'uni  and  nuisch'S  of  the  pike  and  otlier  fish,  and  it 
has  heen  sliown  experimentally  that  tiiey  ^'row  into  tiie  adult  W(»rm  when 
eaten  by  num. 

Symptoms. — These  parasites  are  found  at  all  ages.  They  are  not 
uncommon  in  children  and  are  oceasioiiully  fouiul  in  sm-klings.  W.  T. 
Plant  refers  to  a  niimlu  r  of  cases  in  children  under  two  years,  and  there  is 
u  case  in  the  literature  in  which  it  is  stated  that  the  tape-worm  was  found 
in  an  infant  live  days  old. 

The  parusitea  may  cause  no  disturbance  and  are  rarely  dangerous.  A 
knowledge  of  the  existence  of  the  worm  is  generally  a  source  of  worry  and 
anxiety;  the  patient  nuiy  have  considerable  distress  and  complain  of  ab- 
dominal pains,  nausea,  and  sometimes  diarrluea.  Occasionally,  the  appetite 
is  ravenous.  In  women  and  in  lu'rvous  jjaticnts  the  constitutiomd  tlis- 
turbance  may  be  considerable,  and  Ave  not  infrcfpiently  see  great  mental 
depression  and  even  hy|)ochondria.  Various  nervous  phenomena,  such  as 
chorea,  convulsions,  or  epilepsy,  are  believed  to  be  caused  by  the  i)arasites. 
Such  effects,  however,  are  very  rare. 

The  di'(i(/nosis  is  never  doubtful.  The  presence  of  the  segments  is  dis- 
tinctive. The  ova,  too,  may  be  recognized  in  the  stools.  It  makes  but 
little  difference  as  to  the  form  of  tape-worm,  but  the  ri[)e  segments  of  the 
tmnia  saginata  are  larger  and  broader,  and  show  differemes  in  the  gen- 
erative system  as  already  mentioned. 

The  jii'op/ii/la.ris  is  most  important.  Careful  attention  should  be  given 
to  two  points.  First,  all  tape-worm  segmcaits  should  be  burned,  'they 
should  never  be  thrown  into  the  water-closet  or  outside.  And  second,  the 
meat  should  be  cooked  throughout,  in  Avliich  way  alone  larva'  are  destroyed. 
Possibly  it  is  owing  to  the  fact  that  in  this  country  pork  is,  as  a  rule,  better 
cooked  than  beef  that  the  twnin  saf/i/uifa  is  the  most  common  form.  Cer- 
tainly in  the  market  aiul  at  the  abattoirs  one  more  commonly  sees  measly 
pork  than  measly  veal.  In  t,ie  examination  of  a  thousand  hogs  in  Mont- 
real there  Avcre  seventy-six  instances  of  cysticerci.  The  measle  is  more 
rca<lily  overlooked,  in  beef  than  in  pork,  as  in  the  former  it  has  not  such 
an  oi)aque  Avhite  color. 

Treatment. — For  two  days  prior  to  the  administration  of  the  reme- 
dies tbj  patient  should  cake  a  very  light  diet  and  have  the  bowels  moved 
occasionally  by  a  saline  cathartic.  The  practitioner  iias  the  choice  of  a 
large  number  of  drugs.  As  a  rule,  the  male  fern  acts  promptly  and.  well. 
The  ethereal  extract,  in  two-drachm  doses,  may  be  given  fasting,  and.  fol- 
lowed in  the  course  of  a  couple  of  hours  by  a  brisk  purgative.     This  usu- 


DISKASES  CAUSED  HY  CKSTODES. 


1039 


IS  clis- 
:os  but 

of  the 
10  geu- 


.1,  the 
stvoycii. 

,  better 
11.    C:er- 

measly 

ilont- 
|is  more 

lot  such 

L  rcme- 
L  moved 
lice  of  IV 
Ind  well, 
liind  f  ol- 
Ihis  usu- 


ally snccocdrt  in  l)rin;,'in}i;  iiwiiy  a  large  portion,  but  not  always  the  entire 
worm. 

A  coinbiiiiition  of  the  remedies  is  srvtii'tinica  V(>ry  elTcctivc.  .\m  in- 
fusi(»n  is  madt of  poincj^Tuiiatc  root,  hall"  an  oiiiici' ;  iiumpivin  sceils,  oiio 
ounce  ;  powdered  ergot,  a  drachm  ;  and  hoiiing  water,  ten  ounces.  '!'(» 
an  emulsion  of  the  undo  fern  (u  drachm  of  ethereal  extract),  made  with 
acacia  powder,  two  miidnis  of  croton  oil  arc  added.  The  patient  shoidd 
have  had  a  low  diet  the  previous  day  and  have  taken  a  dose  of  salts  in  the 
evening.  The  emulsion  and  infusion  are  nu.xed  and  taUen  fasting  at  nine 
in  the  morning. 

T\w  ponu'granate  root  is  a  very  eflicient  remedy,  and  may  he  given  as 
an  infusion  of  tlu;  hark,  three  ounces  of  which  may  he  niiieerated  in  ten 
ounces  of  water  and  then  reduceil  to  (»ne  lialf  by  evaiioration.  The  eidiro 
quantity  is  then  taken  in  divided  doses.  It  occasiomdly  produces  colic,  but 
is  a  very  etTective  remedy.  The  active  i>rineij)le  of  the  root,  pelletierine,  is 
now  much  employed.  It  is  given  in  doses  of  one  fourth  to  one  half  of  a 
grain,  and  is  followed  in  an  lunir  by  a  purge. 

Pumpkin  seeds  are  son'ctimes  very  ellicient.  Three  or  four  ounces 
should  be  carefully  bruised  and  then  macerated  for  twelve  or  fourteen 
hours  and  the  entire  qunutity  taken  and  followed  in  an  hour  by  a  purge. 
Of  other  remedies,  koosso,  turpentine  in  ounce  doses  in  honey,  and  kaniala 
may  be  mentioned. 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  instances  are  ex- 
traordinarily obstinate.  l)oubtless  it  depends  a  good  deal  u[)on  the  ex- 
posure of  the  worm.  Tho  head  and  neck  may  be  thoroughly  i^rotected 
beneath  the  valvuliu  conniventes,  in  which  case  the  remedies  may  not  act. 
Owing  to  its  armature  the  twnia  solium  is  more  difficult  to  expel.  It  is 
probable  that  no  degree  of  peristalsis  could  dislodge  the  head,  and  unless 
the  worm  is  killed  it  docs  not  let  go  its  extraordinarily  lirm  hold  on  the 
mucous  membrane. 

II.  Visceral  Cestodes. 

"Whereas  adult  ta^ni.T  cause  little  or  no  disturbance  and  rarely,  if  over, 
prove  directly  fatal,  thf-  affections  caused  by  the  larvtc  or  imnuituro 
forms  in  the  solid  organs  arc  si:ious  and  important.  There  are  two  chief 
cestodc  larva)  known  to  frequent  i.aan — [it)  the  cyslircrcuH  cdlnlosw,  the 
larva  of  the  tmnia  soUum,  and  (b)  the  echinococcus,  the  larva  of  the  twnia 
echinococcus. 

I.  Cysticercus  Cellulosas. —  When  man  accidentally  takes  into  his 
stomach  the  ri})e  ova  of  ioiuia  soli  it  in  he  is  liable  to  become  the  interme- 
diate host,  apart  usually  played  for  this  tape-worm  by  the  pig.  This  acci- 
dent may  occur  in  an  individual  the  subject  of  td^nin  solium,  in  which 
case  the  mature  proglottides  either  themselves  wander  into  the  stomach 
or,  what  is  more  likely,  are  forced  into  the  organ  in  attacks  of  prolonged 


lOiO 


DISEASES  DUE  TO   ANIMAL  PARASITES. 


:i. 


It 


vomiting.  Of  course  the  accidental  ingestion  from  the  outside  of  a  few 
ovu  is  quite  possible,  and  the  liiil)ility  of  infection  should  always  be  borne 
in  mind  in  handling  the  segments  of  the  worm. 

The  symptoms  dejiend  entirely  ui)on  the  number  of  ova  ingested  and 
the  localities  reached.  In  the  hog  the  cysticerci  i)roduce  very  little  dis- 
turbance. The  muscles,  the  connective  tissue,  and  the  brain  may  be 
swarming  with  tlie  measles,  as  thev  are  called,  and  vet  the  nutrition  is 
maintained  and  the  animal  does  not  ai)pear  to  be  seriously  incommoded.  Jn 
the  invasion  period,  if  large  numbers  of  the  parasites  are  taken,  there  is, 
in  all  ])robability,  constitutional  disturbance  ;  certainly  tliere  is  in  the 
calf,  when  fed  with  the  ripe  segments  of  fa-nia  mfjinata. 

In  man  a  few  cysticerci  lodged  beneath  the  skin  or  in  tlie  muscles  may 
cause  no  damage,  and  in  time  the  larva?  die  and  become  calcified.  They 
are  occasionally  found  in  dissection  subjects  or  in  post-mortems  as  ovoid 
white  bodies  in  the  muscles  or  subcutaneous  tissue.  In  this  country  they 
are  very  rare.  I  have  seen  but  one  instance  in  my  post-mortem  experi- 
ence. Depending  on  the  number  and  the  locality  specially  affected,  the 
symptoms  may  be  grouped  into  general,  cerebro-spinal,  and  ocular. 

(1)  General — Asa  rule  the  invasion  of  the  larvfB  in  man,  uidess  in 
very  large  numbers,  does  not  cause  very  definite  sym])t()ms.  It  occa- 
sionally happ(?ns,  however,  that  a  striking  picture^  is  pi'oduced.  For  in- 
stance, ii  patient  was  admitted  to  my  wards  very  stilf  and  helpless,  so 
much  so  that  he  had  to  be  assisted  up-stairs  and  into  bed.  lie  com- 
plained of  numbness  and  tingling  in  the  extremities  and  general  weakness, 
so  that  at  first  ho  was  thought  to  have  a  pei'ipheral  neuritis.  At  the  ex- 
amination, however,  a  number  of  painful  subcutaneous  nodules  were  dis- 
covered, which  proved  on  excision  to  be  the  cysticerci.  Altogether  seventy- 
five  could  be  felt  subcutaneous^y,  and  from  the  soreness  and  stiffness  they 
probably  existed  in  large  numl)ers  in  the  muscles.  There  were  none  in 
his  eyes,  and  he  had  no  symptoms  pointing  to  brain  lesions. 

(2)  Cerebrospinal. — Remarkable  symptoms  may  result  from  the  pres- 
ence of  the  cysticerci  in  the  brain  and  cord.  In  the  silent  region  they 
may  be  abundant  without  ])roducing  any  symptoms.  I  have  in  my  pos- 
session the  brain  of  a  pig  containing  scores  of  "  measles,"  yet  the  animal 
in  the  few  moments  in  which  I  saw  it  just  prior  to  death  did  not  pre- 
sent any  symptoms  to  attract  attention.  In  the  ventricles  of  the  brain  the 
cysticerci  may  attain  a  considerable  size,  owing  to  the  fact  that  in  regions 
in  which  they  are  unrestrained  in  their  growth  the  bladder-like  body 
grows  freely,  as  in  the  peritouivum.  When  in  the  fourth  ventricle  re- 
markahle  irritative  symptoms  may  be  produced.  In  1S84  I  sj'v,  vith 
Friedlilndcr  in  Berlin  a  case  from  Riess's  wards  in  which  during  life  thore 
had  been  symptoms  of  diabetes  and  anomalous  nervous  symptoms.  Post 
mortem,  the  cystieercus  was  found  beneath  the  valve  of  Vieussens,  pressing 
upon  the  floor  of  the  left  ventricle. 

(.'})   Ocular. — Since  von  (Jraefe  demonstrated  the  presence  of  the  cysti- 


DISEASES  CAUSED  BY  CESTODES. 


104:1 


regions 
ke  body 
ride  re- 
vith 
ife  thore 
Post 
pressing 

he  cysti- 


cercus  in  the  vitreous  humor  many  cases  have  been  placed  on  record,  and 
it  is  a  condition  easily  recognized  by  oculists. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  Avhcn  the  cysti- 
cerci  are  subcutaneous,  one  may  be  excised.  It  is  possible  that  when 
numerous  throughout  the  muscles  they  may  be  seen  under  the  tongue,  in 
which  situation  they  may  exist  in  the  i)ig  in  numbers. 

II.  Echinococcus  Disease. — The  hydatid  worms  or  echinococci  arc  the 
larva)  of  the  kenia  echinocuccus  of  the  dog.  This  is  a  tiny  costode  not 
more  than  four  or  five  millimetres  in  length,  consisting  of  only  throe  or 
four  segments,  of  which  the  terminal  one  alone  is  nuiture,  and  hii.s  a  length 
of  about  two  millimetres  and  a  breadth  of  0-0  millimetre.  The  head  is 
small  and  provided  with  four  sucking  disks  and  a  rostellum  witli  a  double 
row  of  booklets.  This  is  an  exceedingly  rare  parasite  in  the  dog.  ('ob- 
bold  states  that  he  has  never  met  Avith  a  natural  specimen  in  England. 
Leidy  had  not  one  in  his  large  collection.  I  have  not  met  with  an  in- 
stance in  this  country,  nor  do  I  know  of  its  ever  having  been  described. 
The  only  specimens  in  my  cabinet  I  [)rocured  experimentjilly  by  feeding  a 
dog  with  echinococcus  cysts  from  an  ox.  The  worms  ai'c  so  snuill  that 
they  may  be  readily  overlooked,  siiu^o  they  form  small  wliite,  tlircad-like 
bodies  closely  adherent  among  the  villi  of  the  small  intestines.  Tiic  ripo 
segment  contains  about  5,000  eggs,  Avhich  attain  their  development  in  the 
solid  organs  of  various  animals,  particularly  the  hog  and  ox  ;  mow.  rarely 
the  horse  and  the  sheep.  In  some  countries  man  is  a  common  intermedi- 
ate Iiost,  owing  to  the  accidental  ingestion  of  the  ova. 

Dcvehipment. — The  little  six-hooked  embryo,  freed  from  the  egg-shell 
by  digestion,  cither  burrows  through  the  intestinal  wall  and  rcixches  the 
peritoneal  cavity  or  the  muscles;  more  commonly  it  enters  the  portal  ves- 
sels and  is  carried  to  tLa  liver.  It  may  enter  the  systemic  vessels,  and, 
passing  the  pulmonary  capillaries,  as  it  is  protoplasmic  and  elastic,  may 
reach  the  brain  or  other  parts.  Oiu'o  having  reached  its  destination,  it 
undergoes  the  following  changes:  The  booklets  disapiiear  and  the  little 
embryo  is  gradually  converted  into  a  small  cyst  which  i)resents  two  dis- 
tinct layers — an  external,  laminated,  cuticular  membrane  or  capsule,  aiul 
an  internal,  granular,  ])arenchymatous  layei",  the  endocyst.  The  litth^ 
cyst  or  vesicle  contains  a  clear  fluid.  There  is  more  or  less  reaction  in  the 
neighboring  tissues,  and  the  cyst  in  time  has  a  fibrous  investment.  When 
tliis  primary  cyst  or  vesicle  has  attained  a  c'3rtain  size  buds  develop  from 
the  parenchynuitous  layer,  which  are  gradually  converted  into  cysts,  pre- 
senting a  structure  identical  with  that  of  the  original  cyst,  namely,  an  elastic 
chitiuous  membrane  liiunl  with  a  granular  parenchymatous  layer.  These 
secondary  or  dai'.ghter  cj'sts  are  first  coniu'cted  with  tiie  lining  meinbrano 
of  the  primary,  but  are  soon  set  free.  In  this  way  the  jirimary  cyst  as  it 
grows  may  contain  a  dozen  or  more  daughter  cysts.  Inside  these  daughter 
cysts  a  similar  process  may  occur,  ami  from  buds  in  the  walls  grand- 
daughter cysts  are  developed.     From  the  granular  layer  of  the  parent  and 


!: 


1042 


DISEASES   DUE  TO   AXI.MAL   PAHASITES. 


11 


1^' 


(huigliter  cysts  buds  arise  whicli  develop  into  brood  capsules.  From  tlie 
lining  menil)riine  the  little  outgrowths  arise  and  gradually  develo])  into 
bodies  known  as  scolices,  which  represent  in  reality  the  head  of  the  twuia 
echinococcux  and  present  four  sucking  disks  and  a  circle  of  booklets. 
Each  scolex  is  capable  when  transferred  to  the  intestines  of  a  dog  of  de- 
veloping into  an  adult  tape-worm.  The  ditference  between  the  ovum  of 
Jin  ordinary  tape-worm,  such  as  the  twnia  sulitiin,  and  the  /(eniii  cchino- 
voccus  is  in  this  way  very  striking.  In  the  former  case  the  ovum  devel- 
ops into  a  single  larva — the  cijsticercus  ceUuJuxcc — whereas  the  egg  of  the 
twnia  cchinociiccus  develo^is  into  a  cyst  which  is  cai)ablo  of  multij)lying 
enormously  and  from  the  lining  meml)rane  of  which  millions  of  larval 
tape-worms  develop.  Ordinarily  in  man  the  development  of  the  ecliino- 
coccus  takes  place  as  above  mentioned  and  by  an  endogenous  form  in 
which  the  secondary  and  tertiary  cysts  are  contained  within  the  })rimary  ; 
but  in  animals  the  formation  may  be  dilTerent,  as  the  buds  from  the  pri- 
mary cyst  i)enetrate  between  tlu?  layers  and  develop  externally,  forming 
the  c.ro(/(')WHs  varietj'.  A  taird  form  is  the  multilocular  echinocnecus,  in 
which  from  the  primary  cy^its  buds  develop  which  are  cut  olf  completely 
and  arc  surrounded  by  thick  cajjsules  of  a  connective  tissue,  which  join 
together  and  ultimately  form  a  hard  mass  represented  by  strands  of  con- 
nective tissue  enclosing  alveolar  spaces  about  the  size  of  peas  or  a  little 
larger.  In  these  spaces  are  found  the  remnants  of  the  echinococcus  cyst, 
occa:;ionally  the  scolices  or  booklets,  but  they  are  often  sterile. 

The  fluid  of  the  echinococcus  cysts  is  clear  and  limpid,  and  has  a  spe- 
cific gravity  from  1-005  to  1-009.  It  does  not  contain  albumen,  but  may  con- 
tain traces  of  sugar.  As  a  rule,  the  cysts,  avIiqu  not  degenerated,  contain 
the  hydatid  heads  or  scolices  or  the  characteristic  booklets. 

Changes  in  the  C'i/st.—\t  is  not  known  definitely  how  long  the  echino- 
coccus remains  alive,  but  it  probably  lives  many  years — according  to  some 
authors  as  long  as  twenty  years.  The  most  common  change  is  death  and 
the  gradual  inspissation  of  the  contents  and  conversion  of  the  cyst  into  a 
mass  containing  putty-like  or  granular  material  which  may  be  partially 
calcified.  Kcmnants  of  the  chitinous  cyst  wall  or  booklets  may  be  found. 
These  obsolete  hydatid  cysts  are  not  infrequently  found  in  the  liver.  A 
more  serious  termination  is  rupture,  which  may  take  place  into  a  serous 
sac,  or  perforation  niay  take  place  oxtei'nally,  when  the  cysts  are  discharged, 
as  into  the  bronchi  or  alimenta.y  canal  or  urinary  passages.  More  unfa- 
vorable are  the  instances  in  which  rupture  occurs  into  the  bile-i)assages  or 
into  the  inferior  cava.  Recovery  may  follow  the  rupture  and  discharge  of 
the  hydatids  externally.  Sudden  death  has  been  known  to  follow  the 
rupture.  A  third  and  very  serious  mode  of  termination  is  suppuration, 
which  may  occur  spontaneously  or  follow  rupture  and  is  found  most  fre- 
quently in  the  liver.  Large  abscesses  may  be  formed  which  contain  the 
liydatid  membranes. 

Geoffi'aphicnl  Distribution  of  the  Echinococcus. — The  disease  prevails 


DISEASES  CAUSED  BY  CESTODES. 


1043 


1110- 

some 
and 

uto  a 
i;iUy 
iud. 
A 
irons 
•god, 


most  extensively  in  those  conntries  in  which  man  is  brought  into  close 
oontiict  with  the  d(ig,  particnlarly  when,  as  in  Australia,  the  dogs  are  used 
extensively  for  herding  sheep,  the  animal  in  which  the  larval  form  of  the 
fmnia  cchinococcus  is  most  frequently  found.  In  Iceland  the  cases  are 
very  numerous.  In  Europe  the  disease  is  not  uncommon.  In  this  coun- 
try it  is  extremely  rare  and  a  great  majority  of  all  cases  are  in  for- 
eigners. Up  to  July,  1891,  I  have  been  able  to  find  in  the  literature 
(and  in  the  museums)  only  85  cases  in  the  United  States  and  Canada.* 

DistribiUioH  i"  the  liody. — Of  the  1,802  cases  comprised  in  the  statis- 
tics of  Davaine,  Cobbold,  Finsen,  and  Neisser,  the  parasites  existed  in  the 
liver  in  953,  in  the  intestinal  canal  in  103,  in  the  lung  or  jileura  in  153,  in 
the  kidneys,  Ijladder,  and  genitals  in  180,  in  the  brain  and  spinal  canal  in 
127,  bone  01,  heart  and  blood-vessels  01,  other  organs  158.  f  Of  the  85 
cases  in  this  country,  the  liver  was  the  seat  of  the  disease  in  59.  Of  50 
consecutive  cases  treated  by  Mosler  at  the  Greifswald  clinic,  36  involved 
the  liver,  10  the  lungs,  3  the  right  kidney,  and  1  the  spleen. 

Symptoms. — {a)  llj/datids  of  the  Liver. — Small  cysts  may  cause 
no  disturbance ;  large  and  growing  cysts  produce  signs  of  tumor  of  the 
liver  with  great  increase  in  the  size  of  the  organ.  Naturally  the  physical 
signs  depend  much  upon  the  situation  of  the  growth.  Near  the  anterior 
surface  in  the  epigastric  region  the  tumor  may  form  a  distinct  prominence 
and  have  a  tonso,  firm  feeling,  sometimes  with  fluctuation.  A  not  infre- 
quent situation  is  to  the  left  of  the  suspensory  ligament,  forming  a  tumor 
which  pushes  up  tlie  heart  and  causes  an  extensive  area  of  dulness  in  the 
lower  sternal  and  left  hypochrondriac  regions.  In  the  right  lobe,  if  the 
tumor  is  on  the  posterior  surface,  the  enlargement  of  the  organ  is  chiefly 
upward  into  the  pleura  and  the  vertical  area  of  dulness  in  the  posterior 
axillary  line  is  increased.  Superficial  cysts  may  give  what  is  known  as 
the  hydatid  fremitus.  If  the  tumor  is  palpated  lightly  with  the  fingers 
of  the  left  hand  and  percussed  at  the  same  time  with  those  of  the  right 
there  is  felt  a  vibration  or  trembling  movement  which  persists  for  a  cer- 
tain time.  It  is  not  always  present,  and  it  is  doubtful  whether  it  is  pecul- 
iar to  the  hydatid  tumors  or  is  due,  as  Brian(;on  held,  to  tlie  collision  of 
the  daughter  cysts.  Very  largo  cysts  are  accompanied  by  feelings  of 
pressure  or  dragging  in  the  liopatic  region,  sometimes  actual  pain.  The 
general  condition  of  the  patient  is  at  first  good  and  the  nutrition  little,  if 
at  all,  interfered  with.  Unless  some  of  the  accidents  already  referred  to 
occur,  the  symptoms  indeed  may  be  trifling  and  due  only  to  the  pressure 
or  weight  of  the  tumor. 

Suppuration  of  the  C5'st  changes  the  clinical  picture  into  one  of  pyajmia. 
There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight. 
Perforation  may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  exter- 

*  American  Journal  of  tlie  Mcdinal  Sciences,  October,  1882.     Since  that  date  Alfred 
Mann  has  collected  for  nie  24  cases  in  addition  to  the  01  there  reported, 
t  Dictionnaire  Encyclopedique  des  Sciences  Medicales,  tome  32,  1885. 
U 


M 


1044 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


lioinlj'' 

m 

Jj   ; 


1 


nally,  and  in  some  instances  recovery  has  taken  place.  Perforation  into 
tho  pericardium  and  inferior  vena  cava  is  fatal,  in  the  latter  case  tlio 
daughter  cysts  have  been  found  in  the  heart,  phig;<?in{?  the  tricuspid  ori- 
fico  and  the  pulmonary  artery.  Perforation  of  the  bile-i)assayes  causes 
intense  jaundice,  and  may  lead  to  suppurative  cholangitis. 

An  interesting  symi)tom  connected  with  the  ru])ture  of  hydatid  cysts 
is  the  development  of  urticaria,  Avhich  may  also  follow  aspiration  of  tho 
cysts  and  is  probably  due  to  the  absorption  of  toxic  materials  contained  in 
the  fluid. 

Diagnosis.  —  Cysts  of  moderate  size  nuiy  exist  without  producing 
symptoms.  Large  multiple  echinococci  may  cause  great  enlargement  M'ith 
irregularity  of  the  outline,  and  such  a  condition  })ersisting  for  any  time 
with  retention  of  the  healtli  and  strength  suggests  hydatid  disease.  An 
irregular,  painless  enlargement,  particularly  in  the  loft  lol)e,  or  the  pres- 
ence of  a  large,  smooth  lluctuating  tumor  of  the  epigastric  region  is  also 
very  suggestive,  and  in  this  situation,  ■when  accessible  to  jialpation,  it 
gives  a  sensation  of  a  smooth  elastic  growth  and  possibly  also  the  hydatid 
tremor.  When  suppuration  occurs  the  clinical  picture  is  really  that  of 
abscess  and  only  the  existence  of  previous  enlargement  of  the  liver  with 
good  health  would  point  to  the  fact  that  the  suppuration  Avas  associated 
with  hydatids.  Syphilis  m.ay  produce  irregular  enlargement  without  much 
disturbance  in  the  health,  sometimes  also  a  very  definite  tumor  in  tlie 
epigastric  region,  but  it  is  usually  lirm  and  not  fluctuating.  The  clinical 
features  may  simulate  cancer  very  closely.  In  a  case  which  I  reported 
the  liver  was  greatly  enlarged  and  there  were  many  nodular  tumors 
in  the  abdomen.  The  post-mortem  showed  enormous  suppurating  hy- 
datid cysts  in  the  left  lobe  of  the  liver  which  had  perforated  tho 
stomach  in  two  places  and  also  the  duodciuim.  The  omentum,  mes- 
entery, and  pelvis  also  contained  numerous  cysts.  As  a  rule,  the 
clinical  course  of  he  disease  would  suffice  to  separate  it  clearly  from  can- 
cer. Dilatation  cE  the  gall-bladder  and  hydronephrosis  have  both  been 
mistaken  for  h'aatid  disease.  In  the  former  the  movable  character  of 
the  tumor,  its  shape,  and  the  mucoid  character  of  the  contents  suffice  for 
ihe  diagnosis.  In  some  instances  of  hydronephrosis  oidy  the  exploratory 
puncture  could  distinguish  between  the  conditions.  More  frequent  is  tho 
mistake  of  confounding  a  hydatid  cyst  of  the  right  lobe  pushing  up  tho 
pleura  with  pleural  effusion  of  the  right  side.  The  licart  may  be  dislo- 
cated, the  liver  depressed,  and  dulness,  feeble  breathing,  and  diminished 
fremitus  are  present  in  both  conditions.  Frcrichs  lays  stress  upon  tho 
different  character  of  the  line  of  dulness;  in  the  echinocoecus  cyst  the 
upper  limit  presents  a  curved  line,  the  maximum  of  which  is  usually  in 
tho  scapular  region.  Suppurative  pleurisy  may  be  caused  by  the  perfora- 
tion of  the  cyst.  If  adhesions  result,  the  perforation  takes  place  into  the 
hmg,  and  fragments  of  the  cysts  or  small  daughter  cysts  may  be  coughed  up. 
For  diagnostic  purposes  the  exploratory  puncture  should  be  used.     As 


b 

h 


DISEASES  CAUSED   BY  CESTODES. 


1045 


stated,  tlie  fluid  is  usually  perfectly  clear  or  slightly  opalescent,  the  reactioi) 
IS  neutral,  and  the  specific  gravity  varies  from  1-005  to  I'OOO.  It  is  non- 
alhuminous,  but  contains  chlorides  and  sometimes  traces  of  sugar.  Ilook- 
lets  may  he  found  cither  in  the  clear  fluid  or  in  the  suppurating  cysts. 
They  are  sometimes  absent,  however,  as  the  cyst  may  be  sterile. 

(b)  Echinocotxus  of  the  Respiratory  System. — Tlie  larvo3  may  develop 
primarily  in  the  pleura  and  attain  a  large  size.  Tiio  symptoms  are  at  first 
those  of  eomi)ression  of  the  lung  and  dislocation  of  the  heart.  The  ])hysi- 
cal  signs  are  those  of  fluid  in  the  pleura  and  the  condition  could  scarcely 
be  distinguished  from  ordinary  effusion.  The  line  of  dulness  may  be  quite 
irregular.  As  in  the  echinococcns  of  the  liver,  the  general  condition  of 
the  patient  may  be  excellent  in  spite  of  the  existence  of  extensive  disease. 
Pleurisy  is  rarely  excited.  Tlie  cysts  may  become  inflamed  and  perforate 
tlie  chest  wall.  In  a  case  of  I).  F.  Smith's,  of  Walkcrtown,  Ontario,  a 
girl,  aged  twenty,  had  a  running  sore  in  the  eighth  left  intercostal  space. 
This  was  freely  opened,  and  in  the  pus  which  flowed  out  were  a  number  of 
well-characterized  echinococcus  cysts  of  various  size.  The  patient  n\- 
covercd. 

Echinococci  occur  more  frequently  in  the  lung  than  in  the  pleura.  It 
small,  they  may  exist  for  some  time  without  causing  serious  symptoms. 
In  their  grcwtli  they  compress  the  lung  and  sooner  or  later  lead  to  inflam- 
nuitory  processes,  often  to  gangrene,  and  the  formation  of  cavities  which 
connect  with  the  bronchi.  Fragments  of  membrane  or  small  cysts  may  Ik* 
expectorated.  Ilivmorrhage  is  not  infrequent.  Perforation  into  the  pleura 
with  empyema  is  common.  A  majority  of  the  cases  are  regarded  during 
life  as  either  phtliisis  or  gangrene,  and  it  is  only  the  detection  of  the  char- 
acteristic membnines  or  tlie  booklets  which  leads  to  the  diagnosis.  The 
condition  is  usually  fatal;  only  a  few  cases  have  recovered.  Of  the  85 
American  cases,  in  six  the  cysts  occurred  in  the  lung  or  pleura. 

(r)  Echinococcu)^  of  the  Kidneys. — In  the  collected  statistics  referred 
to  above  the  genito-nrinary  system  comes  second  as  the  seat  of  hydatid 
disease,  though  it  is  rare  in  comi)arison  with  the  affection  of  the  liver.  Of 
the  85  American  cases,  there  were  only  three  in  which  the  kidneys  or  blad- 
der were  involved.  The  kidney  nniy  be  converted  into  an  enormous  cyst 
resembling  hydronephrosis. 

The  diagnosis  is  only  jiossible  by  puncture  atid  examination  of  the 
fluid.  The  cyst  may  perforate  into  the  pelvis  of  the  kidney  and  portions 
of  the  membrane  oc  cysts  may  be  discharged  with  the  urine,  sometimes 
producing  renal  colic.  I  have  reported  u  case  in  which  for  many  months 
the  patient  passed  at  intervals  numbers  of  small  cysts  with  the  urine. 
The  general  heidth  was  little  if  at  all  disturl)ed,  except  by  the  attacks  of 
oolic  during  the  passage  of  the  parasites. 

{(l)  Echinococcus  of  the  Nervous  System. — In  this  country  very  few 
instances  have  occurred  in  the  brain.  One  or  two  reports  indicate  clearly 
that  tlio  common  cystic  disease  of  the  choroidal  plexuses  has  been  mis- 


1046 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


I 


^ 


taken  for  hydatids,  Davies  Thomas,  of  Australia,  has  tabulated  9T  cases, 
including  some  of  the  cysticercus  ceUulu.-t(e.  According  to  his  statistics, 
the  cyst  is  more  common  on  the  right  than  on  the  left  side,  and  is  most 
frequent  in  the  cerebrum. 

The  symptoms  are  very  indefinite,  as  a  rule,  being  those  of  tumor. 
Persistent  headache,  convulsions,  either  limited  or  general,  and  gradually 
developing  blindness  have  been  prominent  features  in  many  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  diifers  so  remarkably  from  the  usual  type  of  the  disease.  About 
one  hundred  instances  are  on  record,  the  great  majority  of  which  have  oc- 
curred in  Bavaria  and  in  Switzerland.  Only  one  case  has  been  reporttd 
in  the  United  States.*  The  patient  was  a  German,  who  had  been  in  the 
counti'y  five  years.  For  a  year  previous  to  his  death  he  was  out  of  health, 
jaundiced,  and  somewhat  emaciated.  A  fluctuating  tumor  was  found  in 
the  right  lumbar  and  umbilical  regions,  a])parently  connected  with  the 
liver.  This  was  opened,  and  death  followetl  from  liaimorrhage.  About 
a  fourth  of  the  right  lobe  of  the  liver  was  occupied  by  an  irregular  cavity 
with  rough,  ragged  walls,  which,  in  places  were  from  one  to  two  inches  in 
thickness  and  enclosed  irregular  small  cavities.  The  lamellated  cuticula 
charactsristic  of  the  echinococcus  cyst  was  found  lining  these  cavities.  In 
some  instances  the  tumor  bears  a  striking  likeness  to  colloid  cancer,  as  on 
section  it  presents  a  fibrous  stroma  with  cavities  containing  gelatinous 
material.  They  are  often  sterile — that  is,  without  the  hydatid  heads  or 
larvoa.  This  form  is  aliuost  exclusively  confined  to  the  liver,  and  the 
symptoms  resemble  more  those  of  tumor  or  cirrhosis.  The  liver  is,  as  a 
rule,  enlarged  and  smooth,  not  irregular  as  in  the  oi'dinary  echinococcus. 
Jaundice  is  a  common  symptom.  The  spleen  is  usually  enlarged,  there 
is  progressive  emaciation,  and  toward  the  close  haemorrhages  are  com- 
mon. 

Treatment  of  Echinococcus  Diseasp.— Medicines  are  of  no 
avail.  Post-mortem  re])orts  show  that  in  a  considerable  number  of  cases 
the  parasite  dies  and  the  cyst  becomes  harmless.  Operative  measures 
should  be  resorted  to  when  the  cyst  is  large  or  troublesome.  The  simple 
aspiration  of  the  contents  has  been  successful  in  a  large  number  of  cases, 
and  as  it  is  not  in  any  way  dangerous,  it  may  be  tried  before  the  more 
radical  procedure  of  incision  and  evacuation  of  the  cysts.  Suppuration 
has  occasionally  followed  the  puncture.  Injections  into  the  sac  should 
not  be  practised.  With  modern  methods  surgeons  now  open  and  evacuate 
the  echinococcus  cysts  with  great  boldness,  and  the  Australian  records, 
which  are  the  most  numerous  and  important  on  this  subject,  show  that 
recovery  is  the  rule  in  a  large  proportion  of  the  cases.  Suppuratire  cysts 
in  the  liver  should  be  treated  as  abscess.  Naturally  the  outlook  is  less 
favorable.     The  practical  treatment  of  hydatid  disease  has  been  greatly 


*  Delafleld  and  Prudden,  Putliologicul  Anatomy,  third  edition,  page  317. 


iniijr 


PARASITIC   ARACnNIDA. 


1047 


advanced  by  Australian  surgeons.  The  recent  work  of  James  Graham,  of 
Sydney,  may  be  consulted  for  interesting  dettiils  in  diagnosis  and  treat- 
ment. 


V.  PARASITIC  ARACHNIDA. 

(1)  Pentastomes. — (a)  The  pentasfomum  tamioides  has  a  somewhat 
lancet-shaped  body,  the  female  from  three  to  four  inches  in  lengtli,  the 
male  about  an  inch  in  length.  The  body  is  tapering  and  marked  by 
numerous  rings.  The  adult  worm  infests  the  frontal  cinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
tlic  pentastomnm  dentiadatum,  is  found  in  the  internal  organs,  particu- 
larly the  liver,  but  has  also  been  found  in  the  kidney.  The  adult  worm 
has  been  found  in  the  nostril  of  man,  but  is  very  rare  and  seldom  occa- 
sions any  inconvenience.  The  larvce  are  by  no  means  uncommon,  par- 
ticularly in  parts  of  Germany. 

[b)  The  pcntastomum  constrictum,  which  is  about  the  lengtli  of  half 
an  inch,  with  twenty-three  rings  on  the  abdomen,  was  found  by  Aitken  in 
the  liver  and  lungs  of  a  soldier  of  a  AVest  Indian  regiment. 

The  only  case  of  pentastomes  which,  so  far  as  I  know,  has  been  re- 
ported in  tliis  country  is  the  one  referred  to  in  Flint's  Practice  of  Medi- 
cine. From  75  to  100  of  tlie  parasites  Avere  expectorated.  The  liver  was 
enlarged  and  the  parasites  probably  occupied  this  region.  In  18G9  I  saw 
a  specimen  which  had  been  passed  in  the  urine  by  a  patient  of  James  H. 
Richardson,  of  Toronto. 

{'I)  Demodex  (Acarus)  Folliculorum. — A  minute  parasite,  from  0-3 
millimetre  to  0*4  millimetre  in  length,  which  lives  in  the  sebaceous  folli- 
cles, particularly  of  the  face.  It  is  doubtful  whether  it  produces  any 
symptoms.  Possibly  when  in  large  numbers  they  may  excite  inflamma- 
tion of  the  follicles,  leading  to  acne. 

(3)  Acarus  (or  Sarcoptes)  Scabiei  {Itch  Insect).— 'Y\\is,  is  the  most 
important  of  the  arachnid  parasites,  as  it  produces  troublesome  and  dis- 
tressing skin  eruptions.  The  male  is  -23  millimetre  in  length,  and  -10  mil- 
limetre in  breadth  ;  the  female  is  0-45  millimetre  in  length  and  0'35  milli- 
metre in  width.  The  female  can  bo  seen  readily  with  the  naked  eye  and 
has  a  pearly-white  color.  It  is  not  so  common  a  parasite  in  the  United 
States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  one  centimetre  in  length, 
which  it  makes  for  itself  in  the  epidermis.  At  the  end  of  this  burrow  the 
female  lives.  The  male  is  seldom  found.  The  chief  seat  of  the  parasite 
is  in  the  folds  where  the  skin  is  most  delicate,  as  in  the  web  between  the 
fingers  and  toes,  the  backs  of  the  hands,  the  axilla,  and  the  front  of  the 
abdomen.  The  head  and  face  are  rarely  involved.  The  lesions  which  re- 
sult from  the  presence  of  the  itch  insect  are  very  numerous  and  result 
largely  from  the  irritation  of  the  scratching.     The  commonest  is  a  papular 


1048 


DISEASES  DUE  TO  ANIMAL   PARASITES. 


and  vesicular  rash  or,  in  cliildron,  an  ccthymatous  eruption.  The  irrita- 
tion and  pustulation  which  follow  the  scrali'hinpf  may  completely  destroy 
the  burrows,  but  in  typical  cases  there  is  rarely  any  doubt  as  to  the  diag- 


nosis. 

rii 


The  treatment  is  simple.  It  should  consist  of  warm  baths  with  n  thor- 
ough use  of  a  soft  soap,  after  which  the  .skin  should  be  anointed  with 
suljjhur  ointment,  wiii(;h  in  the  case  of  children  should  be  diluted.  An 
ointment  of  naphthol  (drachm  to  tlic  ounce)  is  very  ellicacious. 

(4)  Leptus  Autumnalis  {Harvest  yy ////).— This  reddish-colored  para- 
site, about  one  half  millimetre  in  size,  is  often  found  in  large  numbers  in 
fields  and  in  gardens.  They  attach  themselves  to  animals  and  man  with 
their  sharp  proboscides,  and  the  hooklets  of  their  legs  produce  a  great  deal 
of  irritation.  They  are  most  frequently  found  on  the  legs.  Thoy  are 
readily  destroyed  by  sulphur  ointment  or  corrosive-sublimate  lotions. 

Several  varieties  of  ticks  are  occasionally  found  on  man — the  Ixodes 
ricimis  and  the  Ixodes  americanus,  which  are  met  with  in  horses  and  oxen. 


VI.    PARASITIC   INSECTS. 

(1)  Tediculi  {Phihirinsis  J  Pediculosis). — There  arc  three  varieties  of 
the  body  louse,  which  are  found  only  in  persons  of  uncleanly  habits. 

Pediculiis  Capitis. — The  male  is  from  1  to  1-5  millinu;tro  in  length 
and  the  female  nearly  ^  millimetres  in  length.  The  color  varies  some- 
what with  the  dilfcrent  races  of  men.  It  is  light  gray  with  a  black  mar- 
gin in  the  European,  and  very  much  darker  in  the  negro  and  Chinese. 
'I'hey  are  oviparous,  and  the  female  lays  about  sixty  eggs,  which  mature  in 
a  week.  The  ova  arc  attached  to  the  hairs,  and  can  be  readily  seen  as 
white  specks,  known  popularly  as  nits.  The  symptoms  are  irritation  and 
itching  of  the  scalp.  When  numerous  they  may  excite  an  eczema  or  a 
pustular  dermatitis,  which  causes  crusts  and  scabs,  particularly  at  the  back 
of  the  head.  In  the  most  extreme  cases  the  hair  becomes  tangled  in  these 
crusts  and  nuitted  together,  forming  at  the  occiput  a  firm  mass  which  is 
known  as  plica  polonica,  as  it  was  not  infrequent  among  the  Jewish  in- 
habitants of  Poland. 

Pedictilus  Corporis  (  Vestimentorum). — This  is  considerably  larger 
than  the  head  louse.  It  lives  on  the  clothing  and  in  sucking  the  blood 
causes  minute  ha)morrhagic  specks,  which  are  very  common  about  the 
neck,  back,  and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria, 
and  the  scratching  is  usually  in  linear  lines.  In  long-standing  cases,  par- 
ticularly in  the  old  dissipated  characters,  the  skin  becomes  rough  and 
greatly  pigmented,  a  condition  which  has  been  termed  the  vagabond's  dis- 
ease— morbus  erroru7n — and  which  may  be  mistaken  for  the  bronzing  of 
Addison's  disease. 

Pediciilus  pubis  differs  somewhat  from  the  other  forms,  and  is  found 


Eoe 


SE 


PARASITIC  INSECTS. 


1049 


larger 
lie  blood 
)out  tbo 
lirticaria, 
Ivses,  par- 
]ugh  and 
jud's  dis- 
[nzing  of 

is  found 


in  the  parts  of  the  body  covered  with  sliort  hairs,  as  the  puhos;  more 
rarely  the  axilla  and  eyebrows. 

The  tiirlics  bicndtrcs  are  stated  by  l-Vcnch  writers  to  l)e  excited  by  tlic 
irritation  of  peilieuli.  They  are  certaiidy  associated  witii  thcni  in  a  con- 
siderable luiniber  of  ases,  but,  if  rually  caused  by  these  parasites,  it  is  difli- 
cult  to  uiKJerstaJid  wliy  they  should  oidy  be  present  with  fever. 

Treatment. — For  tiio  pcdinthis  capUis,  when  tlie  cotxlition  is  very 
bad,  the  hair  sliould  he  cut  sliort,  as  it  is  very  diHicult  to  destroy  thor- 
oughly all  tiie  nits.  IJepeatetl  saturations  of  tlie  hair  in  co:d  oil  or  in 
turpentine  are  usually  elbcaeious,  or  with  lotions  of  carholic  acid,  one  to 
iifty.  Scrupulous  clcaidiness  and  care  are  suflieient  to  prevent  rocurrenco. 
In  the  case  of  the  jwdirubdi  corpori.s  the  ch)tliing  should  he  placed  for 
several  iiours  in  a  disinfecting  oven.  To  allay  tlie  itching  a  warm  bath 
containing  four  or  live  ounces  of  bicarljonate  of  soda  is  useful,  'i'lie  skin 
may  bo  rubhed  with  a  lotion  of  carbolic  acid,  two  drachms  to  the  pint, 
with  two  ounces  of  glycerin.  For  the  prdiculiis  pubis  wiiite  ])rccipi- 
tato  or  ordinary  mercurial  ointment  should  be  used,  and  the  parts  should 
be  thoroughly  washed  two  or  three  times  a  day  with  soft  soap  and  water. 

(2)  Cimex  Lectuarius  {Common  Bed-buy). — This  parasite  is  from  three 
to  four  millimetres  in  length  and  has  a  reddish-brown  color.  It  lives  in  the 
crevices  of  the  bedstead  and  in  the  cracks  in  the  iloor  and  in  the  walls.  It 
is  nocturnal  in  its  habits.  The  j)eculiar  odor  of  the  insect  is  caused  by  the 
secretion  of  a  special  gland.  The  ])arasite  possesses  a  long  j)roboscis,  Avith 
which  it  sucks  the  blood.  Individuals  dilTor  remarkably  in  the  reaction 
to  tlie  bite  of  this  insect;  some  are  not  disturbed  in  the  slightest  by  them, 
in  others  the  irritation  causes  hyperannia  and  often  intense  urticaria. 
Thorough  fumigation  with  sulphur  or  scouring  with  corrosive-sublimate 
solution  destroys  them. 

(3)  Pulex  Irritans  {The  Co)nmon  Flea). — The  male  is  from  2  to  2*5 
millimetres  in  length,  the  female  from  3  to  4  millimetres.  The  flea 
is  a  transient  parasite  on  man.  The  bite  causes  a  circular  red  spot  of 
hyperamiia  in  tlio  centre  of  which  is  a  little  speck  Avhere  the  boring  appa- 
ratus has  entered.  The  amount  of  irritation  caused  by  the  bite  is  variable. 
Many  persons  suffer  intensely  and  a  diffuse  erythema  or  an  irritable 
urticaria  develops ;  others  suffer  no  inconvenience  whatever. 

The  pulex  penetrans  {sand-jlen ;  jiriger)  is  found  in  tropical  coun- 
tries, particularly  in  the  West  Indies  and  South  America.  It  is  much 
smaller  than  the  common  flea,  and  not  only  penetrates  the  skin,  but  bur- 
rows and  produces  an  inflammation  Avith  pustular  or  vesicular  swelling. 
It  most  frequently  attacks  the  feet.  It  is  readily  removed  with  a  needle. 
Where  they  exist  in  large  numbers  the  essential  oils  are  used  on  the  feet 
as  a  preventive. 


■(.  i 

I 

■ 


1050 


DISEASES  DUE  TO  ANlMAli   PARASITES. 


VII.     PSEUDO-PARASITES  (Myiaaia). 


Of  these,  the  most  important  arc  the  hirvtv  of  certain  diptera,  particu- 
larly the  flesh  ^'ws—crcophila.     The  condition  is  called  myiasis. 

The  most  common  form  is  that  in  which  an  external  wound  becomes 
living,  as  it  is  called.  This  myiasis  vulnerum  is  caused  by  the  larva)  of 
either  the  blue-bottle  or  the  common  flesh  fly.  The  larvte  can  be  removed 
readily  with  the  forceps ;  if  there  is  any  difticulty,  thorough  cleansing  and 
the  application  of  an  antiseptic  bandage  is  sutticient  to  ki'l  them.  The 
ova  of  these  flies  may  be  deposited  in  the  nostrils,  the  ears,  or  the  con- 
junctiva— the  myiasis  narium,  aurium,  conjunctiva?.  This  invasion  rarely 
takes  place  unless  these  regions  are  the  seat  of  disease.  In  the  nose  and 
in  the  ear  the  larvte  may  cause  serious  inflammation. 

The  cutaneous  myiasis  may  be  caused  by  the  larva?  of  the  imisca  vomi- 
toria,  but  more  commonly  by  the  bot-flies  of  the  ox  and  siieep,  which 
occasionally  attack  man.  This  condition  is  rare  in  temperate  climates. 
Matas  has  described  a  case  in  which  ojstrus  larva;  were  found  in  the  glu- 
teal region.  In  parts  of  Central  Anic.ica  the  eggs  of  another  bot-fly,  the 
dermatobia,  are  not  infrequently  dej)Osited  in  the  skin  and  produce  a 
swelling  very  like  the  ordinary  boil. 

Myiasis  interna  may  result  from  the  swallowing  of  the  larva;  of  the  com- 
mon house  fly  or  of  species  of  the  genus  anthomyia.  There  are  many 
cases  on  record  in  which  the  larvae  of  the  musca  clomcstica  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larva;  have  been 
passed  in  the  fjEces  are  less  common.  Finlayson,  of  Glasgow,  has  recently 
reported  an  interesting  case  in  a  physician,  who,  after  protracted  consti- 
pation and  pairi  in  the  back  and  sides,  passed  large  numbers  of  the  larva; 
of  the  flower  fly — anthomyia  canicularis.  Among  other  forms  of  larvae  or 
gentles,  as  they  are  sometimes  called,  which  have  been  found  in  the  faeces 
are  those  of  the  common  house  fly,  the  blue-bpttle  fly,  and  the  tcchomyza 
fttsca.  The  larvae  of  other  insects  are  extremely  rare.  It  is  stated  that 
the  caterpillar  of  the  tabby  moth  has  been  found  in  the  faeces. 

Here  may  be  mentioned  among  the  effects  of  insects  the  remarkable 
urticaria  epidemica,  which  is  caused  in  some  districts  by  the  procession 
caterpillars,  particularly  the  species  cncthocampa.  There  are  districts  in 
the  Kahlberger  Schweiz  which  have  been  rendered  almost  uninhabitable 
by  the  irritative  skin  eruptions  caused  by  the  presence  of  these  insects,  the 
action  of  which  is  not  necessarily  in  consequence  of  actual  contact  with 
them. 


INDEX. 


i  I 


Abiwio,  986. 

Abdomen  in  typhoid  fever,  22, 

Abdoniiiml  typlius,  1. 

AbduuuiiH  norvc  (see  Sixth  Nkuvk),  79-1. 

Abcrriint,  thyroid  (.diinda,  712  ;  iidreniilM,  77'^- 

Abortion,  in  clioreii,  9;J1  ;  in  rolap.siiiif  lover, 
45;  in  Bnin!i-i)ox,  .Ifi  ;  in  syi)liili«,  ISO. 

Abscess,  of  bruin,  HO.');  in  iippcndicitiH, 4o7;  in 
glanders,  2t)0  ;  in  typhus,  42 ;  of  kidney  (pyo- 
nephrosis), 7r)8;  of  liver,  44»);  of  luiiK,  002; 
of  incdiiistinuin,  579;  of  piirotid  jflimd,  ,'V.'8  ; 
of  tonsils,  334;  perinephrio,  773;  i>yicniio, 
lie  ;  retroiieritoneiil,  408  ;  retrophurynijual  iu 
cervical  caries,  332,  851, 

Aeanthoeephalu,  103G. 

Aearditt,  ()5!t. 

Acurus,  Hcabiei,  1047;  follieuloruni,  1047. 

Accentuated  second  sound,  in  chronic  Bright's 
disease,  753  ;  in  arterio-selurosi-s,  008. 

Accessory  spasm,  810. 

Accphalocysts  (sec  IIydatio  Cvsts),  1041. 

Acetona'inift,  301. 

Acetone,  299;  test  for  (Lo  Nobel's),  299. 

Acctonuria,  730. 

.\chondroplasy,  308. 

Achromatopsia  in  hysteria,  972;  honiiaoiiro- 
niatopsia,  787. 

Acid,  free,  in  giistrlc-juice,  tests  for,  .'545. 

Acne,  from  iodide  of  potu.siiiuni,  950 ;  rosacea, 
1003. 

Acromegalia,  991. 

Actinomyces  or  ray  fungus,  261. 

Actinomycosis,  201. 

Acupuncture,  in  drop.sy,  745 ;  in  lumbago,  282 ; 
in  sciatica,  820. 

Acute  bulbar  paralysis,  860. 

Acute  tuberculoses,  197. 

Acute  yellow  atrophy,  42C. 

Addison's,  diseaso,  708;  pill,  183;  keloid,  993. 

Adonic,  704. 

Adenitis  in  scarlet  fever,  73. 

Adenitis,  tuberculous,  205. 

Adenoid  growths  in  pharynx,  335. 

Adeno-typhoid  (Malta  fever),  207.     . 

Adherent  pericardium,  589. 

Adirondack  M.ountuinB  for  tuberculosici,  251. 


Adronola  in  Addison's  disease,  709. 

i^Igophony,  5:ii',  M2. 

.\ge,  inllueneu  of,  iu  tuberculosis,  192. 

Ageusia,  805. 

Agraphia,  901. 

.Ague,  147. 

Ague  cake  (sec  K.sm.auoed  Splben),  154. 

Ainluim,  994. 

"  Air-hunger"  in  diabetes,  301. 

Air,  impure,  intUienec  in  tuberculosis,  194. 
.Albini,  nodules  of,  OiiO. 

Albinism,  in  lepro.sy  (lepra  alba),  25S;  of  the 
lung,  540. 

Albumen,  tests  for,  727. 

Albuminuria,  725;  and  life  assurance,  729; 
cyclic,  720;  febrile,  720;  functional,  720; 
in  aoiito  Bright's  disease,  742;  iu  chronic 
Bright's  disease,  752;  in  dialietes,  299;  in 
diphtheria,  lOO ;  iu  epilepsy,  952;  in  cry- 
sipcla.s,  113;  in  gout,  293;  in  pneumonia, 
521  ;  in  scarlet  (ever,  70, 72 ;  in  typhoid  fever, 
20 ;  iu  variola,  55 ;  neurotic,  727  ;  physio- 
logical, 720  ;  prognosis  in,  728. 

Albuminous  exiieetor.ition  in  pleurisy,  570. 

Albuminuric  retinitis,  784. 

Albumosc  in  cultures  of  tubercle  bacilli,  IHO. 

Alcaptonuria,  737. 

Alcohol,  etreets  of,  on  the  digestive  Rystcni, 
1002;  on  the  kidneys,  1003;  on  the  nervous 
system,  1002;  poisonous  cll'ects  of,  1001, 

Alcoholic  neuritis,  778. 

Alcoholism,  1001  ;  acute,  1001  ;  and  tubercu- 
losis, 1003;  chronic,  1001;  treatment  of,  1004. 

Alexia,  901. 

Algid  form  of  malaria,  153. 

Alimentary  canal,  tuberculosis  of,  239. 

Alkaloids,  putrefactive,  1012. 

Allantiasis,  1013. 

AUoolieiria,  844. 

AUorrythmia,  050. 

Alopecia,  lOS. 

Altitude  in  tuberculosis,  185,  251. 

Altitude,  ottects  of  high,  208. 

Amaurosis,  hysterical,  785 ;  toxic,  785 ,  un»- 
mic,  754 ;  iu  haimatemesis,  387. 

Amblyopia,  785 ;  croascd,  78D. 


1052 


INDEX. 


i! 


Atiiliulutory  tyjilioiil  fcvor,  29. 

Ainti'liii  oi)li  I  iiiiKi  liii  (lyHfiitiirini),  13!!;  in  livtT 

ul)Hi'L'!<i4,  lilj;  in  Hplltll,  I'M, 

Ainu'liic  (l_v,siiitii-j,  l.'i'J. 

Amiiioniiu'iil  tlf(.i>iiiiM>,siti()n  ofuiiiio,  T;i.'. 

AiniMoliin'riiiii,  "'■>><,  Viil. 

Ainiicsiii ;  miilitnrj,  nul ;  viKiiiil, 'JUO, 

Amiilioric  liri'iitliiii),',  227,  &7U. 

Amiiliurii'  I'clio,  •_':i7. 

Aniyldul  tlihi'ii!<i',  in  i)litliini»,  '_'IS;  Im  H^philix, 
ltl',1;  (if  kidiHV',  7."'V  ;  <il'  liviT,  4.ii!. 

Aiiiyotl'oiiiru'  liiUiiil  si'li.rosir*,  s,")7,  8.')!), 

AniiMiiin,  i'iJ<l;  in  mK'liylo.stuiiiiasi.i,  lu;)^;  from 
JUlliiir/iu,  10:;  t;  (Voin  (fimti-ic  iitroiihy,  u,">4; 
from  liu'nHirrliUL.'i',  i'M\  from  inanition,  liSti; 
from  li'ail,  loos;  iili()|)atliii',  t''H'.(;  in  i,'a.stric 
oalK'cr,  ;i.sl  ;  in  jrasti'li'  iilt'cr,  .';7-';  mountain, 
liiiS;  in  rlu^umatism, '.'72  ;  in  t*y  pliilis,  108;  in 
t.vi>lioitl  fovor,  17;  primary  or  I'ssfiitiai,  (j.Sfi; 
ciilonwis,  (i8i) ;  proj,'ri'SMivi!  pornioious,  CS'J; 
8(i'onilary  or  syniptoniutic,  liHI;  toxif,  080. 

Anivniio  nnninurs  (.sco  ILkjiu;  .Miumi  its). 

Anii'stlii'sia,  tloloro.sa,  8.')1 ;  in  chorea,  0.17;  in 
lii;nii|)I(.;,'ia,  (S7'>;  in  liystoria,  1)71  ;  in  It'pro- 
By,  251);  in  locomotor  ataxia,  81.1;  in  .Mor- 
vaii's  (liscaMc,  s."ii) ;  in  railway  spine, 'JSO  ;  in 
unilateral  lesions  (jf  tlic  coril,  S'>^. 

Analifcsia,  in  liystcria,  !)71;  in  Morviin'.s  Jis- 
ciwo,  8.')0  ;  in  cyringo-niyulia,  B.'iO. 

Anarthriii,  81i8. 

Ana.san'a  (sec  Dnorsv). 

Ancliy  lostomiasis,  10;U. 

Ancliylostoimim  (luodcnalc,  1001. 

Anuurisiii,  07U;  arlcriu-vunous,  070,  OSii;  cir- 
soid, (570;  cyliiulricul,  070;  disscctinir,  Ii70 , 
embolic',  071;  ctioloiry  (.f,  070;  false,  070; 
fusiform,  070 ;  mycotic,  071;  of  tlio  abiloini- 
luil  aorta,  080;  of  the  liranches  of  thu  nli- 
domiiuil  aorta,  tlsi;  of  the  cerebral  arteries, 
883  ;  of  the  euuliac  u.\i.s,  081 ;  of  heart,  (Uii ;  of 
the  hepatic  artery,  )i82 ;  of  thu  renal  artery, 
082;  of  the  .splenic  artery,  081 ;  of  the  supe- 
rior mesenteric  artery,  0o2;  of  pulmonary 
artery,  217. 

Aneurism,  of  thoracic  aorta,  <'71  ;  i  :)ui,'h  in,  C7.'> ; 
diajjfnosi.s  of,  075;  dyspna-a  !■;,  075;  lui'iiior- 
rhiiiio  in,  075;  pain  in,  075;  physical  siu'iis 
of,  073  ;  symptoms  of,  072;  treatnu'ntof,  07S  ; 
Tufnell's  treatment  of,  078 ;  unilateral  sweat- 
ing in,  070. 

Ancuri.sm,  true,  070;  verminous,  in  the  horse, 
071,  loyi. 

Aii'/ma  pectoris,  055 ;  pseudo-  or  liystcrical, 
057 ;  vaso-motoria,  050. 

Angina,  Ludovici,  332;  simplex,  330;  sulFoca- 
tiva,  99. 

A  ngio-neurotic  oedema,  989;  heredity  in,  989; 
recurring  colic  in,  990. 

Angio-sclcrosis,  C07. 


Aiii,'iiilliila  Bt'Tcoriilis,  A.  IntcRtinnlifi,  1038, 

Animal  lymph,  Ot. 

Ani«ocoriii,7'.i2. 

.■\nlvlo  clonus,  in  liysterleal  paraplegia,  fi;J9, 
U70;  in  spastic  paiaplegiii,  8;;8;  bpurioiw,  UO'J, 

Aiinrcxiu  nervosa,  973. 

Ano.sniia,  783. 

Ano-veslcul  centre,  855. 

.\ntcrior  crural  nerve,  paralvsis  of,  817. 

,\nlerior  cerebral  artery,  embolism  of,  8S1. 

Aiillioiriyii  eaiiiculiiris,  lo.'<o, 

.Anthnudsis,  of  lun;.'s,  55'! ;  of  livi-r,  MO. 

.\ntlira.\,  150;  bacillus,  I5ii,  m  anlnutlH,  156. 

Antiperistalsis,  302. 

Aiitipneiimotoxin,  51  i. 

Antiseptic  meiruatiini  in  typhoid  fi'ver,  30. 

Anuria,  compute,  717. 

.Xniis,  impcrfor.ite,  415. 

Aorta,  aneurism  of,  ii71  ;  dynamic  pulsation  of, 
077,  throbbing,  980;  liypophisiu  of  in  chlo- 
rosis, 087  ;  tuberculosis  of,  .'hi. 

.\ortic  incompetency,  0(.)'J;  sudden  death  in, 
C(i7 ;  symptoms  of,  Oi't. 

Aortic  orillee,  congenital  losion.s  of,  001 ;  size 
of,  003. 

Aortic  steno.sis,  0O8. 

Aortic  valves,  bicuspid,  condition  of,  000; 
relative  insullleieiiey  of,  Oii.l. 

.\pc.\  of  lung,  catarrh  of,  2,11  ,  puckering  of, 
2111;  in  tuberculosis,  211. 

Apex  iincumonia,  5U2,  525, 

.■\liluisia,  81)8;  .matomical  localization  of,  902; 
iiiuxic,  i)Ol  ;  hemiplegia  with,  901;  in  in- 
I'lmtilc  hemiplegia,  908;  mixed  forms  of, 
902;  motor,  901;  of  conduction,  9()'J ;  in 
phthisis,  229;  prou'nosis  of,  90'!;  scn.sory, 
89!);  in  typhoid  fever,  25;  tests  for,  902; 
tniiisieiit,  in  111  I L.' rail  11',  9.")S;  Wernieke'ti,  902. 

A]iheiiiia  isce  .\rii,\MA). 

Aphonia,  liystei-ical,  972;  in  acute  laryngitis, 
480;  in  adductor  paralysis,  807;  in  pcricar- 
dical  cll'usion,  585. 

Aphtlue  (see  .SroM.vnris,  Ai'iiriiois),  323. 
Apoplectic  /laliihis,  870. 

Apoplexy,  cerebral,  870;  ingravescent,  873; 
pulmonary,  508. 

Apparitions  in  migraine,  957. 

.Appendicitis,  40,5,  400;  eiiturrhal,  407,  409; 
perforative,  407,  409  ;  ulcerative,  407. 

-Vppendi.v  verniiforinis,  situation  of,  400;  per- 
foration of,  in  typhoid  fever,  7. 

A  prose  xi  a,  335,  338. 

Arachnida,  parasitic,  1047. 

-Arachnitis  (sec  Mkningitis),  863. 

Aran-I)uch'nne  type  of  muscular  utmphy, 
8,")7;  in  lead-poisoning,  1010. 

Arch  of  aorta,  aneurism  of,  672. 

Arcus  senilis,  044. 

Arijijll- Robertson  pupil,  702;  in  otaxlo,  842. 


Muu-iaaa'ry^rT 


IXDKX. 


1053 


:ys.i. 
I'fiit,  87»; 


[407,  40'.i; 

I""- 
400 ;  pcr- 


atmphy, 


lla,842. 


Ann,  pcrlphornl  pnriilyRwof  (hoo  PAnAi.VMs  or 

ItUAI'IIIAI.  I'i.kxl'm), 

Aiotliiuiii,  tl'iO. 

AwiMi'u'iil  iiiiirifH,  77!'. 

Awuniortl  iii;{iiiiiitatii)ii,  1011  ;  ill  I'lioreu.  !>:>''. 

Anii'n'ioftl  polsoiilii]^,  li'U  ;  jmnilynU  In,  loli'. 

Aitcrios,  ilisi'iwus  <)!',  iliji!;  cuU'illv'iitiDri  of,  >W.\; 
ili'i;('iu'iiitiuii  of,  ijii:',;  futty,  Wi\  liyul'me, 
()i)l ;  tulifl'i'ill'isiM  iif,  'J  Id. 

AitiMio-ciipillniy  lllirosis,  (WA. 

Arlorio-Holi,TOHi'<,  (iili;  dill'iiHO,  Oiii!;  in  Icml- 
])i)isonin'.(,  1010;  in  miu'riiino, '.i"iH ;  niKJuliir 
form,  lidri ;  in  phtliislo,  •_'.;;!;  scniio  form,  HOii; 
Myiiiptoms  of,  tills;  tiiiitniont  of,  001). 

Arteritis  in  typlioiil  fever,  S). 

ArtoritiH,  Ky|)|iililii',  17S. 

Arthrnl;,'ia  from  Iciul,  1010. 

Artliriti.'i,  27');  lU'iito,  in  infi\nt?<,  '27>'>;  grmor- 
rliir:il,  ->0  ;  in  ncnld  myelitis,  s-.'ll ;  in  eerobro- 
K|iinal  nuMiiMiiilis,  DO;  in  deU'.'ue,  111;  in 
(lysi'ntery,  l;J7  ;  in  iliplitlieria,  100;  in  lui'mo- 
pliiliii,  !i21 ;  in  tiibus  d-ir.-iali!*,  814;  mnltipie 
Meeoiitlary,  'J7") ;  in  i)urpin-ii,  ;J17  ;  rlicumutoid, 
'.'SJ ;  in  HOiirlct  fever,  7:i;  Hcptic,  'J7.'>. 

Artliritis  delormaiis, 'iSi  ;  eiironie  form,  M^'t; 
ifolK^ral  proiires.sivu  form,  281;  J/rl)iri/eii\H 
nodosities  in, '.iSl ;  partial  or  inono-urticulur 
form,  280. 

Artliropatliios  in  tubes,  Sil. 

Aseariusis,  102."). 

Aspiiris  lumliriooides,  102r). 

Aseite.i,  401);  oliyious,  471;  from  oaneeroiis 
peritonitis,  40',) ;  from  eirrhosis  of  tlie  liver, 
4Ui ;  from  syphilis  of  tlic  liver,  177  ;  in  eanei^r 
of  tlio  liver,  4.')1;  in  tiiherouloiis  periloniti-i, 
2'!8;  physical  I'i^n.-i  of,  4(U;  treatment  of,  l"-". 

.•\seitio  fluid  ;  cliylou.s,  471  ;  serous,  471  ; 
hxmorrliaj,'ic,  471, 

.\speet,  facial;  in  typlioid  fever,  10;  in  i)neu- 
nionia,  r>17;  in  lieredilary  lues,  171  ;  in  pa- 
ralysis U'^'itans,  927. 

.Vsperijillus  in  luni,',  222. 

Aaphy.viu,  local,  !)S7  ;  in  diphtheria,  10.">;  deatli 
by,  in  plitliisis,  204. 

A.spiration,  J!iiW(lit(:h''H  conehisiona  on,  .''>70; 
in  empyema,  .")71 ;  in  pericardial  etfusion, 
580 ;  in  pleuritic  ell'usion,  oOD ;  tuberculosis 
after,  194. 

Aspiration  pneumonia,  537. 

Astusia-abasni,  930. 

Asthma,  broneiiial,  497  ;  etiolocfy  of,  407 ;  nasal 
affections  in,  498;  s])utum  in,  499;  symptoms 
of,  499 ;  treatment  of,  fiOO ;  cardiac,  497  ;  luiy, 
477;  Lei/dell's  crystals  in,  000;  renal,  497; 
thymic,  .')80. 

Atavism,  in  h«;mophilia,  320  ;  in  gout,  287. 

Ataxia,  cerebellar,  921  ;  hereditary,  848  ;  in 
poriplicral  neuritis,  779;  in  progressive  pare- 
Bia,  917  ;  locomotor,  840 ;  after  sninll-pox,  55. 


Ataxic  (jalt,  843. 

Atii\ie  paraplegia,  8.19. 

Atelectasis,  puliiioiiary,  5-17. 

Atlieroma  (sue  Aurtitio-si^LKiioaiHand  I'ni.Kiio- 

eci.Kiiosis). 
Athetosis,  908;  bilateral  or  double,  910. 
Athlete's  heart,  00!. 
Atrophy,  iiliopathic  museiihir,  090;  of  brain, 

dilVuse,  in  general    paiiwis,   !'l."i;    of    brain, 

unilatitral,  907  ;  of  muscles,  various  forms  of, 

991) ;  proj<rcssive  inusiuilar,  of  spinal  origin, 

H,")7;  unilateral,  of  faei',  990. 
Attitude,    in    pseudohyi)ertrophic    muscular 

paralysis,  990;  in  paralvsis  a','itiins,  927. 
•Viiditory    eeiilre,    alleelioiis  of,    bol  ;   ncrvn, 

diseases  of,  hOl  ;  vertigo,  803. 
.\ura,  forms  of,  in  e|)ilepsy,  9.")0. 
Auto-infeetiori  in  tuberculo>is,  198. 
.\utouiatism,   in  petit   maty   9.')2  ;    in   cerebral 

syphilis,  173. 
.Autunmal  fi^ver,  3. 
.Vvian  tuberculosis,  181. 

Bacillus,  anlhracis,  ir)0;  of  cholera,  119. 

Hacillus  coli  c(»iiiiiituin  "~  i\\n\!\i\i:V\iA\  from 
ty|ihoiil  bacillus,  ;>;  in  bile-passages,  43.');  in 
fieees  of  sucklings,  391,  392;  in  fat  necrosis 
with  colitis,  4')9;  in  peritonitis,  40;'.;  in  sup- 
purative ependymitis,  hO,");  in  caiuruiu  ori^', 
320. 

Uacillusdipbtlieriic,  100;  attcnualed  form,  101  ; 
value  of,  in  diagnosis,  108. 

Uaeillus,  gastricus,  351;  of  glainlers,  259;  of 
smegma,  105;  in  \vhoopini;-eougli,  M;  rmi- 
lariic,  142;  of  leprosy,  258;  of  sypliilis,  105; 
of  tetanus,  103;  parotitis,  82;  strepto-,  in 
typhus  fever,  40. 

Bacillus  tuberculoses,  180;  diagnostic  value  of, 
230;  distribution  of,  180;  in  s|>utuui,  220; 
methods  of  detection,  221 ;  products  of  growth 
of,  180. 

Racillus  typhosus,  3. 

Haeteria,  proteus  group  in  diarrhoea,  392;  rela- 
tion to  diarrluca,  391,  393. 

Bacterium  coli  connnune  (sec  Bacillls  Coli 
Co.m.mi:nis)  ;  lactis  aerogenes,  391. 

Balanitis  in  diabetes,  300. 

Ball-thrombu.s  in  left,  auricle,  OIG. 

liantiriifs  method  in  obesity,  1O20. 

"Barben  cholera,"  1015. 

Barrel-shaped  chest  in  emphysema,  540,  518. 

liiuedow^s  disco.se,  7 1 2. 

Basilar  artery,  embolism  and  thrombosis  of, 
880. 

Baths,  cold,  in  typhoid  fever,  84 ;  in  hyperpy- 
rexia of  rheumatism,  277;  in  sr.-ilot  fever, 
75. 

Beaded  ribs  in  rickets,  309. 

Bed-bug,  1040. 


s 


I 


1054 


INDEX. 


i .  I 

l:i 


Bed-sores,  ncuto,  829;  in  pnraplejfia,  RW. 

Bder-ilrinkern,  heart  diseiuse  in,  G;!',». 

McWs  {Luther)  iiiunio,  0'J4. 

JieWs  piilsy,  7!i7. 

Beri-bcri,  780;  in  Jupun,  780;  in  the  United 
States,  780. 

"  Bii,'-jiiw"  in  cattle,  201. 

Bile  eolorinjr  matter,  tests  for,  424. 

Bilc-duetM,  iiscarides  in,  4y7 ;  cancer  of,  4.37, 
4r);j ;  stcnos  s  of,  437. 

Bilious  remittent  fever,  151. 

Bitliurzia  liwmatobia,  1024. 

Biliary  "olic,  402. 

Biliary  fistulic,  430. 

Birth  palsies,  'JOO. 

Black  vomit,  120. 

Black  spit  of  miners,  S.'ii). 

Blacider,  paralysis  of,  in  locomotor  ataxia,  844  ; 
care  of  in  myelitis,  833  ;  hypertrophy  of, 
in  diabetes  insipidus,  300. 

"Bleeders,"  321. 

Bleedinjf,  in  artcrio-scleropls,  070;  in  cerebral 
haiiiorrliajfe,  tiN2 ;  in  emiiliyscmu,  .'JH);in 
heart-diseiu'e,  024;  in  pneumonia,  .'i30;  in 
sunstroke,  lol'.i ;  in  yellow  fever,  12'J. 

Blepiuirosi>asm,  HdO. 

Blood  and  ductless  |,'lands.  diseases  of,  084. 

Blood-eastM  (see  Casts;. 

Blood,  characters  of,  in  aniemia,  084;  in  cancer 
of  the  stomacii,  3Sl ;  in  dilorosis,  OH"  ;  in 
cholera,  121 ;  in  diabetes,  2117;  in  gout,  2SS; 
in  lucmophilia,  321;  in  leukremia,  G'.tO;  .n 
pernicious  aniemiu,  0'.i2 ;  in  pscudo-leukic- 
mia,  Hodrrkin's  diseiuxe,  700;  in  purpura, 
319;  in  secondary  amemia,  084. 

Blood-vessels,  affections  of,  82.'J. 

"  Blue  diseiuse,"  0ii2. 

Blue  line  on  pums  in  lend  poisoninjr,  IOCS. 

Boils,  in  diabetes,  300  ;  after  small-iidX,  .V). 

Bones,  lesions  of,  in  acromcjfalia,  992 ;  in  con- 
ftcnital  syphilis,  171;  in  leukicmia,  702;  in 
rickets,  308;  in  typlioid  fever,  27. 

Borboryi;mi,  3t')2. 

Bothriocciiiialus  latus,  1038. 

Botulism,  1013. 

Botyroid  liver  in  sypliilis,  177. 

Bovine  tuberculosis,  184. 

Bowel,  affections  of  (sec  Intestines);  infarc- 
tion of,  404. 

Brachial  jilcxus,  afl'ectlons  of,  814. 

Brachyeardia  (Hrndycnrdia),  053. 

Brain,  disea.«cs  of,  802;  abscess  of,  903;  ancemin 
of,  808 ;  atrophy  and  sclerosis  of,  907 ;  con- 
gestion of,  807  ;  cortical  centres  of,  889  ;  cysts 
in,  919;  disca.ses  of  substance  of,  8S7  ;  echi- 
nceoceus  of.  1045 ;  foci  of  sclerosis  in  sy|)hili8, 
172;  glioma  of,  918;  liypcramiia  of,  807;  in- 
flammation of,  903;  oedema  of,  809;  porcn- 
ccphulus  of,  907. 


Brain,  Kf'crosis  of,  911;  difTuRC,  912;  insular, 
913;  n.iiiary,  912;  tuberous,  013. 

Bruin,  soltciiiiig  (»f,  red,  yellow,  and  white,  878, 
879. 

Brain,  tubercle  of,  242,  918. 

Brain,  tumors  of,  918;  medical  treatment  of, 
922 ;  8ur;.'ical  treatment  of,  922 ;  symptoms, 
general  and  localizing,  919. 

Brain-imirmur  in  rickets,  310. 

JirandU  niethod  in  typhoid  fever,  34. 

Breakbone  fever  (see  Denul'e),  90. 

Brciist-pang,  055. 

Breath,  odor  of,  in  diabetic  coma,  301  ;  foul,  in 
scurvy,  314  ;  fcetid,  in  enlarged  tonsils,  338. 

Breathing  (See  UKSi'iUATm.v) ;  mouth,  335. 

Brick-maker's  ansjcmia,  1032. 

Bright's  disea.se,  acute,  741 :  dintrnosis  of,  743 ; 
etiology  of,  741 ;  prognosis  in,  741 ;  symptoms 
of,  742 ;  treatment  of,  744. 

Bright's  disease,  chronic,  740  ;  interstitial  fonn 
of,  749 ;  causes  of,  749 :  cardlo-vascular 
clumgcs  in,  753;  liereditury  influences  in, 
749;  symptoms  of,  752;  treatment  of,  755; 
parenchymatous  form  of,  747. 

Brisbane  Hospital,  statistics  of  Brand's 
method  at,  30. 

"  Hroken-winded,"  030. 

Bromism,  950. 

Hionchi,  cast*  of,  502  ;  diseases  of,  490. 

Uronchial  catarrh  (lironchitis),  490. 

Bronchial  glands,  tuberculosis  of,  190,  19.3,198, 
207  ;  enlargement  in  whooping  cougli,  80, 
577  ;  suppuration  in,  577  ;  perforation  of  into 
flDsoj)hagus,  578. 

Bronchiectasis,  495;  iibsccss  of  brain  in,  497  ; 
congenital,  495 ;  cylindrical,  495  ;  etiology 
of,  495  ;  rheumatoid  afiections  in,  497  ;  sac- 
cular, 495  ;  sputum  in,  496  ;  universalis,  495. 

Bnmehiolitis  exudativa,  497. 

Bronchitis,  490;  acute,  490;  etiology  of,  490; 
symptoms  of,  490;  treatment  of,  491;  capil- 
lary, 530 

Bronchitis,  clironic,  492;  etiology  of,  492; 
symptoiiis  of,  493;  treatment  of,  494. 

Bronchitis,  fibrinous,  501. 

Bronchitis,  in  irudaria,  146;  in  measles,  79; 
in  small-pox.  55;  in  typhoid  fever.  23;  pu- 
trid, 494. 

Bronchocelo  (see  Goitre),  711. 

Bronchophony,  520. 

Broncho-pneumonia,  acute,  530;  chronic,  .533; 
otuite  tuberculous,  211. 

Bronchorrha-a,  493  ;  serous,  494. 

Bronzoskin,  in  phthiriosis,  1048;  in  Addi- 
son's disea.sc,  709. 

I'rown  induration  of  lung,  504. 

Brown  atrophy  of  heart,  04.3. 

Brown-S(5(iuard's  paralysis,  85.3. 

Bruit,  d'airain,  676 ;   du   cuir   neuf,  583 ;   do 


ir,. 


INDEX. 


1055 


insulaT, 

iiiU',  878, 

tncnt  of, 
luiitoniB, 


;  foul,  in 

isils,  338. 
h,  335. 

(is  of,  743; 
symptoms 

stitiul  form 
lo-viwoulur 
lucnccs  in, 
ut  of,  7r>r); 

)f     BrantVs 


480. 
0. 

1190, 103,  i;t8, 
I'outtli,  86, 

ution  of  into 

rain  in,  407  ; 

;    utiolony 

in,  407  ;  sat- 

ursalis,  405. 

logy  of,  400; 
■lo:  i  capil- 

,jry    of,   402; 
404. 

iiicmilcs,  79; 
cvur,  '23 ;  pu- 


clironic,  533; 
18;  in   Addi- 

Ineuf,  583;  do 


diablo,  C89;  do  pot  fdl6  (soc  Ch.vcked-pot 

SouNu),  227  ;  de  Houfflc,  594. 
Bubo,  parotid  (sot;  also  Pauotitis),  323. 
Bulbar    paralyses,  s<;o  ;   acute,  800 ;   chronic, 

8til ;  in  pro),'ru.ssivi)  muscular  utropliy,  8(i0. 
Bulimia,  300. 
Butyric  acid,  test  for,  in  gastric  juice,  ."40. 

Cachexia,  in  cancer  of  tijc  stomach,  378,  883 ; 

malarial,  l.'>3;  saturnine,  1008;  struuiipriva, 

715;  sypliilitic,  IGS. 
Ciucitis,  stercoral.  411. 
("ujcum,  perforation  of,  400. 
Caisson  disease,  827. 
Calcareous  concretions,  in  phthisi.s,  216  ;  in  the 

t(msi!s,  338. 
Calcareous  dcfjeneration,  of  arteries,  003 ;   of 

heart,  043 ;  of  muscle  fibres,  995. 
Calcification,  annular,  of  arteries,  003. 
('alcifioation  in  tubi^rcle,  19.">. 
Calculi,  biliary,  431 ;  "coral,"  705;  pancreatic, 

400  ;  renal,  706 ;  tonsillar,  338  ;  urinary,  forms 

of,  705. 
Calculous  pyelitis,  758. 
Calm,  K.tage  of,  in  yellow  fever,  127. 
Cancer,   of  bile-passai^es,   43.',  453;  of  !>')wel, 

415;   of  brain,   918;   of    gull-bladder,   453; 

of  kidney,  770;  of  liver,  4'. I;  of  luns?,  550; 

of  oesophairus,  342  ;  of  pane  rcius,  40 1 ;  of  peri  to- 

nicum,  miliary,  40s ;  of  pleura  and  luii;.,,  550  ; 

of  stomach,  370. 
Cancrum  oris,  320. 
California,  southern,  climate  of,  for  lubci-cu- 

losis,  251. 
Canities,  the  result  of  ncural^fia,  000. 
Canned  goods,  poisoning  by,  1014. 
Capillary  pulse,  in  aortic  insutficiency,   000; 

in  neurasthenia,  980;  in  i)hthisis,  2i,8. 
Capsule,  internal,  lesions  of,  897. 
Caput  Medusa\  442,  470. 
Caput  quadratum,  in  rickets,  310. 
Carboluria,  737. 
Carbuncle  in  diabetes,  300. 
Cardiac,  compensation,  rupture  of,  034;  disease 

(see  J)lSK.\SK  OK  IlKAiiT). 

Cardiac  niurnnn-s,  fuvniic,  in  chlorosis,  089;  in 
chorea,  930 ;  in  idioiiuthic  anannia,  003. 

Cardiac  murmurs,  organic,  in  aortic  insutU- 
cicncy,  005 ;  in  uortic  stenosis,  009 ;  in  con- 
genital heart  atJ'ections,  002;  in  mitral  in- 
competency, 013 ;  in  mitral  stenosis,  010  ;  in 
trlcus]iid  valve  disease,  018. 

(^^ardiac  nerves,  neuralgia  of,  055.  > 

Cardiac  overstrain,  03ti. 

('ardiac  septa,  anomalies  of,  059. 

<'ardialgia  fsee  (iastuamha). 

tlardinal's  ea.so  (hydrocephalus),  923. 

Cardioceutcsis,  048. 

Cardio-respiratory  murmur,  227. 


Cardio-sclerosia,  043. 

Cardio-vascular  changes  in  renal  disease,  75.3. 

Caries  of  spinl^  851. 

Carinated  abilomeii,  203. 

Carotid  artery,  ligature  and  eomprc8.sion  of, 
in  cerebral  ha;morrhage,  882. 

Carphologiu,  25. 

Carpo-pedal  spasm,  900. 

Carreau,  230. 

Caseation,  195. 

Casta,  blood,  of  bronchial  tubes  in  hmmopty- 
sis,  508;  in  fibrinous  broncliitis,  502;  of  pel- 
vis of  kidney  and  ureter,  770. 

Casts  of  urinary  tul)ules,  744 ;  epithelial,  742, 
744;  fatty,  748;  granular,  748,  753. 

Casts,  tube,  in  acute  Briglit's  disease,  742 ;  in 
chronic  Briglit's  disease,  749,  753. 

Catalepsy  in  hy.steria,  975. 

Cataract,  diabetic,  302. 

Catarrh,  acute  gastric,  348 ;  autumnal,  477  ; 
bronchial,  490;  chronic  gastric,  351;  dry, 
494;  nasal,  475;  Himplo  chronic  (ua.sal),  475; 
suffocative,  540. 

Catarrhal  inflammation,  infiuence  in  tubercu- 
losis, 193. 

Catarrhe  sec,  494. 

Catarrh  us  icstiviis,  477. 

Cats,  diphtheria  in,  100. 

Cauda  c(piina,  lesions  of',  854. 

Ca.'ernous  breathing,  227. 

Cavities,  pulmonary,  physical  sigiw  of,  227 ; 
quiescent,  217. 

Cellulitis  of  the  neck,  3.32. 

Centliocaiiipa,  10.")0. 

(^■ntnun  ovale,  lesions  of,  897. 

Cephalalgia  (see  Headache). 

Cephalic  tetanus,  104. 

Cciilialodynia,  282. 

Ccrcomoiuis  intestiiuilis,  132. 

Cerebellor,  ataxia,  921 ;  vertigo,  921. 

Cerebellum,  tumors  of.  921. 

Cerebral  urterics,  aneurism  of,  883;  arterio- 
sclerosis of,  8S4 ;  endarteritis  of,  884 ;  syphi- 
litic endarteritis  of,  8S1. 

Cerebral  Inemorrliaite,  870;  aneurisms,  miliary, 
in,  871;  convulsions  in.  s77 ;  diagnosis  of, 
87'i ;  etiology  of,  870 ;  forms  of,  87 1 ;  morl>i(i 
anatomy  of,  871  ;  prognosis  in,  877;  symp- 
toms of,  872 ;  treatiiient  of,  882. 

Cerebral  localization,  8^:i. 

"Cerebral  pneumonia,"  522. 

"  Cerebral  rheumatism,"  274. 

Cerebral  sinuses,  thrombosis  of,  885;  softening, 
878. 

Corebrltis  (see  KNcKniAi.iTis),  003. 

Cenjbro-spinal  meningitis,  cpidc:  •,  92 ;  anom- 
alous t'orms  of,  90;  coniplieu..on.s  of,  911; 
malignant  form,  94. 

Cerebro-spinal  motoi  segment,  lesions  of,  894. 


f 


1056 


INDEX. 


i  'f 


I  I 


Ocrvicnl  pnc'liyincnin;;'tlH,  821. 

Cervico-lii'iicliiiil  iicMinilijiii,  i)(i(*. 

Ci'.rvico-occipiUil  iicunilfr'ui,  1)00. 

Ciistodfs,  disc'iusu  due  to,  103(i. 

Chiili'.'osi.s,  t)'>;>. 

('liancrc,  lOfl. 

Cliarbon,  \M\. 

ClMnvVn  orystiils,  IWO,  CO?  ;  joints,  814. 

Chattering  tectli,  700. 

('Ii(juk,  frantrrcno  of,  020. 

(JliiiL'se,  i)()is(tni(iy;  by,  1014. 

Ohecsy  ]inc'iiiiK)iiiii,  l'.i7. 

Clitst  expansion,  tliniinution  of,  in  Grave.-'s 
di.sease,  714. 

C/ii\i/iic-S/i)hs  breutliinj;,  in  apoplexy,  873;  in 
fatty  lieart,  Ml ;  insuiisti'oUe,  liUS;  in  tuber- 
eiilous  nicMitiLjitis,  11)1);  in  uni'tiiia,  7ol). 

Cliiasnia  and  tract,  all'eetions  of,  787. 

Chieiien-breiust,  SIO. 

Cliiel<en-)iox,  (!."). 

Child-erowinLr,  4Sf). 

(Jliildrcn,  coiistipatioii  in,  121  ;  dialictcs  in,  "(lO ; 
tiibei-eiiloiis  broncho  -  pneumonia  in,  212; 
pneunionia  in,  52") ;  typlioid  fever  in,  21i ; 
tuberculosis  of  incscntcric  jilandu  in,  20>; 
mortality  from  small-pox  in,  SO  ;  rlieuniati.-iin 
in,  270. 

Chills  (see  I!i(i(ii:s). 

Cidoasnia  plilhisieoruni,  2oO. 

Chioro-ana-mia  in  [ihthisis,  22vS. 

Ciiloi'osis,  tisi! ;  and  anieinia,  .sinus  tliroiuliosis 
in,  88.");  dia.L'nosis  of,  (ISl);  dilatation  of  stom- 
ueh  in,  088;  lO^^ypliau,  i0;i2;  etiolo^ry  of, 
C80;  fever  in,  080;  lieart  symptoms  in,  089; 
menstrual  disturbuneo  in,  08'.>;  morbid  anat- 
omy of,  fls7 ;  symptoms  of,  087;  tlxrondiosis 
in,  08;). 

Choked  disk,  780. 

Cliolicmia,  42."). 

Ciiohinjiitis,  eatarrhnl,  -("l ;  stippurative,  43"). 

Clioleeysteetomy,  imlieations  lin',  4:1',). 

Ciiolecystitis,  suppurative,  4;!4;  phlejrmonous, 
434. 

Cholecystotomy.  439. 

Cliolera,  asiatiea,  IIS;  bacillus  of,  111);  in- 
fantum, 31)3 ;  no.strius,  123;  sicca,  122;  typhoid, 
122. 

Ciiolerine,  122. 

Cliolelithiasis,  431. 

Cholcsteraniiia,  4  J."). 

Cliolosterine  in  liiliary  calculi,  432. 

(■lioluria.  7"m . 

Clioreii,  acute,  920;  etiolotry  of,  029;  lieart 
symptoms  of,  030  ;  infectious  or'^rin  of,  933; 
in  pre;,Mianpy,  931  ;  paralysis  in,  035;  rheu- 
matism and,  930;  soasoiud  relations  of,  030. 

Chorea,  canine,  031,  91") ;  clironic,  914. 

Chorea,  ]ud)itor  spasm,  942. 

Chorea,  lluntiiujdoii^s  or  Iiereditary,  044. 


Clioren  insnniens,  935;  mnjoi',  942;  pandemio, 
012;  prehcmi picnic,  873;  rliyihmie  or  liys- 
terieal,  04.');  senile,  944;  Sjjdtukains,  020. 

(Hioroid,  tubercles  in,  204. 

t'horoid  plexuses,  sclerosis  of,  923. 

Choroiditis  in  syphilis,  108. 

Cliyluria,  non-parnsitic,  730;  parasitic,  1033. 

Circumcision,  inoculation  of  tuberculosis  by, 
189;  in  luemopliilia,  321. 

Claw-hauil  (main  en  frrille'),  859. 

Climate,  iulluciice  of;  in  asthma,  501;  in  eliroidu 
Iiri;rht,'s  disciuse,  755  ;  in  tuberculosis,  250. 

Cicatrices  listulcuses,  217. 

Ciliary  muscle,  paralysis  of,  702. 

Cimcx  lectuarius,   1040. 

Circulatory  systeni,  diseases  of,  581. 

Circundlex  nerve,  aticctiuns  (if,  815. 

Cirrhosis,  of  kidney,  740  ;  of  liver,  440 ;  of  lunjf, 
532;  of  pancreas,  400 ;  veutricull,  352. 

Cladothrix,  201. 

Clapotcmi^nt.  300. 

('/(irl'x,  Alnii:n,  siirn,  411. 

Clarkc'K,  vesicular  colun.u, !  i  '. 

Clnviceps  purpurea,  poison. p      ,.    •    '. 

Clavus  hystericus,  071. 

Cloisters,  tul)erculosis  in,  190. 

Clonus  (sec  .\nki.k  ("loni's). 

(Mownism  in  liysteriu,  909. 

Cobalt  miners,  cancer  of  lung  in,  550. 

Coceidium  oviforme,  1022. 

Coceydynia,  9(11. 

Coehin-China  diarrha'a,  lO.'JO. 

Ca'liae  affection  in  ehildren,  394. 

Collee-groinul  vomit,  379. 

Coi,'-wheel  respiration,  220. 

Coin-sound,  570. 

Cold  pack,  metiiod  of  ^rivinjj,  75. 

Colic,  biliary,  432;  in  aiii^io-neurotic  oedema, 
989;  in  purpura,  318;  lead,  1009;  reiud,  707. 

Colica  Pictonum,  1007. 

Colitis,  mucous,  390  ;  simple  ulcenitivo,  G9'  . 
croupous,  521. 

Collapse  stage,  in  cholera,  121;  in  pcritj,.'t,i. , 
404. 

Collateral  (jcden       f  h  ig,  520. 

Collective  investigation,  Reports  of  the  ISntish 
Medii'ul  .\ssoeiation,  191.  270. 

rVi/AsV  law,  100. 

Colloid  cancer,  of  lung,  550 ;  of  peritonucum, 
409;  of  stonuieh,  377. 

Colon,  cancer  of,  415 ;  dilatation  of,  403. 

Conui,  diabetic,  301  ;  epileptic,  951  ;  from 
licat-stroke,  1018 ;  in  al)scess  of  brain.  90") ;  in 
acute  yellow  atrophy,  427;  in  uleoliol  ,  "oi- 
soning,  1001 ;  in  .ipoplexy,  873,  877  ;  >  oe'i- 
bral  syphilis,  173;  in  general  parc«i'',  i'  ■■' 
in  iiiul  iplo  seleros:is,  914;  in  pernicious  ma- 
laria, 153;  in  til'  )mbosi'-  f  cerebral  sinuses, 
885 ;  lu  typlioiu  f  (.  or,  25 ;  urtciniu,  739. 


( 
( 

( 

(J 
C 

c 

c^ 

Ci 
C( 

('< 

Co 


INDEX. 


1057 


IVC,    oV 


iL  Hnti(*h 


•iton:riiiii, 


ComatoHc  form  of  Mulnrifi,  ITiS. 

Coiiiii-viijH,  ill  typlio'ul  lover,  2o;  in  typhus 
fuvor,  41. 

Coiunm  kii'illiis,  11 9. 

Coiiiiiioii  hi U-duct,  obstruction  of,  4:i3. 

OonipiMisiitiiin  in  valve  lesions,  (iOl  ;  periods 
in,  >'M\  niplure  of,  'V-'A. 

Composite  portriiiture  in  tuberculosis,  lOi!. 

Compression  paruplegia,  8.')1. 

Couerelions  (see  Cai.caui;oi:s). 

(Concussion   if  spinal  cord,  'Mi. 

Confusiopal  insanity,  v!."). 

Conge'iital  heart  allections,  05'J. 

Congenital  syphilis,  IHO. 

Coni,'o-red  test  for  free  acid,  -'iti!. 

OoiijuLrate  deviation;  in  brain  tumor.  Oil;  in 
hemiiilcLria,  SM;  in  meningitis,  -JOl. 

Consecutive  nephritis,  7"<H. 

Constipation,  4-JO;  in  adultH,  4'JO;  in  infants, 
4Ul  ;  treatment  of,  4-2± 

Constitutional  diseases,  i!70. 

Consumption  (see  TtnKucuLOsis),  20S. 

Contracted  kidneys,  74'.». 

Contracture,  hysterical,  HOO;  in  hemiplegia, 
87") ;  of  nurses,  y(J5. 

Contusion  pneimionia,  ol'J. 

Conus  arteriosus,  stenosis  of,  (!(il. 

Conus  medullaris,  lesions  ol',  S.")4. 

Convalescence,  fever  of,  13  ;  from  typhuitl  fever, 
management  of,  liS. 

Convulsions,  epilejitie,  9.")!;  hysterical,  1)54, 
yilS;  in  acute  yellow  atroi)hy,  4'_'7  ;  in  alco- 
holism, I'JiH  ;  in  aspiration  of  pleural  ellu- 
tiion,  071;  in  cerebral  Ineaiorrhago,  >>7o ;  in 
cerebral  syphilis,  174,  :•,',!■  iu  cerebral  tu- 
mors, DIO;  in  I'hronic  Hriirht's  disease,  748. 

Convulsions,  infantile,  W4."i ;  diai;nosis  of,  U47  ; 
ctioloiry  of,  04.');  relation  to  rickets,  ;ill; 
symptoms  of,  '.I4ii;  treatment  of,  1)47. 

Convulsions,  in  nenerat  paralysis,  Olti;  in  he- 
patic colic,  4o3;  in  infiuitilc  hemiplcL'ia,  1;07  ; 
in  nieniiiiritis,  SM\  in  sun-stroke,  1018;  in 
lUNcmia,  7:'>'.i ;  Jacksonian,  'J.')3 

Convuksive  tic,  91-',  94:1. 

(.'o-ordinution,  di.sturbance  of,  in  tabes,  843. 

Copaiba  eruption,  80. 

Copiier  test  fir  sugar,  299. 

Copriumia,  <i87. 

Coprolalia,  943. 

Cor  ndiposum,  043. 

Cor  bilocularc,  (i."i9. 

Cor  bovinum,  (iOl.  i 

Cor  villosuiii,  r)82. 

Cornea,  ulceration  of,  in  snnill-pox,  M. 

Coronary  arteries,  in  nngiim  peetorlB,  Go6;  ob- 
literation of,  1141. 

Corpora  ipuidriircmijia,  tumoi-s"  in,  920. 

Corpulence,  lol9. 

C'oWjyaw.'*'  disease,  002. 


Corrifjan\f  pulso,  006. 

Coryza,  acute,  474;  foetida,  470 ;  from  tho  io- 
dides, 183. 

Costiveness,  420 

Cougli,  barkin,',  of  puberty.  972;  hysterical, 
972;  in  acuti;  bronchitis,  491;  in  ciironic 
bronchitis,  l'.i3;  in  (nMtussis,  8.">;  in  pblliisis, 
221)  ;  during  aspiralinn  of  [vleiiral  etl'usion, 
.')70;  in  pneumonia,  ol9  ;  paroxysmal,  in 
broneiiieetasis,  49(i;  ])aro.\ysmul,  in  libroid 
phthisis,  232  ;  stonuieh,  354. 

Coup  de  solcil,  1017. 

(;o\v-po.\,  00,  08. 

('raoked-pot  sound,  227. 

Cramps,  in  cholera,  121 ;  ingout,2;i2;  in  chronic 
Uriglit's  disease,  7.">4. 

Cranio-sclerosis,  310. 

Cranio-tabes,  relation  to  con,'inital  syphilis, 
310;  in  rickets,  310. 

Creophila,  10.")0. 

Crescents  in  blood  in  malaria,  143. 

Cretniism,  fii'tal,  ."'.OS;  siioi'adic,  711. 

Cri:tinoid  change,  714. 

Crises,  gastro-intestinal ;  in  angio-neurotio 
uidenui,  989;  in  locomotor  ataxia,  374,  8-4-1; 
in  purpura,  31 S. 

Crisis,  in  ]ineumonia,  ."117  ;  in  typhus  fever,  42. 

Croup,  482;  relation  to  diphtheria,  4b2 ;  spas- 
modic, 487. 

Croupous  pneumonia,  .Ml. 

("rura  cerebri,  lesions  of,  81i7. 

(Jrutcli  paralysis,  81."). 

CruveiUiU'i',1  palsy,  8.'i7. 

(Jry,  liydroeeplialic,  202;  hystericnl,  972;  in 
congenital  .syphilis,  170. 

Crystals,  Lci/Jeii's,  .'ioO,  .103. 

Curdling  ferment,  test  for,  347. 

('in:i('/iiitaiiu\s  spirals,  .''lOO,  .'103. 

("yanosis,  in  acute  tuberculosis,  200 ;  in  congen- 
ital heart-disease,  001 ;  in  empliysenm,  547. 

Cyclopl(>iria,  792. 

Cynanche  maligna.  99. 

(Cystic  disciLse,  of  kidn(\v,  772;  of  liver,  773. 

Cystic  duct,  obstruction  of,  433. 

Cy.-iliccrcus  cellulosoc,  1039 ;  ocular.  10 10 ;  subcu- 
taneous, 1010;  symptoms  of  invasion  ol',  1010. 

Cystine  calculi,  731,  700. 

Cystiimria,  734. 

Cystitis,  in  locomotor  ataxia,  844;  in  trans- 
vcrso  myelitis,  831 ;  tubereulou.s,  244. 

Cyst.'i,  in  kidneys,  772;  of  brain,  apoplectic!, 
872;  porencephalic,  907;  of  brain,  throm- 
botic, 879;  pancreatic,  400. 

Dnneinir  mania,  912. 
Dandy  fever  (dengue),  00. 
Deaf  nuitism  alter  e"rebro-spinnl  fevor,  97. 
Deafness,  in  cerebral   tumor,  02!  ;  in  ciu-ebro- 
spiual  nieuingititi,  07;  in  hysteria,  972;  in 


1058 


INDEX. 


U  • 


rii! 


M-Mni-rc's  disciisc,  803;  in  scarlet  fever.  73; 

ill  tiil)os  doi-siilis,  814;  norvoua,  80'2. 
l)(;ulli,  iiioiles  of,  in  tuberculosis,  \i",i  ;  sudden, 

in  tvplioid  fever,  31  ;  in  pleural  ellu.sion,  50;'.. 
Debility,  nervous  (see  Nki.uastiiema),  i)78. 
Diboi'ch  forced  feedinj^,  2,")3. 
Decubitus,   ueuto,   871;   (bed-sores)    in   tnins- 

vorso  myelitis,  HJJO. 
Defen-sivc  ulkiiloids,  1012. 
Dc^fjeiierution,  reliction  of,  780,  700. 
])o^lutition,  diiticult  (see  Dvsimiagia). 
Deglutition  imeuMioniu,  h-',". 
Dojjlutatory  murmurs,  iiuscultiition  of,  345. 
Deluyed  resolution  in  pncimionia,  5i.'7. 
Deliiyod  sensation  in  tubes,  S|;;. 
Dtiliriutn,   acute,  ifJl;    acute,  in   lead-])oison- 

ini^,    1010;  cordis,   32,   (iW,   051;  expansive, 

910:   in  acute  rheumatism,   27-t;   in  jmeu- 

nio:       .-'"  •  i"  tyi)hoid  fever,  25;  in  tyi)lius 

fevei    '.  ens,  1003. 

J>oltoid,  p.i  :i  of,  815. 

l>elu.sioual  ii.    ..lity  alter  fevers,  25,  55,  522. 
Delusions  of  j;randeur,  OIC. 
Dementia  paralytica,  014;  alcoliol  as  n  factor  in, 

1002. 
Demodex  folliculorum,  1047. 
Deni,ni(i,  '.»). 

Dentition,  in  conjicnital  syphilis,  171 ;  in  mer- 
curial stomatitis,  327  ;  in  rickets,  310. 
])ermatitis,  exfoliative  form,  73. 
Dennatobia,  1050. 
Desiccation  in  small-pox,  52. 
Desquamation,  in  inciuslcs,  78  ;  in  ruliella.  81 ; 

in  scuT'let  fever,  70 ;  in  Bmall-pox,  52 ;  in 

typhoid  fever,  15. 
Deviation,  secondary,  793. 
Devonshire  colic,  1007. 
Dextrocardia,  050. 
Diabetes  insipidus,  .305  ;  heredity  in,  305  ;  in 

al)dominal  tumor,  3O0 ;  in  tuberculous  peri- 
tonitis, 301). 
Diabetes    mellitus,    205  ;    acute    form,    208 ; 

ehronio  form,  208;  coma  in,  301;  diet  in, 

303;  dietetic  form,  203;  (fanirrene  in,  ."00; 

hereditary   influences    in,   205 ;    in   obesity, 

205;  in  children,  300;  lipocrenic  form,  208; 

neurotic  form,  20S  ;  pancrea.s  in,  21t(;,  207  ; 

pancreatic  form,   208 ;    paraplcjiia   in,  302 ; 

theories  of,  20(i ;  treatment  of,  302  ;  urine  in, 

'208, 
DittbetcB,  phospliatie,  735. 
Diabetic,  centre   in   medulla,  205;    cirrhosis, 

2117  ;  phthisis,  207  ;  tabe.s,  301. 
Diaeotic  ueid,  737. 

Diai;nosis,  topical,  in  brain-disenses,  8S7. 
Diaphrau'm.  ]iaraly>is  of,  811 ;  dcgciieriition  of 

niu.sclc  of,  8U, 
Diurrhuea,  388 ;    acute   dyspeptic,  3!t2 ;    alba, 

894 ;  bacteria  in,  391 ;  chronic,  treatment  of, 


400 ;  eliyloHU,  394 ;  endemic,  of  liot  coun- 
tries, 1030  ;  from  anchyWtomiasis,  1031 ; 
liiil,  305;  in  children,  treatment  of,  400;  in 
cholera,  121  ;  in  dysentery,  131,  135,  130;  in 
hysteria,  073 ;  in  ])hthisi.s,  220 ;  in  typhoiil 
fever,  2(»;  in  uricmia,  740  ;  nervous,  389;  of 
Cochin-Cluna,  1030  ;  tubular,  300. 

Diathesis,  j,'outy,  288,  201  ;  lithicmic,  733 ;  tu- 
bcrculoas  or  scrofulous,  192. 

]>iazo-reaction  in  typhoid  fever,  20. 

Dicrotlsm  of  pulse  in  typhoid  fever,  10,  17. 

Di(tt,  in  chronic  dyspepsia,  355;  in  constipa- 
tion, 422;  in  convalescence  from  typhoid 
fever,  38  ;  in  diabetes,  303  ;  in  frout,  203  ;  in 
infantile  diarrlicca,  401  ;  in  leprosy,  257  ;  in 
obesity,  1020 ;  in  scurvy,  310;  in  tuberculo- 
sis, 253 ;  in  typhoid  fever,  33. 

DiLTcstive  system,  diseases  of,  323, 

Dilatation,  of  bronchi,  405  ;  of  stomach,  304. 

Diphtheria,  00;  and  croup,  104,  482;  bacillus 
cif,  loo  ;  contagiousness  of,  99  :  diairnosis  of, 
108;  in  aninuds,  100;  laryn!,'eal,  104;  mor- 
bid anatomy  of,  102  ;  nephritis  in,  100  ;  neu- 
ritis in,  107  ;  of  nares,  104 ;  pseudo-diph- 
theritic processes,  101;  symptoms  of,  103; 
systemic  infection,  105  ;  treatment  of,  100. 

Diphtheritic,  colitis,  305  ;  mcmljrane,  histolon;y 
of,  102 ;  processes  in  pneumonia,  510  ;  pro- 
cesses in  typhoid  fever,  27. 

Diplcfiia,  facial,  708  ;  in  children,  909. 

Dij)lococcu8,  in  empyema,  504 ;  in  endocar- 
ditis, 590;  in  epidemic  cerebro-s])inal  menin- 
f.'itis,  93;  in  intluenza,  88;  in  jieritonitis,  403. 

Di[)loct)ceus  pneumonia',  403,  512, 

Diiiloiiia  (see  Double  Vision),  794. 

Dipsomania  (see  Ciironio  Alcoholism),  1001, 

Discrete  form  of  small-pox,  51, 

Disinfection,  method  of,  in  diphtheria,  100; 
in  typfloid  fever,  32. 

Dissecting  aneurism,  070. 

Distoma  hepaticum  ;  I),  lanceolatum  ;  1).  eras- 
sum  ;  D,  endemieum  ;  D,  pcrniciosuni,  1024, 

Distoma  Uiii'reri,  1025. 

Distomiasis,  1024. 

r-)ittnihh  plugs,  494. 

Diuresis,  305, 

Diver's  paralysis,  827. 

Diverticula  of  u'soiiluigus,  344. 

Dochinius  duodcnalis,  1031. 

Dorsodynia,  282. 

Dotliienenterite,  1.  • 

Double  vision,  704  ;  in  ataxia,  842. 

Dracontiasis,  1034. 

I>racuneuluB  inedincnsLs,  1034, 

Drainasrc,  and  dii)litheria,  09  ;  and  scarlet  fever, 
Oh;  and  tonsillitis,  332  ;  and  typhoid  fever,  4. 

Dreamy  .state  in  epilepsy,  950. 

T)repanidium  ranarum,  143, 

Dropsy,  cartliac,  treatment  of,  620  ;  in  anco- 


INDEX. 


1059 


tu- 


D.  crns- 
kuiu,  1024. 


Lrlct  fever, 
liidt'cvcr,4. 


l, ;  In  ance- 


inia  (uedeinu),  «9«  ;  in  acute  Bri^lit's  disciixe, 
742;  in  uortii;  iiisulHciitn(;y,  007;  in  aortic 
stulKwis,  (iO'.l ;  in  i-uucur  of  stoniucli,  ;!81  ;  in 
clironic  Brij<lit's  ili.suasc,  "Jt;  in  mitral  in- 
Hullioionfy,  (il'2;  in  initnil  stenosis,  CIS;  in 
jilitliisis,  J  ;0  ;  in  sfurli't  fevur,  72. 

l>ru;r-raslie.i,  74,  UK). 

Drunkcnnusa,  diui,'no.<is  from  upoplexy,  877, 
1001. 

Duchenne's  paraly.si!4,  3ii0. 

Duliic.H.s,  inovubli!,  in  pluural  ollu.sion,  502 ;  in 
pnouiuothorux,  570. 

Dumb  a<fue,  l.")"). 

Duoclonal  ulcer,  diairnosi.-i  of,  fro:n  jjasti'ic,  374. 

Duodenum,  defect  of,  415  ;  ulcer  of,  ;Ji)8. 

Dura  muter,  disea.ses  of,  820,  802;  liuiuiatoma 
of,  HO'2. 

I)tiraii(lc'«  mixture,  4:iS. 

DurozUz'ii  murmur,  000. 

Dust,  diseases  due  to,  534,  553;  tubercle  bacilli 
in,  187. 

Dy.saousis,  802. 

Dysentery,  l;)0 ;  abscess  of  liver  in,  133,  137; 
acute  catarrhal,  131;  amoeba  coli  in,  132; 
ebriinie,  130;  iliphtlieritic,  134;  treatment 
of,  138;  tropical  or  amcx'bic,  132. 

Dyspepsia,  acute,  348;  ebronic,  351  ;  nervous, 
3iiO;  treatment  of,  355. 

Dyspniea,  cardiac,  treatment  of,  020;  from 
aneurism,  075;  hysterical,  972,  982;  in  acute 
tulierculosi.s,  200 ;  in  bilateral  paralysis  of 
iibductors,  8U0  ;  in  cardiac  dibitation,  038;  in 
chlorosis,  089;  in  croup,  483;  in  diabetic 
coma,  301;  in  mitral  insutlieiency,  012;  in 
mitral  stenosis,  617;  in  pneumonia,  517 ;  in 
phtliisis,  222 ;  in  (edema  of  the  irlottis,  482  ; 
in  spasmodic  laryuiritis,  480  ;  urcumic,  739. 

Dysphagia,  hysterical,  310,  973;  in  cancer  of 
the  (jBsopliai,'Us,  343;  in  hydrophobia,  100; 
in  a>so))liaicisnms,  341 ;  in  uesophasjitis,  340; 
in  pericardial  etl'usion,  585;  in  thoracic 
aneurism,  070  ;  in  tulterculous  laryngitis,  488. 

Dystrophy,  primary  nmscular,  990. 

Ear,  complications  of  scarlet  fever,  73 ;  affec- 
tions of,  in  syphilis,  108,  171. 

Ears,  care  of,  in  scarlet  fever,  7(5. 

Eb)itfiii''s  metiiod  in  obesity,  1020. 

Eburnation  of  cartilages,  285. 

Echinococeus  disease,  lO'll. 

Echinoeoccus,  endogenous,  1012;  exogenous, 
1042;  fluid,  1042;  multllocular,  1040. 

Ecliinorhynchus  gigius;  K.  moniliformis,  1030. 

Eeliokinesis,  943. 

Echolalia,  943. 

Eclampsia,  945. 

Ectopia  cordis,  050. 

K/ir/ic/i^K  reaction  in  typhoid  fever,  20. 

Ela.stic  tissue  in  sputum,  221. 
67 


Electrical  reactions,  in  facia!  palsy, 799  ;  in  idio- 
pathic muscular  atrophy,  997  ;  in  Landri/'s 
paralysis,  830;  in  multiple  neuritis,  780 ;  in 
periodical  paralysis,  980 ;  in  i)olio-myelitis 
anterior,  833 ;  in  y7(r>//i,«(;«'((  disease,  999. 

Electrolysis  in  aneurism,  079. 

Elephantiasis,  1034. 

Emaciation,  in  anorexia  nervosa,  973 ;  in  ga«- 
trie  cancer,  378  ;  in  (esophageal  cjincer,  343  ; 
in  phthisis,  22.5. 

Embolism,  and  aneurism,  071 ;  in  chorea,  933 ; 
in  typhoid  fever,  19  ;  of  cerebral  arteries,  878 ; 
of  cerebral' arteries,  diagnosis  of,  880. 

Embryoeardia,  051. 

P''uphysoma,  544;  atrophic,  549;  compensa- 
tory, 544;  hypertrophic,  545;  hypertrophic, 
cyanosis  in,  547 ;  liypertroi)bic,  hereditary 
character  of,  545 ;  interstitial,  544. 

Emphysema,  subcutaneous,  alter  tracheotomy, 
580;  in  giustric  ulcer,  309;  in  plithisis,  230. 

Emprosthotonos  in  tetanus,  104. 

EniiiyoMui,  bacteriology  of,  504;  necessitatis, 
505,  077;  piM-foration  of  lung  in,  505;  ter- 
minations of,  505  ;  treatment  of,  570. 

Encephalitis,  meningo-,  chronic  dill'use,  914; 
meningo-,  foital,  909  ;  polio-,  of  Slfuiiijiell, 
907;  suppurative,  903. 

Encephalopathy,   lead,    1010;   syphilitic,   173. 

Enjhondroma  of  lung,  550. 

Endocarditis,  acute,  592 ;  chronic,  599 ;  dii)l!- 
tlicritic,  595;  etiology  of,  595;  in  chorea, 
595,  1132;  infectious,  595  ;  in  the  to'tus,  liOl, 
001  ;  in  gonorrlKca,  595;  in  pne\imonia.  595; 
in  puerperal  fever,  595  ;  in  rheumatism,  273, 
595 ;  in  septica'mia,  595 ;  in  tuberculo.sis, 
218,  594;  malignant,  594;  mcniiiiritis  in, 
595;  micro-organisms  in,  590;  n\ural,  590; 
recurring,  594;  .sclerotic,  i!01;sim\>le  or  verru- 
cose,  592  ;  syphilitic,  178  ;  ulcerative,  595. 

Endophlcbitis,  008. 

Enteric  fever  (see  Tvphoid  Fever),  1. 

Enteritis,  catarrhid,  388  ;  croupous,  395  ;  diph- 
theritic, 395  ;  in  children,  391  ;  phlegmonous, 
390  ;  membranous  or  tubular,  390  ;  ulcerative, 
397. 

Entero-colitis,  acute,  394,  405. 

Entcroclysis,  124. 

Enteroliths,  400,  410  ;  as  a  cause  of  appendici- 
tis, 400  ;  in  saeculi  of  colon,  421. 

Enteroptosis,  718,  719,  980. 

Entozoa  (sec  A>fiMAi,  P.vn.^siTEs),  1022. 

Environment,  in  tuberculosis,  250 ;  experiment, 
of  Trudeau,  250. 

Eoainophiles  in  leukajnita,  099. 

Ependymitis,  purulent,  805,  924 ;  granular,  in 
chronic  alcoholism,  915. 

Ephemeral  fever,  204. 

Epididymitis  (sec  OncniTis),  179,245. 

Epilepsia,  larvata,  953  ;  nutniu,  812. 


|l    !| 


I    II 


r 


1060 


INDEX. 


W^ 


Kpilciwy,  !)48;  iind  syphilis,  049,  Or4  ;  diiiirno- 
niHof,  '.153 ;  (ai()i(V'y  of,  1148;  hfivdily  in, 
l»41»;  ill  t'hi-oiiic  crffiitisiM,  lolT) ;  in  ju'iiiciu! 
imri'xis,  '.tlO;  in  Iciul  ix.isoiiiii^,  KUii;  in 
A'ai/iiainrK  ili.soa.sc,  !»ns  ;  in  sunstroke,  IDln  ; 
JachonidH,  h'.ir>,  '.);'>;)  ;  imwl<c'il,  ll,j;i ;  jih,.- 
noiiicnuof,  S12;  powt-qiileptic  Hyinptoiiis  of. 
".•.IL';  prooui-sivi-,  ii,")!  ;  rcttcx,  !t,"i() ;  rotiitory, 
U.'il  ;  Hiiinui,  b;is  ;  tturifioiil  trcutiiifiit  of,  <jr,i; ; 
trciitiiii'iit  of,  '.•.'ii"). 

Kpiii'ptic  ttt-f,  Mtiijics  of,  li.M. 
ICpistiixis,  478 ;  in  lia-iuopliiliii.  ;i-_'l  ;  in  scurvy, 
.•(14;  in  typhoid  fuvcr,  •£',;  "  ri'iiul,"  7^3;  v'i- 
C'urious,  47'.'. 

Kpithelioid  I'l'lls  in  tuhcri'lo,  T.i,">. 

Krftotisin,  UU,".;  convulsive,  loi,->;  (rim^frcnoiis, 
lOIfl. 

Krifliit(ii\  disduMo  (riiilwuy  spine),  Itfsl. 

Erosion  of  tt'eth,  'iT,. 

Krroni'ous  projection  from  strahisnuis,  71)4. 

Kruetiitioiis,  3,')3. 

Eruptions  (see  Rasiiks). 

Erysipelas,  110;  ahsecss  in,  li;{;  after  vaccina- 
tion, 01  ;  coniplications  of,  li;i;  diiyiiosis  of, 
11;!;  facial,  112;  /•;///</«,«'*•,  strei)tococcus 
of.  111;  in  typhoid  fever,  •_'7 ;  nii)irnuis,  11.". ; 
piieriieral,  HI. 

Erythema,  exudativiim,  ,T17;  in  pella^rni,  HHii; 
in  typhoid  fever,  1.'). 

Erythrodextrin,  test  for,  in  jriustric  juice.  ."47. 

Erythromelalifia,  \HVL 

Eschar,  r.loufthiiitr,  in  lieiiiiplegia,  874. 

Eustronirylus  tritfus.  lo;'>(!. 

Exaltation  of  ideas  in  ffeneral  paresis,  910. 

Exanthen'"tic  typhus,  .39. 

Exfoliative  dermatitis,  73. 

Exophthalmic  {ro'tre,  71 '2;  acute  fonu,  7l'-i; 
diminution  of  electrical  resistance  in,  714; 
piiruieiitatioii  in,  71!!,  tremor  in.  711!,  urti- 
caria in,  714. 

Extierts,  medical,  function  of,  in  railway  cases, 
!IH4. 

Eye,  motor  nerves  of.  paralysis  of,  79.". 

Eye-strain  in  miirraine,  9.'>7. 

Eyes,  conjugate  deviation  of,  in  brain  tuinor, 
9'Jl ;  in  liemipleijria,  iS74;  in  meiiiiyiti.s,  'J04. 

Facial,  asymmetry,  810,  990  ;  diplegia,  798  ; 
hemiatrophy,  990 ;  nerve,  paralysis  of,  797  ; 
I>iiralysis  from  cold.  798  ;  jiaralysis  from 
lesion  of  trunk  of  nerve,  798  ;  paralysis 
from  lesion  of  cortex,  797  ,  paralysis,  symp- 
toms of,  798. 

Facial  spasm,  800. 

Facies,  Illppdcrafic,  4(:4  ;  leontinn.  in  lopro- 
liy,  L'.)8;  in  niouth-bivathers,  337;  Birkin- 
nonian,  928,  syphilitic,  171. 

Fcecal.  accumulation,  410,  421 ;  concretions,  400, 
421 ;  vomiting,  419. 


Fa-ees,  hacteria  in.  ;!91 ;  in  Jaundice,  42-1.       r 
Fulkenstein  Siuiiliuiiiiii,  2.")2. 
Fallopian  tulii>.  liilicrculosis  of,  24.">. 
Famine  fever     'i  UKi.Ai-si.N.i  Fkvku;,  43. 
Farcy,  acute,  •."■n;  chronic,  200. 
Farcy-liuds.  -.•.■■i'. 

/'((/■/•(■'w  tulii '' -i'^.  ■1'"'2. 

Fut  eiiil)()li>iii  in  diuhetes.  801. 

Fat  iiecrosi;-,  l'i9  ;  of  pancreius,  in  diabetes,  298. 

Fatty  deiri  Miration,  in  anii'inia,  091 ;  of  lieurt, 

042;  III'  liiiliieys,  747  ;  of  liver,  4.')5. 
Fatty  sti-ils,  4ill. 

FebriculM.  -'04. 

Febris.  riiriii.s,  39 ;  eomiilicata,  207 ;  rccurrenH, 

4;i. 
Fi-hliiii/s  test  for  HUjjar,  299. 

FerniiiUation,  fever,  114;  test  for  sujjar,  291). 

Fever,  ill  cholera,  121  ;  jrnt'tric,  34.H  ;  liystericat, 
97''i ;  pernicious  malarial,  1,V'!;  in  piieumoniii, 
,'il7;  in  aciitti  pneumonic  phthisis,  2Iii,  211 ; 
ill  anite  miliary  tuberculoses,  199 ;  in  primary 
imiltiple  i'.oiiritis,  777  :  in  meninj;itic  tuber- 
(ulipsis,  2'';:;  in  pulmonary  tuberculosis,  222; 
ill  pya'iiiia,  117;  in  i>yleplilebitis,  suppura- 
tive, 4.'")Ci;  in  interiiiitteiit  fever,  \'^^\  in  ro- 
lalisiiiu'  fever,  4.");  in  remittent  fever,  1.">1 ;  in 
scarlet  fever,  70;  in  septicieiiiia,  114;  in 
simill-iM»x.  .50;  in  sun-stroke,  Uil8;  m  a|)|)en- 
dicitis,  410;  in  .secondary  syiiiiilis,  107;  in 
tyiihoid  fever.  1;! ;  in  yellow  fever,  127  ;  luiiif, 
.Ml;  Malta,  200;  Mediterranean,  200;  Nea- 
l>olitan,  200;  sliij),  39;  splenic,  150;  spotted, 
39;  typho-iiialarial,  l.">2;  yellow,  127. 

Fever;  intermittent,  in  ab.scess  of  liver,  448; 
in  ajrue,  l.")0;  in  chronic  ob.struction  of  bile- 
liassai;es,  43.");  in  fjastric  euncer,  381  ;  in 
lltkhjkin^n  discfuse,  7(17;  in  pyicmia,  117;  in 
pyelitis.  700  ;  in  .secondary  s>phili.s,  107  ;  in 
tuberc'ulosis,  219,  223. 

Fibrillation,  8,19. 

Fibrinous,  broiichitLs,  501  ;  pneumonia,  511. 

Fibro-caseous  chan|.fe  in  tubercles,  190. 

Fibroid  di.sease  of  heart,  041. 

Fi^vre,  inflaitimatoire,  1019;  typholde  k  fornio 
r(5nale,  20. 

Fifth  nerve,  paralysis  of,  795  ;  jrustatory  branch, 
790;  symiitoms  of,  790;  trophic  chimges  in 
parnly.sis  of,  790. 

Filuria,  Bancrnftl,  1032;  mpdincnsis,  1034', 
sanifuinis  hominis,  1032. 

Filaria  loa;  F.  lentis;  F,  labni'.:.^;  F.  hominis 
oris;  F.  bronchialis;  F.  iinitis,  1035. 

Filariasis,  1032. 

First  sound  of  heart,  obliteration  of,  in  typiioid. 
fever,  17. 

Fish,  poisoniiifT  by,  1014. 

Fin/wr^H  brain  murmur,  310. 

Fistula  in  ano  in  phthisis,  233.  241. 

Flagellated  organisnis  in  blood  in  nmlunn,  143. 


WnmstVBtWTr/^^jtif-' 


INDEX. 


1061 


Flatuk'Uuf,  in  liy.-<Utr\ii,  'J"!!;  in  riorvous  liyx- 

|u;|).sia,  IWi.". ;  tn^iituiciit  of,  lii'iH. 
Fliiit^K  iimriiiur  in  hciirt-ilisfunn,  <R'5,  (ilii. 
Floutinjc  kidni'.v,  717. 
l''li)riilii  t'ovor,  lOlli. 
Fliii<(',  iironi'iiial,  Kii'>. 
Kiukos,  (liNi'uscH  t'iiU!<i'<l  by,  l(i:il. 
l'"u^tul  iK'urt-rliytlnn,  (i'll. 
Fnitus,  utuloi'iirilitiN  in,  <'><iO;  Hypliilis  in,  1(19; 

tul)i'rciii<»si«  in,  1H7,  1M8. 
Folic  l{ri};iiti(iui),  MH. 
Foliiciiliir  colitis,  !i',i4. 

Food  (^SCI!   DlKT). 

Foot-ilrop,  777,  778. 

Fori'itrn  iHulios  in  intestines,  41ti. 

Fourtii  lUTvi'.  ~'ri\  ;,umlysi«  of,  7'.t3. 

Friu'tuivs  in  ricki'tH,  .'ill. 

Fremitus,  vpciil,  W.'),  .".'JO;  hydiifiil,  lot;i. 

Frosli-air  treatment  in  tul)ere\il()sis,  ^."lO. 

Frii'tiou,    periearilial,    f)^:i ;     peritoneal,    4ii«; 

lileiu'ul,  227,  M-2,\  pleuro-perieardial,  'iit. 
Frici/n !c/i''k  ataxia,  Htn. 

Friiilrolcl(\'<  sii;n  in  adherent  pcrieardiuin,  o'MK 
Frontal  eonvoliitions,  lesions  of,  1(20. 
Fntntal  sinuses,  jientastonies  in,  1047. 
Funjii  in  pulmonary  eavities,  222. 

(lait,  ataxic,  84.'?;  in  iiseudo-liypertrophic 
inuseular  paralysis,  '.tlMi ;  in  spastic  jiara- 
lilei;ia,  s;iT  ;  pscudo-talietic,  84.') ;  stcppaj^e, 
.'1  peripheral  neuritis,  770. 

Gull-bladder,  atrophy  of,  4;!4;  calcification  of, 
4:i4  ;  dilatation  of,  4;33  ;  empyema  of,  4;!4; 
forminfT  abdominal  tumor, 4U3;  phlugniouous 
inflammation  of,  4;}4. 

(iall-stones,  4;il. 

(iuUop-rhythhi,  0.")1. 

(ialloi)iiiLr  coiisumi)tion,  200. 

(ialvano-puncture  in  aneurism,  (170. 

tiame-birds,  poisoniiiff  by.  Kil4. 

(iantflia,  basal,  tumors  of,  02i). 

(ian<:renc,  in  diabetes,  ;iOO;  in  erjrotism,  101.'); 
in  p:ieunn)iiia,  .")27  ;  in  typhoid  fever,  10;  in 
typhus,  42;  local  or  symmetricul,  Oas;  of 
lunjt,  i>M\  01  mouth,  ;)2t>. 

(raiTuWn  thread  test  for  uric  acid,  280. 

(ia.strali{ia,  .■i.'>0. 

(liLstreetiLsis,  3ti4. 

(lastric,  crises,  844 ;  fever,  .".48. 
.  (Jiustric  juice,  ehemieal   examination  of,  .'545; 
liypenicidity  of,  8(51,  370;  subivcidity  of,  301. 

(tustr'c  ulcer,  308;  clinical  forms  of,  372. 

(Jastritis,  acute,  348;  acute  suppurative,  .^oO; 
chronic,  3.")1 ;  diphtheritic,  .'iol  ;  membranous, 
;!.'d  ;  mycotic,  3.")1  ;  parasitic,  3.")l ;  phlejjmon- 
ous,  3.'')0 ;  poly|Kisa,  S.'iS ;  sclerotic,  3r)2 ;  sim- 
ple, 348 ;  simple  chronic,  3.52 ;  toxic,  3nO. 

liastrodynia,  350. 

(liistrorrhttj^ia,  385. 


(iastrotomy,  343. 
(iastroxynsis,  :u\\. 

(ieiieral    paralysis  of  the   ilisatlfl  (i{cn(!ral   pa- 
resis), 014;  dia;,'nosis  of,  from  syi)liilis,  17;', 
017;  intlueiice  of  syphilis  in,  173. 
(ieiiito-urinary  system,  tuberculosis  of,  243. 
(iirliii'x  disease,  804.  ' 

(iernum  measles,  M. 
(liant  cells,  105. 
(iiifantoblasts,  (i03. 
^/<7A(/'rw  syru]),  is'i, 
(lUlm  lis-  III  T(iuritti\  disease,  043. 
(iin-ilrinker's  liver  (see  CiitHUosis  ok  Livkk), 

4-10. 
Girdle-feelin;;  in  transverse  myelitis,  8.30. 
Glanders,  250;  aeuti;,  2(!0;  chronic,  2tJ0;  diag- 
nosis from  suudl-pox,  58. 
(ilioma  of  brain,  018. 
Gliosis,  840. 
Globulin  in  urine,  728. 
Globus  hystericu.s,  008. 
Glomerulo-tiephritis,  742. 
(ilosso-labio-laryti;;eal  pn.  ilysis,  800. 
Glosso-pharyn.i,'cal  nerve,  8o5. 
(ilossy  skin  in  arthritis  deformans,  285. 
(Jlottis,  fedemu  of,  481 ;   in  Uriffht's  diseiiso, 
481,    743  ;    in    small-pox,    55  ;    in    typhoid 
fever,  0. 
Gluteal  nerve,  817. 
Glycojjfen,  formation  of,  20(1. 
Glycoifenie  function  of  liver,  290, 
Glycosuria,  200,  737;  gouty,  203. 
(iiiiifhi'K  test,  424. 
Goitre,  711;  exophthahnie,  712;  suddeii  death 

in,  711;  symptoms  of,  711. 
Gonorrhuial     rheumatism,     270  ;    anatomical 

changes  in,  270;  endocarditis  in,  280. 
Gout,  2S7  ;  acute,  200;  chronic,  201;  £hxUiii'''< 
theory  of,  2.-^8;  etiology  of,  2^7;  hereditary 
influence  in,  287 ;  influcnee  of  alcohol   in, 
287  ;  influence  of  fixxl  in,  287  ;  influence  of 
lead  in,  288  ;  irregular,  201  ;  morbid  anatomy 
of,  288;  nervous  theory  of,  28s ;  rctrocedent 
or  suppressed,  20O  ;  symptoms  of,  20O  ;  treat- 
ment of,  203. 
Graefe''s  sign,  713. 
Grain,  jxiisoning  by,  1015. 
(irandeur,  tlclusions  of,  910. 
(irand  nud,  048. 
Granular  kidney,  749. 
Gravel   r<  •ml,  70.5. 
^;/'C()'(V/(  disea.sc,  71'2. 
Green-sickness  (.see  Chlorosis),  686, 
(ircen-stiek  fracture  in  rickets,  311. 
Gregarinidu>,  1022. 
Grinder's  rot,  558.  .      > 

Grippe,  la,  87. 

(iuaiacum  test  for  blootl,  723, 
Guiuea-worin  disease,  1034. 


I 


1062 


INDEX, 


Gunimntn,  in  ncquiird  ayphilitt,  HSO;  in  oon- 
f,'(!iiitul  sypliilis,  17'J;  of  l)rain  mul  Hpimil 
(iord,  17-;  ofluMii-t,  17H;  of  liidnc.VM,  17!»;  of 
livtT,  17i>;  of  luni,'s,  175;  of  rectum,  178;  of 
totiM,  17il;  titructuro  of,  1()7. 

(iiiinuiiitous  ])i'riurtcritiH,  17!'. 

Gums,  liliK'li  lino  on,  in  niinorn,  1000;  idiic 
line  on,  in  Iciul  poisonini;,  IdO.H;  in  Hfurvy, 
31t;  in  stomatitis,  3l!t;  red  linu  on,  in  [ml- 
nioniiry  tulwroulosis,  'J'28. 

(JuHtatory  piinilysis,  7i)<). 

Habit  spasm,  !)4'2;  in  inoutli-bn-athors,  3:i7. 

Habitus,  apoplfotio,  870;  plitiiisicus,  1!)2. 

Huematomt'sis,  SSft ;  causes  of,  SiM") ;  diasfnosis 
from  hiEnioptysis,  ;!87  J  in  enlarged  spleen, 
154;  in  scurvy,  314. 

Hremato-cliyluria,  non -parasitic,  730;  pani- 
sitie,  1033. 

HuJinatogcnous  jaundice,  4'23. 

Hinmatonm  of  dura,  of  bruin,  8i>:i ;  of  eord, 
8iil 

Hicinatomyclia,  821!. 

llicmatorrliaelns,  824. 

Hoimatozoa  of  malaria,  140,  142. 

Jlicmuturia,  7'2'i  ;  lus  a  sign  of  scurvy  in  chil- 
dren, 315;  ondendc,  of  Kgypt,  1024;  in  acute 
ncpliritis,  742;  in  chronic  phtlnsis,  230;  in 
psorospermia.sis,  1023 ;  in  renal  calculus, 
7il8 ;  in  renal  cancer,  770 ;  in  tuberculosis 
of  kidney,  244 ;  malarial,  153. 

Hicmoglobin,  reduction  of,  in  cldornsis,  087. 

Hicmoglobinuria,  723;  epidemic,  in  infants, 
171,724;  in  Jiai/naniVn  disease,  988;  puro.v- 
ysnud,  724;  toxic,  724. 

Hiemolysis,  in  pornicious  anosmia,  OOO ;  in  toxic 
lioemoirlobinuria,  725. 

HoBmo-pcricardiuni,  5ill. 

Hemothorax,  StiO. 

Hsemophilia,  320. 

Haemoptysis,  causes  of,  SOli ;  hysterical,  972 ; 
at  onset  of  phthisis,  219;  in  acute  bronclio- 
pncumonic  phtliisis,  213 ;  in  acute  tubercu- 
losis, 200  ;  in  aneurism,  507  ;  in  aortic  insuf- 
ficiency, G07 ;  in  arthritic  subjects,  507 ;  in 
lironehiectasis,  497;  in  cirrhosis  of  lung, 
535;  in  emphysema,  549 ;  in  miliary  tuber- 
culosis, 200;  in  n)itral  insufficiency,  012;  in 
nntral  stenosis,  018  ;  in  pneumonia,  519  ;  in 
indnionary  gangrene,  551 ;  in  scurvy,  314 ; 
symptoms  of,  507  ;  treatment  of,  509  ;  in  ty- 
phoid fever,  24 ;  relation  to  tulierculosis, 
507  ;  ]iarasitic,  1025  ;  periodic,  507  ;  vicari- 
ous, 507. 

Hrcmorrhago,  cerebral,  870 ;  in  acute  yellow 
atrophy,  427 ;  in  anoemia,  093 ;  in  cirrhosis 
of  the  liver,  443  ;  in  contracted  kidney,  753  ; 
in  hicmophilia,  321 ;  in  hysteria,  972,  974 ; 
in  intu.ssuseeption,  419;   in  leukoumia,  098; 


in  malaria,  153, 154;  in  ncp)irolithiu.sis,  7C8; 
in  ])urpura  hamiorrhagicu,  olil;  in  scarlet 
fever,  71;  in  scurvy,  314;  in  smiill-pox,  52  ; 
in  si)lenic  enlargtiment,  154,  88.">,  702 ;  into 
spinal  cord  820  ;  in  tuberculous  pyelitis,  244  ; 
into  ventricles  of  brain,  872 ;  in  tyi)lioid 
fever,  2i  ;  in  yellow  lever,  127;  pulmonary, 
222. 

1  hemorrhagic  diathesis,  :]->0. 

Hair  tumoM  in  stonuich,  381. 

lluir,  the,  in  typhoid  fever,  10. 

Ilallueiiuitions  in  hysteria,  975. 

Handwriting  in  general  paresis,  910. 

//(irri'ii(>)i\i  groove  in  rickets,  310. 

Ilarvest-bug,  1048. 

Ilay-asthnui  (hay-fever),  477. 

Jleudache,  from  cerebral  tumor,  919;  in  cere- 
bral sy])liilis,  173  ;  in  mouth-breatiicrs,  337  ; 
in  typhoid  fever,  10,  U,  24;  in  uncmia,  739; 
sick,  957. 

Hcad-elieesc,  poisoning  liy,  1013. 

1  lead-tetanus  of  A'w,',  104. 

Heart,  diseases  of,  r)()2 ;  diseases  of,  Oi'HeVit 
treatment  of,  040  ;  amyloid  degencracion  of, 
043  ;  aneurism  of,  040  ;  athlete's,  002  ;  brown 
atrophy  of,  043  ;  ealcareons  degeneration  of, 
043;  congenital  afl'eetions  of,  059  ;  di'ntation 
of,  035  ;  displacement  in  pleuritic  etfusioii, 
500 ;  dis])lacemetit  in  j)neumotliorax,  575 ; 
fatty  disease  of,  042  ;  fragmentation  of  fibres 
of,  C42 ;  liydatids  of,  048  ;  hyijertrojihy  of, 
028;  hypertrophy  of,  in  Uright's  disease, 
753;  in  exophthalmic  goitre,  713;  irritable, 
039,  049  :  j)alpitation  of,  (i49  ;  parenchynui- 
tous  degeneration  of,  042  ;  rujiture  of,  047 ; 
sclerosis  of,  641  ;  valvular  diseases  of,  002. 

Heart-failure,  in  diphtheria,  107 ;  treatment 
of,  in  typhoid  fever,  38. 

IIeart-inuscle,in  fcvei-s,  042. 

Heart-valves,  anomalies  and  lesions  of,  GOO ; 
rupture  of,  003. 

Heat,  exhaustion,  1017  ;  stroke,  1017. 

7/fi«Y/«»'K  nodosities,  284. 

Hebrews,  prevalence  of  diabetes  among,  295. 

Hectic  fever,  224. 

Heel,  painful,  901.  '' 

llelUrh  test,  727. 

Helminthiasis  (see  Animal  Parasites),  1022. 

Hemeralopia,  785  ;  in  scurvy,  315. 

Ileiniachromatopia,  787. 

Hernial bumose,  728. 

Homianresthesia,  in  cerebral  hosmorrbage,  875  ; 
in  hysteria,  971 ;  in  lesions  of  interi\al  capsule, 
897  ;  in  unilateral  cord  lesions,  854. 

Hemianopia, heteronymous,  787;  homonymous, 
787 ;  in  nngraine,  957  ;  lateral,  787 ;  nasal, 
788  ;  significance  of,  790  ;  temporal,  787. 

Hemicrania,  957. 

Hemiplegia,  874  ;  crossed,  875. 


I 


INDEX. 


1003 


llcrniplc^'iu,  inraiitilt;,  tiOO ;  aiiliiutiii  in,  '.mis; 
t'pllcjisy  in,  ".M)H  ;  in  liybteriii,  ittilt ;  nicntiil 
(ict'ei.'t«  ill,  !i(i>s  ;  po.st-tit'inipit'ffic  movunii'Uts 
in,  !i08  ;  hjiiir-ticii  ci'iv'irulis,  li(i8. 

Ilctnipl^^^ic  fius(iui',  h7<!. 

Hepatic,  iil)sc'es»,  440;  artery,  eiiliirfrenient  of, 
4-Jii;  colic,  4;VJ;  interniiltent  t'uver,  435;  vein, 
ufleetioni*  of,  4i!!). 

Hepatitis,  diiruao  syphilitic,  IVfi ;  interwtiliul 
(see  CiKiiiiosis),  44(1;  Kiippiirative,  44f'i. 

Hepatization,  of  limjr,  514  ;  wliite,  of  fu'tus,  175. 

HepatogenouH  jaundice,  42.'!. 

Heredity,  in  BrijfhtV  discuNc,  74lt ;  in  diabe- 
teH  insipidus,  305;  in  liieniopljilia,  3'_'l) ;  in 
idiopathic  niiiscular  atrophy,  li'.H! ;  in  tuber- 
culosis, 187  ;  in  tuberculosis,  chart  of,  188. 

Herpes,  in  trifacial  neurul^fia,  OOO ;  in  ccre- 
bro-spinal  uieniniritis,  05;  in  febricula,  2(!5  ; 
in  nuilarla,  150 ;  in  pncuiiioniu,  521 ;  zoster, 
<J(!1. 

Hiccouffh,  liystcrical,  !)72. 

Hiffh -tension  pulse,  characters  of,  753. 

Hill  diarrhu'a,  .">05. 

Hippocratic,  liicies,  4iJ4  ;  lingers,  230;  succus- 
sion,  57(i. 

Hippus,  ii58. 

llodjrkin's  disease,  704;  intermittent  fever  in, 
707  ;  morbid  aiuitoiiiy  of,  704 ;  syniptonis  of, 
705. 

Horn-pox,  54. 

Hot  Sprinj^s,  of  Virsjiiiia,  271t ;  of  Arkansas, 
270;  of  Banff,  279. 

Iluntingiliin'li  chorea,  044. 

Husband  and  wife,  tuberculosis  in,  101. 

Iltitchinson''ii  teeth,  171. 

Hyaline  easts  in  urine,  742,  748,  753. 

Hybrid  measles,  81. 

Hydatid  disease  (see  EciiiNorofci's),  1041  ; 
prevalence  of,  in  America,  1043. 

Hydatid  thrill  or  fremitus,  1043. 

Hydrarthrosis,  chronic,  2S0. 

"  Hydrocei)haloid  condition,"  303,  SCO. 

Hydrocephalus,  acquired,  023  ;  acute,  201  ; 
chronic,  022;  chronic,  after  eerebro-spinal 
meningitis,  07 ;  congenital,  022 ;  siiurious, 
303. 

Hydrochloric  acid,  tests  for,  in  gastric  juice,  34fp. 

Hydromyclus,  840. 

Hydronephrosis,  702;  congenital,  702;  inter- 
mittent, 703. 

Hydroiiericardium,  501. 

llydroperitonannn,  469. 

Hydrophobia,  150. 

Hydrops  vesica!  fulle»,  43.3. 

Hydrothorax,  .574. 

Hyperaeusis,  802. 

Hypcnesf'.csia,  in  ataxia,  843 ;  in  hysteria,  071  ; 
in  rickets,  .300 ;  in  unilateral  cord  lesions,  854. 

Hyperosmia,  783. 


Hyperpyrexia,  liystcrical,  070;  in  rheumatic 
fever,  273;  in  scarlet  fever,  71  ;  in  sun-stroku, 
lOlH  ;  in  tetaiMLs,  104. 

IlypnoliMiii  in  hysteriii,  fl7ft. 

Hypochondriasis  and  neurasthenia,  97'^. 

Hypodermic  syringe  in  diagnosis  of  pleural 
crt'usion,  508. 

Hypoglo.^fsal  nerve,  iliseascs  of,  812 ;  paraly- 
sis of,  812  ;  spasm  of,  813. 

Hypophysis,  tumor  of,  992. 

Hyjiojilasia  of  aorta,  087. 

Hypostatic  congestion,  in  typhoid  fever,  24 ; 
of  lungs,  505. 

Hysteria,  007 ;  contractures  and  spasms  in, 
000  ;  convulsive  forms  of,  008;  cries  in,  072; 
diagnosis  of,  070  ;  disorders  of  sensation  in, 
071 ;  etiology  of,  007  ;  forms  of  fever  in,  075  ; 
liu'iiioptysis  in,  072;  insanity  in,  075;  joint 
all'eetions  in,  ti74  ;  mentid  symptoms  of,  074  ; 
metabolism  in,  075;  inetallotherapy  in,  071  ; 
non-convulsive  fornift  of,  000;  paralysis  in, 
009  ;  special  senses  in,  972  ;  stigmata  in,  317, 
074;  traumatic,  081  ;  treatment  of,  070;  vIb- 
ceral  numifestations  of,  072. 

Hysterical  angina  pectoris,  057. 

Hystero-epilepsy,  ii53,  008. 

Hysterogenic  points,  971. 

Icc-crcam,  poisoning  by,  1014. 

Ice,  typhoid  bacillus  in,  4. 

Ichthysnius,  1014  ;  paralyticus,  101,5. 

Icterus  (see  Jaundice),  423 ;  acute  febrile, 
205  ;  gravis,  420  ;  neonatorum,  425. 

Idiopathic  aiuemia  of  Addison,  080. 

Idiocy  in  infantile  hemiplegia,  008. 

Ileo-ciecal  region,  in  typhoid  fever,  22  ;  in  ap- 
pendicitis, 410;  in  primary  tuberculosis  of 
bowel,  241. 

Ileus  (see  STiiAxnti.ATioN  of  Bowki.).  413. 

Imbecility  in  infantile  hemiplegia,  008. 

Imitation  in  chorea,  032. 

Impotence,  in  diabetes,  302;  in  locomotor  ata.v 
ia,  844. 

Incarceration  of  bowel,  413. 

Ineodrdinatioii,  of  arms.  843  ;  of  legs,  S43. 

Indians,  American,  chorea  in,  030;  consump- 
tion in,  185  ;  sniall-pox  uinoiig,  47. 

Indicanuria,  73,5. 

Infantile,  convulsions,  045  ;  paraly'>is,  831. 

Infantilism,  171. 

Infarcts,  hicmorrhagic,  in  ty[)hoid  fever,  19; 
pyteinic,  110. 

Inflation  of  bowel  for  intussusception.  420. 

Influenza,  87;  diagnosis  of,  80;  etiology  of, 
88  ;  symptoms  of,  88  ;  treatment  of,  80  ;  com- 
plications of,  SS. 

Inhalation-pneumonia  (see  Aspiuatio.v  Pneu- 
monia), 5.37. 

Inhibition  centre  of  Kroiiecker,  049. 


! 


3 


i 


1064 


INDEX. 


f 


I 


1^' 


Injection,  introvonoHs,  of  milk,  l'i4  ;  intrn- 
vi'iiotix,  (if  milini'H  in  dinlit'tcw,  .'!0") ;  siil^'U- 
tiuu'du.H,  of  HiiiincH  in  clidU'rii,  124. 

Inoouliition,  ajfiiinut  Hnmll-i>o.\,  4tl,  r>4  ;  pro- 
tective, in  elioierii,  I'2M  ;  jiroteetive,  in  liyilro- 
lilioliin,  Iill  ;  ])rotec'tive,  in  ])neiniioniii,  T)!.'!; 
jimteetive,  in  yellow  fuver,  l-j'J  ;  tulierouloHis 
tnitwniitted  by,  188. 

In.-dinity,  jKint- febrile,  2.");  in  ntuall-pox,  .'i.'). 

InHiinify.  relation  of  drink  to,  loii-j;  relations 
of  elironie  phtliittis  to,  22i) ;  relation  of  heurt- 
diseaHC  to,  tJ07. 

Inneets,  pariusilie,  10 18. 

Involution,  1017. 

Insular  Mclerosis,  913. 

Jiitention  tremor  (see  Volitional  Tkemok). 

Intermittent  fever,  147;  forms  of  (see  Fevkk). 

Intermittont  lieputie  fever,  4:i5. 

Internal  capsule,  lesions  of,  8i)7. 

Internal  carotid  artery,  blocking  of,  881. 

Intestinal  easts,  VMt. 

Intestinal  coils,  tumor  formed  by,  2.38. 

Intestines,  diseases  of,  yS8;  aetinomyeosis  of, 
2112 ;  dilatation  of,  403. 

Intestines,  lia-morrhage  from,  in  typhoid  fever, 
8.  21 ;  in  dysentery,  ieil,  ;;!,">;  in  tuberculosis 
o'  bowel,  240;  in  intussu.^ception,  41'.t;  in 
ulceration  of,  :i'f,. 

Inttstines,  infare'aon  of,  404 ;  i.itussuseepfion  of, 
414,4!'.';  ;:;.ajjinationof. 41v  ;  miscellaneous 
atl'ections  of,  403 ;  new  gvnv  tlis  in,  415. 

Intestines,  obstruction  of  4l3,  41!");  acute,  4111; 
by  enteroliths,  41  (j ;  by  foreign  bodies,  410; 
l>y  frail-stones,  410. 

Intestines,  perforation  of,  in  typhoid  fever,  7. 

Intestines,  primary  tuberculosis  of,  240 ;  stran- 
gulation of,  413, 418 ;  strictures  and  tumors  of, 
415;  twi.'its  and  knots  in,  415;  ulcci-s  of,  3'j7. 

Intoxications,  1001. 

Intussusception,  414,  419. 

Invagination,  414;  post-mortem,  414. 

Invei'se  type  of  temperature,  in  tuberculous 
meningitis,  199;  in  typhoid  fever,  13. 

Iodide  eruptions,  183. 

Iridoplegia,  792;  uceominodative,  792;  refle.x, 
792. 

Iritis,  syphilitic,  108, 171. 

Itch,  1047. 

Itch  insects,  1047. 

Itching,  of  feet  in  gout,  292;  of  eyeballs  in 
gout,  292 ;  of  skin  in  Bright's  disease,  754. 

Ixodes  ricinus ;  I.  aincricanus,  1048. 

Jacksonian  epilepsy,  895,  953. 

Japan,  Beri-beri  in,  780;  endemic  fluke  dis- 
ease in,  1024. 

Jaundice,  black,  424 ;  catarrhal,  430 ;  choluria 
in,  424;  from  cirrhosis  of  liver,  443,444;  epi- 
demic form  of,  430 :  febrile,  205 ;  from  acute 


yellow  atrophy, 42(1 ;  from  cancer ofliver, 454 ; 
from  gall-stones,  433,  435;  lia'iiiatogenous, 
423;  hepatogenous,  423;  in  i>neumonia,  521 ; 
in  li'iil'n  disease,  205;  malignant,  420;  of 
the  newborn,  425;  xanthelasma  in,  424;  in 
yello"  fiver,  127. 

Johns  Hopkins  Hospital,  statistics  of  tubercu- 
losis at,  185,  ISM. 

Joints  (see  .\nTiiniTi8). 

Jumpers,  943. 

"June  e.ild,"  477. 

Keloid  «i  Addison,  993. 

Keratitis,  in  small-pox,  50;  intei-stitiul,  of  in- 
herilcd  sypliilis,  171. 

Keratosis  follicularis,  1023. 

Kiiliiey,  diseiLHcs  of,  717;  amyloid  or  lardii- 
eeous  disease  of,  757 ;  anomalies  in  form  and 
]iosition  of,  717  ;  conccr  of,  770  ;  cardiac, 
722;  circulatory  disturbance  in,  721;  cirr- 
liosis  of,  749;  congenital  cystic,  772;  con- 
gestion of,  721 ;  contracted,  749 ;  cyanotic  in- 
duratiin  of,  722 ;  cystic  disease  of,  772 ;  echi- 
nococcus  of,  1045;  fused,  717;  gouty,  749; 
granular,  749;  liorseshoe,  717;  large  white, 
740,  747  ;  movable,  717. 

Kidney,  removal  of,  for  cancer,  771 ;  for  mova- 
ble kidney,  720. 

Kidney,  rhabdo-niyonia  of,  770;  sarcoma  of, 
770;  Bcrofuloiu,  244;  small  white  kidney, 
747;  surgical  kidney,  75i);  syijhilis  of,  179 ; 
tuberculosis  of,  243;  tumors  of,  770;  unsyni- 
metriciil,  717. 

Knee-jciii,  loss  of,  in  ataxia,  842 ;  in  diphtheria, 
108. 

Koch  treatment  of  tuberculosis,  252. 

Lactic  acid,  test  for  in  ga.stric  juice,  340. 

Landry^s  jfaralysis,  835. 

Lardaceous  degeneration  (sec  Amvloid). 

Larvic  of  flies,  diseases  caused  by  (myiasis), 
1050. 

Laryngeal  crises,  844. 

Laryngismus  stridulus,  486. 

Laryngitis,  acute  catarrhal,  480 ;  chronic,  481 ; 
'membranous,  482  ;  oedeinatous,  481 ;  spas- 
mcxlic,  480 ;  syphilitic,  489  ;  tuberculous,  487. 

Larynx,  diseases  of,  480,  800;  adductor  jiaral- 
ysis  of,  807 ;  anicsthesia  of,  808 ;  hypencsthe- 
sia  of,  808;  paralysis  of  abductors  of,  807; 
spasm  of  the  muscles  of,  808 ;  unilateral  ab- 
ductor paralysis  of,  807. 

Lata,  943. 

Lateral  sclerosis— primary,  837;  amyotrophic, 
857. 

Latcritious  deposit,  732. 

Latliyrism,  1016. 

Lavage,  357 ;  in  dilatation  of  Btoniooh,  367 ;  ia 
gastric  ulcer,  375. 


INDEX. 


1006 


Leod,  colic,  1000;  in  the  urine,  1008, 

Leiul-piilny,  looil;  l<X'uli/.c(l  forms  of,  1000. 

Leu(l-|ii|ie  foiitnu'tion,  8;!8. 

Lead-poincniii);,  10(»7;  iiciito,  1008;  iirti'rio- 
HuiiTowis  in,  lolo ;  cciri'i)rul  i<ytii|>toins  in, 
1010;  chronic,  1008;  nouty  dv\>oAU  in,  1010; 
trcuttncnt  of,  loio. 

Leail-worktrM,  ]>rcvuli'ni.'c  of  gout  in,  288. 

LoiclKri-tuljcri'lu,  18U. 

Leprii  ullm,  2">8. 

Lepra  niutiluus,  258. 

Leprosy,  2o>\ ;  nniesthctio,  2.'>8 ;  hncillnB  U^prii' 
in,  yriS ;  i'ontu,'ionsnc.s»  of,  'JoT ;  cltiiffno.si.s 
of,  'J.")!) ;  ctiolo^ry  of,  'iM ;  niuculiir  form  of, 
258 ;  morlilil  anatomy  of,  2r)8  ;  trcutincnt  of, 
2")!);  tul)erciilar,  2r>8. 

Leptomcninjiitis,  acute,  8fl;! ;  dironic,  807;  in 
Bri){iit's  disi'iusc,  801;  infantum,  804,  805;  in 
pneumonia,  804. 

Leptotiirix  in  mouth,  203. 

Leptus  autuiiinalis,  1048. 

Leucin,  427. 

Leucocytes,  varieties  of,  099. 

Lcucodcrma,  71''!. 

Leucomaines,  1012. 

Lcucomata,  108. 

Lcul<u?mia,  GltO  ;  acute  lynip-jUtic,  VOO  ;  blood 
in,  6'J'J  ;  conjfcnital,  01)7  ;  definition  of,  Oi)0  ; 
diajjuosis  of,  702;  etiolofry  of,  Oi)0 ;  licredi- 
ty  in,  097  ;  in  animals,  01*7 ;  in  prcfrnancy, 
0'J7  ;  morliid  amitomy  of,  0i)7  ;  inyelo^'cnous, 
0(18;  pro-jnosis  of,  703;  symptoms  of,  O'JS ; 
treatment  of,  703. 

Leyden''»  crystals,  500,  .")03. 

Liek/hehii's  schema,  8!i'J. 

Licntcric  diarrlio'u,  3liO. 

Life  assurance,  and  all)uminuria,  729 ;  and 
syphilis,  183. 

Lijihtnint;  pains  in  ataxia,  842. 

Lipaciduria,  730. 

Lipiemia,  297,  301. 

Lipuria,  730.  /' 

Lips,  tuberculosis  of,  239. 

Lkmuer'i  tract,  842. 

Lithwrnia,  730,  733. 

Lithmmic  state,  291. 

Lithiasis,  733. 

Lithic-aeid  diathesis,  730. 

Lithurio,  730. 

Liver,  abscess  of,  446 ;  actinomycosis  of,  262; 
acute  yellow  atrophy  of,  420  ;  amyloid,  450 ; 
anccmia  of,  427  ;  angionuiof,  453  ;  cardiac,  428. 

Liver,  cirrhosis  of,  440 ;  ascites  in,  443 ;  atro- 
phic, 441 ;  fatty,  441 ;  (rlmonian,  441 ;  hncm- 
orrhage  from  stomach  in,  443  ;  hypertrophic, 
441,  444 ;  in  acute  tuberculosis,  242  ;  in  chil- 
dren, 440 ;  jaundice  in,  443 ;  to.xic  symp- 
toms in,  443;  with  cancer,  452. 

Liver,  cysts  of,  453;  fatty,  455;  guminata  of, 


170  ;  heputophlebotomy  in  conifestion  of,  429 ; 
hydatids  (if,  1043  ;  hyperiemia  of,  427  ;  infarc- 
tion of,  42,1 ;  mclaiiii-Harcoma  of,  4.")3 ;  new 
jfrowtlis  ii.,  4.')1 :  nutnii'if,  428  ;  pa.isive  eon- 
Kcstion  of,  428 ;  periodical  enlarxcmcnt  of, 
428;  jirimary  cancer  of,  452;  psorospermiasiH 
of,  lo'2-J  ;  pulsation  of,  428  ;  Harcoiiui  of,  4.'i3; 
seeondary  eani'cr  of,  452;  syphilis  of,  170; 
tul)erculo«i,s  of,  242. 

Liver  duliiess,  obliteration  of  in  perforative 
peritonitis,  23. 

Liviiijf  .-ikclctons,  859. 

Lobar  ipneumonia,  511. 

LoIikIi  in^  cancer,  771. 

Localization,  cerebral,  889  ;  spinal,  887. 

Loek-jaw,  102.  , 

Lock-spasm,  904. 

Locomotor  ataxia,  840;  diajrnosis  of,  845;  eti- 
olojry  of,  841;  herniplejria  in,  845  ;  morbid 
anatomy  of,  841  ;  paresis  in,  845;  i)ro)^nosi» 
of,  840;  relation  of  syphilis  to,  841  ;  reputed 
cures  of,  840  ;  symptoms  of,  842 ;  treatment 
of,  840. 

Lon;,'  thoracic  nerve,  allectioas  of,  815. 

Lordosis,  859. 

LoreMs  operation,  307. 

LoHix''  law,  193. 

/,w(/((w';/V  anj^ina,  332. 

Lues  venerea,  105, 

Luinl)a),'o,  281. 

Lun^,  abscess  of,  ,')52  ;  causes  of,  552  ;  embolic, 
552  ;  etiolofry  of,  552  ;  symptoms  of,  ,552, 

Lun>i,  actinomycosis  of,  202  ;  albinism  of,  546  ; 
brown  induration  of,  504  ;  cancer  of,  acute, 
557  ;  carnitication  of,  ,538  ;  cirrhosis  of,  532. 

Lunjr,  di.>!eiuses  of,  503 ;  stones,  216. 

Lung  fever,  511. 

Lungs,  congestion  of,  503 ;  active,  503  ;  acute 
Inemorrhagic,  ,504  ;  hyiiostatie,505  ;  mechani- 
cal, 504 ;  passive,  504. 

L)ings,  cciiinoeoccus  of,  104.5. 

Lungs,  gangrene  of,  550  ;  abscess  of  brain  in. 
551  ;  cause.,  of,  .550;  etiology  of,  5i)0 ;  mor- 
bid anatomy  of,  5,50  ;  symptoms  and  couree 
of,  551  ;  treatment  of,  551 ;  hasmorrliagic  in- 
farction of,  508. 

Lungs,  new  growths  in,  550  ;  in  eobalt-miners, 
550  ;  "hysical  signs  of,  557  ;  diagnosis  of,  1557. 

Lung;-,  demu  of,  505;  splenization  of,  505, 
538  ;  syphilis  of,  174  ;  tuberculosis  of,  208. 

Lupinosis,  1010. 

Lymphadenitis,  general  tuberculous,  200  ;  local 
tuberculous,  200  ;  simple,  677 ;  suppurotivc, 
577. 

Lymphadenonia,  general,  704. 

Lympii-serotuni,  1034. 

Lymph,  vaccine,  63. 

Lymph  vessels,  dilatation  of,  1034. 

Lyssa,  159. 


«     !U 


10C3 


INDEX. 


MiM^iilurHyjiliillcli'H,  1C^. 

Mllill  I'll  (.Tlllf,  HMK 

Maize,  |i(iiwiniiifr  by  (pi'llii);ru'),  1010. 

Miiliiriul  It'vir,  ll<';  ui'i'idciitul  uiid  hifcf  Icftloiis 
of,  IJil;  ulji'nl  foi'iii  <p|',  l.">;l;  cDiiintoso  t'orrii 
of,  liW ;  fontimicHl  mui  ri'inittont  form  of, 
IM  ;  ilc'stTiplioii  ()f  tliii  imroxyuMi  in,  147; 
iliiUfnofi'm  of,  ITit ;  I'tiolojfy  of,  ll(»  ;  k*'"- 
((ru|>liii.'iil  iliHtriliiiti'iii  of,  11";  luiiiiorrliiit'i<' 
form  of,  l'>;!;  inttrmittcnt,  117;  iimliuiiil 
ciiclii'xiu,  lir),  liVl ;  mi'ti'orolou'ii'ul  comlitiiiiis 
iiilluciK'lM);,  H'J ;  murliid  uiiiitoiiiy  of,  Itl; 
purniclou!*,  144,  l.'>2;  (|uurtuii,  151  ;  ((uoticli- 
uti,  ITiO ;  HC'ii.Miii  ill,  lU;  Hpiriflc  j,'»'riti  of, 
14'J;  tcliuric  ooiulitioiiH  iiiliuein'ing,  141; 
tcTtiari,  1.10;  treiitiiii'iit  of,  I'l'i. 

Mulivtiiuiit,  (I'lluiiiu,  I.')"  ;  pu.stiili',  l.')7. 

MhHu  fuvcr,  '2(it>. 

Muriimury  Kliiiulfi,  liypcrtropliy  in  tiiln  iviilosis, 
•j;!0;  in  liyjttcriii,  '.i7»». 

MiiiiimitiH,  (ihroniu  intunttitiul,  in  tuberculosis, 

Mimiii  a  putu,  100.3.  ^ 

Mania,  Hell's,  !i'J4. 

Marmiti<'.  thrombi,  88."i. 

Maritii!  Hospital  Service,  statistics  of  iiiiilaria 
ill,  140. 

Marriaifc,  question  of,  in  Inemopliilia,  ."j'_'-J  ;  in 
Hyiiliilis,  iK,".;  in  tabes  doi'salis,  s|7  ;  in  tu- 
berculosis, '247. 

Marrow  of  bones,  in  siiiall-i>ii.\,  40  ;  in  leu- 
kiemia,  (11)8  ;  in  pernicious  aniemia,  (lOl. 

MuHquo  lies  femmca  encointc,  710. 

iMassacliusetts  (ieiieriil  Hospital,  rejrulations 
rcf^'anliiif,'  ilisiiifeetion  in  tyiihoid  fever  at, 
;!v! ;  statistics  of  typhoid  cases  at,  \i\>  \  typhus 
fever  at,  \i. 

Mutfticution,  spasm  of  the  muscles  of,  7iHl. 

Mv/tiiriiei/'i  tender  point,  411. 

Measles,  77  ;  complications  and  sequclie  of,  7!) ; 
eontairiousncss  of,  77:  dcsi|uaiiiatioii  in,  78; 
diav'nosis  of,  80;  eruption  in,  78;  ctiolojfy 
of,  77  ;  Gernum,  81 ;  morbid  anatomy  of,  77  ; 
period  of  incubation  in,  77 ;  proL'nosis  of, 
80  ;  symptonis  of,  77  ;  treatment  of,  80. 

.Measly  meat,  examination  of,  lo.W. 

Meat,  poisoninir  liy,  Iol;i;  tuberculous  infec- 
tion by,  1"J1  ;  inspectiiMi  of,  fur  trichina', 
1028. 

Mt'ckeVs  diverticulum,  41.3. 

Me<lian  nejve,  atl'ections  of,  81  li. 

Mediastinum,  att'eetinns  of,  h~'  ;  abscess  of, 
57!) ;  tumors  of,  578  ;  cancer  of,  r)78  ;  diajrnosis 
of,  57't ;  pleural  effusion  in,  ^u'i  ;  sarcoma  of, 
578  ;  symptoms  of,  578. 

Mctliterranean  fever,  'JliO. 

.Medulla  oblongata,  tumors  of,  'J'Jl. 

Megaloeytes,  692. 

Mcgaetric,  .304. 


M'.lirnu,  in   duodenal   ulcer,  .174;  in  ty|(lioid 

fever,  '.'I  ;  neonatorum,  !!K)I. 
MeliiiioMireoma  of  liver,  4511. 
Meliiiiili-ia,  7.'!ti. 
Mehisina  suprarenale,  710. 
Mtinh'r'n  disease,  80;). 
Meniiii;eal  lueniorrliage,  K71  ;  in  birth  palsies, 

ilO',1. 

Meniiiu'cs,  alVections  of,  8'JO. 

.Meiiiiiiritis,  acute  siiinal,  8'.".';  in  erysipelttti, 
111;  in  gout,  'Jlfi;  posterior,  '.t'J4  ;  tubercu- 
lous, yol  (^see  also  LKiTOMKNiNorns,  8ti.'l). 

Meiiingo-cncephalitii*,  ehronie  dill'usu,  U14; 
tuliereiilous,  \>U-i, 

.Mercurial  tremor,  D'Ji). 

.Meryeismus,  JUiy. 

.Mcsenterio  artery,  eiiibolisin  of,  404. 

.Mesenteric  gliinds,  tulierculosia  of,  li08;  tuber- 
culous tumors  of,  'I'W  \  in  typhoid  fever,  8. 

Mesentery,  lueiiiorrhage  into,  457. 

.Mesocolon,  liU'iiiorrhage  into,  457. 

Metallic,  echo,  57(> ;  tinkliiiit,  'J'J7,  5711. 

.Metallotlierapy,  !)71. 

.Metastasis  in  mumps,  Hii. 

.Metastatic  abscesses,  11(1. 

Mete(U'ism  in  typhoid  fever,  treatment  of,  .37. 

•Micrococci,  in  ehorcii,  '.t;t4  ;  m  dengue,  ilO;  in 
Malta  fever,  2(17 ;  in  rheunuitic  fever,  271  ;  in 
vaccine  virus,  (10  ;  in  varicella,  '"  ^ 

Mieroeytes,  (>t»2. 

.Middle  cerebral  artery,  cinbob  '  throm- 

bosis of,  881. 

.Migraini!,  y57  ;  treatment  of,  !»58. 

.Miliary  absces.ses  in  tyi)lioid  fever,  8. 

.Miliary  aneurism,  871. 

.Miliary  fever,  2(18  ;  e])idemics  of,  2(18. 

Miliary  tidtercle,  105;  tuberculo.sis,  acute,  107; 
tuberculosis,  chronic,  215. 

Milk,  and  scarlet  fever,  (17  ;  and  typhoid  fever, 
5;  product**,  poisoning  by,  1014;  sickness), 
2il(i;  tuliereulous  infection  by,  101. 

Mind-blindness,  OOO. 

Mind-dcafncHs,  900. 

Miner's,  unicmia  or  cachexia,  10.32  ;  lunjf,  i>5.3  ; 
nystagmus,  702  ;  sarcoma  of  lung,  55(1. 

Miryachit,  04;t. 

.Mitchell,  Weir,  treatment  in  hysteria,  077. 

Mitral  incompetency,  610 ;  diagno.si»  of,  614; 
etiology  of,  (110;  morbid  anatomy  of,  610; 
jihysical  sifjns  of,  013  ;  symptonis  of,  (112. 

Mitral  stenosis,  (114;  chorea  and,  614;  etiology 
of,  014;  morbid  anatomy  of,  015;  pliysical 
signs  of,  016;  presystolic  murmur  in,  616; 
rlieuniatism  and,  614;  symptoms  of,  016. 

Moist  sounds,  22(1. 

.Molluscum  contagiosum,  psorospcrms  in,  1023. 

Mono|ilegia,.  805,  800  ;  facial,  707;  in  hysteria, 
900  ;  in  traumatic  neuro.ses,  083. 

Montaigne  on  renal  colic,  767. 


INDEX. 


1007 


Montri'ul  (ii'iu'nil  IIoH|>itii1,  iiutopHli'N  in  iliph- 
thi-ritt,  li>a;  ill  tjplioiil  I'l^vtr,  ft;  <lfiitli-nit(i 
from  typtiiiitl  IVvit  iit,  Jll.  StiitlntirM,  of'll|u'^• 
ll•Rum«  ill  l.i"'ii  uiitii|i>ii'H,  '.'lit;  of  il.vsfiitcry, 
i;i();  (if  liu'iiiiirrliaijir  Krnall-|i<i\,  r>'j;  i)f  imcii- 
iMoniii,  Ti'-'V  ;  i>f  riiciiiiiiitii'  ftvur,  '-'7i*;  "f  ty- 
phoid fiivcr,  2,  3. 

Aloiitrciil  »*iiiull-|io.\  cpidoiiiii-  1Hn5-'H(1,  ftli,  rtft. 

Morliilli  liii'iiiorilia«ii'i,  71). 

M<irl)us  nrniliiis,  (liiii. 

Morlms,  ciiMi'  ^^■nili»,  yH-l,  •jHii;  crroruiii,  lois; 
iiiuculosiix,  .'tlM. 

Morpliiii  Imldt,  loo.'i ;  tri'iitiiicnt  of,  Iddi). 

Mor|iliini»iii,  liio,"i. 

Mor|iliioiiiuniu,  loo.'), 

Morplio'a,  \i\n. 

Mortality,  in  oi'ivliro-wpiiial  in('nliij.'itii*,  OS;  in 
]>iii'Uiiionia,  fiiiT  ;  in  typlioid  fiver,  ;)1  ;  In 
who(i|iiii){-coii^'li,  Kti ;  ill  yi'llow  feviT,  I'JH. 

Morvan's  disianc.  hM. 

MoHiiuitoiM,  ivhilioii  of,  to  flhiria  fliMfUsc,  Id.'l.'l. 

Motor  oi'iitrc!*,  hMii. 

Motor,  niic'lfi,  I'liroiiie  di'^i'iiiTation  of,  s,">7  ; 
nyHtfiii,  k'wions  of,  Mit;>, 

Mountain,  aiiii'inia,  lo;i-j  ;  fi-vor,  'J<1H. 

Mouth- brciit hill;,',  ;>:!.'>. 

Mouth,  discusi's  of,  Jl'J.'l ;  ]iutrid  sore,  3-Jt. 

Movable  kidiiiy,  717 ;  dilatation  of  stoiiiii'  .i  in, 
710 ;  »yiiij)toiim  of,  71'J ;  trt'iitiuent  of,  "iM. 

Mucous  I'olitix,  .'iliti. 

Mucous  )iatflics,  lt;H. 

Muj^uot,  ;iu'."i. 

"  Mullicrry  "  calculi,  705. 

MuiiipH,  H'J, 

Municli  I'atlioloirit'al  Institute,  statistics  of  au- 
topsies in  typhoid  fever  at,  Ti ;  of  tuhcivulo- 
sis  in  children  at,  'SM. 

Municli,  reduction  of  typhoid  mortality  in,  :W. 

Murmur,  in  aneurism,  (174  ;  bruin,  310;  cardio- 
respiratory,'2'J7  ;  in  ooiiirenital  heart-disease, 
()t)2  ;  Flint's,  tlo,") ;  hii'inie,  (isll ;  in  endocar- 
ditis, .594;  in  lun;;  cavity, 'J'J7  ;  in  suliclavian 
artery  in  jihthisis, '.';i7 ;  in  valvular  ilisease, 
OO."),  601»,  til 3,  (ilti,  019. 

Muscii  doinesticn,  lo,')!) ;  M.  vomitorisi,  lo,">o. 

ISIuscle  callus  in  sterno-inastoid  in  infants,  sio. 

Muscles,  disoaties  of,  'J'.i,') ;  dei^enerution  of,  in 
typhoid  fever,  10, 

iluscular  atrophy,  idiopathic,  QUO;  fiicio-hu- 
iiieral  type,  i»it7;  from  lesions  of  motor  nu- 
clei, '.)Wi ;  from  neuritis,  !(1I0  ;  hereditary  form 
of  Leydcn,  ii!»7  ;  heredity  in,  (titO  ;  juvenile 
tyi>e  of  Erb,  9',t7 ;  i)eroneal  form,  smT  ;  pri- 
mary atrophic  form,  yii7  ;  in  heiuiplejria,  870. 

Muscular  atrophy,  pro^jressive  spinal,  807  ;  etl- 
olojry  of,  K)H  ;  hereditary  intluenec  in,  858  ; 
morbid  anatomy  of,  85K  ;  symptoms  of,  ^511, 
Muscular  contraetures,  in  homiplegiu.  1*75;  in 
hysteria,  1'70. 


.Muscular  rhciitiiatism,  iJ^I. 
Musciilo-spirul  jiaralysis,  HIS. 
.Nfii^ii'id  fiKiilty,  loss  of,  in  upliuolu,  001. 
.Musical  muiiiiiirH,  (io'.i,  titi'J. 
Mussel  poisonili;;,  lol  I. 

.Myaliriii,  'Jsi. 

.Myi'osis  intestinalis,  15H. 

.Myelin  ilejfeneration  of  alveolar  cells,  401, 

.Myelitis,  acute  eentrid,  S'Jlt ;  iieiile  dillusi.,  H!ih  ; 
acuti'  transverse,  h.",o;  eoinprission,  H,")l  ;  In 
measles.  Ml ;  of  anterior  horns,  s;;!  ;  reflexi-* 
in,  M30  ;  transverse,  of  cervical  rejjion,  M31, 

.Myelocytes,  700. 

.MyeloLfenoiis  leiiku'inia,  fiOS. 

.Myiasis,  lii,",o ;  of  nostrils  and  of  ears,  lO.'iO; 
vulneriiiii,  lii.'iO. 

.Myocarditis,  ii41 ;  acute  interstitial,  041 ;  (ibroiis. 
fti  ;  in  rheumatism,  'J74  ;  pro;;nosis  of,  04.5 ; 
symptoms  of,  ii43;  syiihilis  in,  17H;  treat- 
ment of,  (;4.">. 

Myocardium,  iliseases  of,  OtO;  lesions  of,  diU' 
to  disease  of  coronary  arteries,  010. 

.Myopathies,  the  primary,  WCt ;  diau'nosis  of,  OOS. 

Myositis,  005;  ossiHcans  protfressivc,  00.5. 

Myotonia  coii(,'enita,  OOS. 

Myotonic  reactiiin  of  Krh,  000. 

.Mytilotoxiiie.  Iiil5. 

.Myxii'ilema,  714;  acute,  715;  con^rcnital  form, 
714  ;  operative,  715. 

Nails,  in  tyiihold  fever,  I'i ;  in  phthisis,  280. 

Nasal  iliphtheria,  lot. 

Niiso-pharyintcal  obstruction,  335, 

Neapoliti  n  fever,  liOO. 

Necrosis,  acuti',  of  l)one,  275;  in  tubercle,  10.5; 
in  typhoid  fever,  27. 

Ni:matodes,  diseases  caused  by,  10'J5. 

Neniatoid  worms  in  the  common  iliict,  4.'!7. 

Nepliralifia,  002. 

Nepliritis,  741  ;  acute,  741  :  after  diphtherin. 
1(»!  ;  chronic,  740  ;  chronic  hiemorrliai.'ie, 
74s. 

Nephritis, chronic  interstitial, 740;  diairniisisof, 
754;  etiology  of,  740  ;  liu'iuorrhagcs  in,  7.54; 
increased  tension  in,  753  ;  morbid  anatomy 
of,  7.50;  ]>rojxno.>is  of,  755;  relation  of  lieiirt 
liyperti-iiphy  to,  751;  symptoms  of,  752; 
treatment  of,  755;  urine  in,  752;  vomitinjr 
in,  754. 

Nephritis,  chronic  parenchymatous,  747  ;  con- 
secutive, 758  ;  in  erysipelas,  113;  in  chronic 
suppuration,  747;  in  maliu-ia,  147,717;  in 
scarlet  fever,  71. 

Nephritis,  lymphomatous,  27 ;  suj^piirative,  750. 

Nephrolitliiasi.s,  705  ;  si  iniitoms  of,  7iii>. 

Nephro-phthisis  (see  Kin.NEv,  TiBEiscfLosiS 

OK). 

Nephroptosis,  717. 
Nephrorrhuphy,  720. 


1068 


INDEX. 


Nephrotomy,  702. 

N('i)liro-tyi>liiis,  \>(). 

"  Nurve-storiiiM,"  UOS. 

Nerves,  discuses  of,  775 ;  diseuscs  of  oraniul, 
782  ;  diseusos  of  spinid,  HVi. 

Nervc-fibrus,  iiillaiiiiimtioii  of,  77">. 

NiTve.s,  IcMioiiH  of,  SslT) ;  unterinr  criind,  817  ; 
eireuiiifiex,  al')  ;  externul  iioplitcal,  818; 
gluteal,  817;  iiiternul  popliteal,  818;  ioii;; 
thoracic,  815;  median,  81(1;  mu;culo-spiral, 
815;  obturator,  817  ;  seiatio,  817;  small  sci- 
atic, 817  ;  ulnar,  8lt». 

Nerve-root  symptoms,  8.')!. 

Nervous  diarrlio'a,  '.(7;>. 

Nettle  rash  (see  Uuticaria). 

Neuraliiia,  ',i.")'.t ;  eauses  of,  D.'jO  ;  cervieo-bra- 
ciiial,  '.k'pO  ;  eervieo-oeeipitul,  si;!,  liilo  ;  intlu- 
enee  of  nudaria  in,  Ko'J;  intercostal,  !'•)!; 
lumbar,  i)(il ;  of  nerves  of  feet,  IMil  ;  phrenic, 
0(11;  pli'.ntar,  <Ji!'.';  reflex  irritation  in,  '.ir.'.i : 
treatment  of,  902;  trifueinl,'  WD;  visceral, 
902. 

Neurasthenia,  978  ;  etiolosry  of,  978 ;  symptoms 
of,  979;  traumatic,  981  ;  treatment  of,  98,"). 

Neuritis,  77");  fascians,  770;  interstitial,  775; 
lii)omatous,  770;  localized,  775,  770;  paren- 
chymatous, 77i') ;  multiple,  775,  777  ;  alco- 
holic, 778;  arsenical,  779  ;  diairnosis  of,  780  ; 
endemic,  780;  in  iliplitherin,  107;  in  chronic 
phthisis,  229;  reeurrinjr,  778;  saturnine,  779; 
treatment  of,  781 ;  optic,  780. 

Neuro;rli()ma,  918. 

Neuroma,  plexitbrni,  782. 

Neuromata,  781. 

Neuroses,  occupation,  90.3 ;  traumatic,  981  ;  di- 
agnosis of,  981;  etiolo;;y  of,  981  ;  pro^^nosis 
of,  98t;  symptoms  of,  981. 

Neutrophiles,  099. 

Ni;,'ht-blindiicss,  78");  in  s.'urvy.  .Tl.". 

Niglit-sweut  •  in  phthisis,  225;  treatment  of, 
255. 

Nipple,  P(we"s  disciuse  of,  102r?. 

Nitrie-aeid  tes^  for  albuuien,  727. 

Nits,  1048. 

Nodilin;?  spasm,  812. 

Nodes,  symmetrical,  in  eonifcnitul  syphilis,  171. 

Noilosities,  I/eherdcii^n,  28-1. 

Nodules,  rheumatic,  275. 

Noma,  ."120. 

Normoblasts,  092. 

No8e,  bleedin^r  from  (sec  Epista.xis),  478. 

Nose,  diseiuscs  of,  47 1. 

Nose-bleedinj;  in  tyi)lioid  fever,  10. 

Nummular  sputa  in  plitliisis,  220. 

Nurse'.s  eontriieture  of  V  ouseeau,  905. 

Nutmeg  liver,  428. 

Nyctalopia,  785;  in  scurvy,  ,11,'). 

Nystaurmus,  792;  in  /■)•(></'/•. /i'/('«  atflxia,  849;  in 
insular  sclerosis,  914 ;  of  minors,  792. 


Obes  ty,  1019. 

()l)--(ssi<in,  94.'!. 

OUsiruction  of  bowels,  413 ;  acute,  416 ;  chronic, 
417. 

Obtin-ator  nerve,  817. 

Occipital  lobes,  tumors  of,  920. 

Occupation  neuroses,  9i'..'!. 

Ocular  ]>alsies,  treatment  of,  79."). 

Oculo-motor  paralysis,  recurriu;.',  7in. 

Odor,  in  small-pox,  59  ;  in  typhoid  fever,  10. 

(Kdema,  an^rio  -  neurotic,  989  ;  eoUuterul,  in 
hm^'.s,  501);  febrile  puri)urie,  ".18;  of  lun;;s, 
505;  malijfiiant,  157  ;  of  brain  iu  uruiuiiu,  870. 

(Kilcuiatous  laryngitis,  481.  ,     ' 

(K.tophageal  bruit,  041. 

(Kso|)hai.'ismus,  340. 

(Ksophaj.'iti.s,  acute,  339;  ehrojiic,  .340. 

(Hsophairus,  disea.ses  of,  3.39;  cancer  of,  342; 
dilatations  of,  344  ;  diverticula  of,  344  ;  pa- 
ralysis of,  341  ;  post-mortem  digestion  of, 
343  ;  rupture  of,  343  ;  spasm  of,  340  ;  strict- 
ure of,  341 ;  sypliilis  of,  178  ;  tubcrculosiu 
of,  240. 

OirtiTti  method  in  obesity,  645,  1020. 

Oidium  albicans,  325. 

Olfactory  nerve,  782. 

Omentum,  tuberculous  tumor  of,  238 ;  tuinoi 
of,  in  cancer,  409. 

Omodynia,  2>2. 

(.)!iycliitt  in  arthritis  deforman.s,  285 ;  in  loco- 
motor ataxia,  844;  syphilitic,  108,  170. 

<  ip'  ration  ptr  s<',  etfects  of,  in  epilepsy,  957. 

Operation,  tuberculosis  after,  194. 

0|)i\thalmiu,  gonorrheal  with  arthritis,  270. 

Ophthalmoplegia,  794;  externa,  794;  interna 
795. 

Opisthotono.q,  cervical,  in  infants,  804  ;  in 
tetanus,  103. 

Opium,  jioisoninyr,  diagnosis  from  urspmia,  740; 
habit,  1005;  smoking,  etfects  of,  10()5. 

Optic  ntropliy,  780 ;  in  ataxia,  843 ;  primary, 
780 ;  secondary,  780. 

Optic  nerve  and  tract,  discn-ses  of,  783,  780. 

Optic  neuritis  in  abscess  of  brain.  904;  in 
brain-tumor,  919;  in  tuberculous  meningitis, 
204. 

Orchitis,  in  malaria,  154;  in  nnnnps,  S3 ;  in- 
terstitial, in  syphilis,  179;  in  typhoid  fever, 
27;  in  variola,  49;  syphilitic,  179;  tubercu- 
lous, 245  ;  value  of,  in  diagnosis,  245. 

Ortliotonos,  in  tetanus,  103. 

Osteitis  defonnans,  992. 

Ostco-arthropathie  pneundquc,  992. 

Ostco-myelitis  simulating  acute  rheumatism, 
275. 

Ovaries,  tuberculosis  of,  245. 

(!)ver-oxertion,  heart  affections  duo  to,  639. 

Oxalatc-of-limo  calculus,  705. 

Oxttlurla,  733. 


il«>fcmaMWM«MII 


'?) 


! 


INDEX. 


1069 


Oxygen,  inhalutions  of,  in  diiiljct'ic  coma,  305. 
OxyuriH  vtniiioularis.  Idl'iI. 
Oysters,  iioisoniiig  by,  lOlo. 
Ozu'iia,  470. 

Piiohynieniniritis  ccrvk'ali.s  liyiiortropliicu,  821. 
riichyiiifniii^ritis    liu.'iiiuiTliuiriL'u,    ol'   ccixbrul 

ilurii,  8(12;  ot'«i>iiml  duru,  )S20. 
PitijiVs  di.  I'use  <>''  1,;..  iiipijk',  1023. 
I'alatu,  puruly.si.s  of,  in  diphtheria,  107  ;  in  facial 

paralysis,  7lt!). 
Ptthite,  tuberculosis  of,  S-tO. 
Palpitation  of  heart,  "lUt. 
Palsies,  cereliral,  of  ehilJrcu  (»eu  IIkmipleoia 

or  ClIILKKKN),  UOC. 

Palsy,  lead,  lOO'.i. 

Puluilisin  (see  Malari.^i,  Fevkk),  140. 

PauoreiLS,  diseuses  of,  4."i7. 

Punorcas,  cancer  of,  401  ;  lesions  of,  in  diabe- 
tes, 2'J7 ;  cysts  of,  4'io ;  hu.'niorrhai;e  into, 
4.')7  ;  intluence  of,  ir.  diabetes,  200. 

Pancreatic  diabetes,  2;».S. 

Pancreatitis,  acute  hitniorrhairic,  4.')^  ;  chronic, 
400;  fat  necrosis  in,  40'J;  gangrenous,  40O  ; 
suppurative,  io'i. 

Papillitis,  780. 

Para\sthesia  (numbness  and  tin),'lini;),  in  neu- 
ritis, 77S;  in  locomotor  ataxia,  K4:i;  in  tumor 
of  brain,  Kl'J  ;  in  j)rimary  combined  sclerosis, 
.S40. 

Para','cusis,  80."), 

Paralysis,  acute  a.scendin);j,  83.') ;  acute  spinal, 
of  adults,  8:).');  acute,  of  infants,  8;!1  ;  as,'itans, 
020;  alcoholic,  77s ;  AVZ/'x,  707;  bulbar, 
acute,  800  ;  cbronie  proirressive,  801 ;  of  blad- 
der, in  myelitis,  820 ;  of  brachial  plexus, 
814;  in  chorea,  935;  of  circumtlex  nerve, 
HI,-);  "crutdi."  815;  Cnn;;//iier\  8.57;  of 
diaphraj;m,  si4;  nftcr  diphtheria,  lOO  ;  I)u- 
c/i<'iin<i''s,  8iiil;  follov.in_'  epilepsy,  052;  of 
facial  nerve,  797 ;  of  liftli  nerve,  795  ;  of 
fourth  ncrvo,  792 ;  (general,  of  tiie  insane, 
914;  of  liypoirlossal  nerve,  812;  liysterical, 
909;  infantile,  831;  labio-i.'l(isso-luryiii.'eal, 
HOO  ;  Lau'lrifs^  835;  of  hirviiireal  alxluctors, 
800;  of  adductors,  807;  in  lateral  scleror's, 
837  ;  from  lead,  1009  ;  in  locomotor  ataxia,  8- .' ; 
of  lonif  tlioracic  nerve,  815;  in  monici'itis, 
203,  800  ;  of  median  nerve,  810  ;  of  mi  -culo- 
spiral  nerve,  815;  of  oculo-motor  nerves, 
700  ;  of  olfactory  nerve,  783  ;  periodical,  085  ; 
in  projxrcssivc  muscular  atrophy,  859; 
pseudo-hypertrophie,  900  ;  radial,  815  ;  of 
rectum,  in  myelitis,  829  ;  of  recurrent  laryn- 
j;feal  nerve,  800  ;  secondary  to  visceral  tlis- 
0U8C,  777 ;  of  sixth  nerve,  703 ;  of  third 
norve,  790;  of  ulnar  nerve,  810;  of  voeul 
cords,  8O0. 

Paruniyoelonus  tuultiplu.v,  909. 


Paraphasia,  902. 

Paraplej,'ia,  from  alcohol,  778  ;  from  antcmiaof 
8[)inal  cord,  8:-'^  from  eoiiii)ression  of  cord, 
851;   doloros  j;   from  hicmorrhage  into 

cord,  820;  fioi..  er^cotism,  lOlO;  hyslericul, 
900;  in  lathyrism,  lOlO;  from  myelitis,  829; 
in  pell  ..;i,  i  10;  spa.stic,  830  ,  sj)astiea  cere- 
bralis,  ^■-,  from  siiinal  curies,  851;  from 
tumor  of  the  cord,  850  ;  in  tabe.s,  845. 

Paraplegic  flaaque,  837. 

Panusites,  diseases  due  to  animal,  1022. 

Panwites,  pseudo-,  10.50. 

I'aratyphlitis,  405. 

"  J'arehment  crackling"  in  rickets,  G08. 

Parenchymatous  nephritis,  747. 

Parioto-occipital  region,  brain  tumoi-s  m,  920. 

'•  I'uris  green,"  poisoning  by,  1011. 

J'arli/ifion'ii  disease,  020. 

Parosmia,  782. 

Parotid  bubo,  328. 

I'arotiti.s,  epidemic,  82  ;  deafness  in,  83;  delir- 
ium in,  83  ;  orchitis  in,  83. 

i'arotitis,  synii>toiiiatic,  328  ;  after  abdominal 
section,  320  ;  in  pneumonia,  524;  in  typhoid 
fever,  20  ;  in  typhus  fever,  42. 

Paroxysmal  liiemoglobiiiuria,  724. 

Patdlar-tendon  rellex  (see  K.nke-jkuk). 

I'ectorilixiuy,  227. 

Pediculi,  1(J48  ;  relations  ot\  to  taeliu  bloualro, 
10.  . 

Pediculosis,  1043. 

Pelbigru,  1010. 

Pelioiiuita,  15. 

Peliosis  rheuiiiatica,  .017  ;  in  chorea,  938. 

Pelvis  of  kidney,  allections  of  (see  Pyelitis^, 

Pemi)higoitl  ])urpuia,  317. 

Pemphigus  neonatorum,  170. 

Pennsylvania  Hospital,  lol",  1018. 

Peiiiisylvaniu  Institution  for  Fecblu-niiudcd 
Cbildrell,  OdO.  948. 

Pentastomes.  1047. 

Pepsin,  tests  for,  in  gastric  juice,  347. 

Pepsinogen,  tests  for,  347. 

l'<ptic  ulcer,  308. 

I'cptoties  in  the  urine,  tests  for,  728. 

Peptonuria,  728. 

Perforating  ulcer  of  foot,  844. 

Perforation  of  bowel  in  dysentery,  137;  in  ty- 
j)hoid  fever,  7,  li'.i. 

Periarteritis,  guiiiiiiatoiis,  170  ;  nodosa,  683. 

Pericardial  friction,  5s:!. 

Pericarditis,  acute  plastic,  582;  acute  tuborcu- 
loiw,  230;  aphonia  in,  58.5,  clironic  ud- 
liesivo,  589;  chronic  tuberculous,  23(1;  de- 
lirium in,  580  ;  cliau'iiosis  of,  .584,  587  ;  dyspha- 
gia in,  585 ;  epidemics  of,  582 ;  epilepsy  u», 
.580;  from  extension  of  disease,  682;  fiv>m 
foreign  body,  581 ;  in  chorea,  937;  in  fa-tus, 
582 ;  in  );out,  292 ;  in  rheumutiuin,  273 ;  kiuni' 


i 


i 


1070 


INDEX. 


|i    li 


orrhugic,  585 ;  hypurpyrexiu  in,  583,  SSii; 
pliysiciil  Higns  of,  5S3,  bSC>\  pririiury,  "isi ; 
prognosia  of,  587;  pulsus  piiriuloxus  in,  aS,"); 
secoiidury.  581  ;  symptoms  of,  583,  585 ;  tivat- 
mcnt  of,  588  ;  witli  eft'iision,  58-i. 

J'eriourdium,  adherunt,  58U  ;  Frii'dn-ic/i'/i  hljrn 
in,  590. 

Piii'itiardiuin,  diseases  of,  581;  tuberculosis  of, 
2'i5;  air  in,  5'Jl. 

JVTichondritis,  laryn-^eul,  in  typhoid  fever,  23; 
in  tuljeroulosis, -188. 

I'eriliopatitis,  441. 

IVriiieplirie  abscess,  773. 

iVriodieal  i)aralysis,  '.185. 

l'eni)lieral  neuritis,  770. 

IVr'istaltic  unrest,  3f;-2, 'J73. 

I'eritona?um,  diseiuscs  of,  4(!'2. 

I'eriloiiieuni,  fluid  in,  4011,  473;  cancer  of,  4G8 ; 
new  tirowtlis  in,  4(18. 

I'eritonicuin,  tuberculosis  of,  237 ;  acute  mil- 
iary, 237;  clironic,  2;i7;  chronic  fibroid,  237. 

Peritomcum,  tumor  formations  in  tubcrculo.-<is 
of,  238. 

Peritonitis,  acute  fjeneral,  402,  471;  clininic. 
4(17,473;  chronic  luemorrlia^ic,  4i'kS  ■  tliil'usc 
adhesive,  4')7 ;  hysterical,  405;  id'.opatliic, 
402;  in  infants,  400;  leukicmic,  702;  local 
adliesive.  407;  'ooalized,  400:  perforative, 
402;  primary,  402;  proliferative,  407  ;  py- 
icmic,  402;  rlieumatic,  402;  Hccoiulary,  402; 
septic,  402;  tuberculous,  ^M. 

Peritonitis,  tuberculous,  effects  of  operation  on, 
473. 

Perityphlitis,  405. 

"  Pcries"of />af;rt«f(;,  4i)0. 

I'erniciou.H  anifmia,  08!). 

Pernicious  malaria,  152. 

Peroneal  type  of  muscular  atrophy,  !)!)7. 

Pertussis  (se(!  Wnoori.NO-toriiii),  84. 

Ptsta  maixna,  4(!. 

I'ctechia!  in  e[iilcpsy,  i)52;  in  rclapsinir  fever, 
44;  in  scurvy,  314;  in  suiall  po.\,  53;  in 
typhus  fever,  41. 

Petit  mal,  ',148,  'J.".2;  in  general  paresis,  91G. 

i'eyer's  patches  in  typlioid  fever,  5;  in  measles, 
77  ;  in  tube  rculosis,  2U. 

Phairocytosis,  111;  in  tuberculosis,  105. 

I'liaryniritis,  330;  acute,  330;  elironic,  330; 
rctro-pharynifcal  al)scess  of,  332;  sicca,  331. 

Pharynx,  diseases  of.  32',t. 

I'haryiix,  acute  infectious  ]ihlcLrnion  of,  331  ; 
liicinorrhaife  into,  32ii:  hypcnemia  of,  329; 
Q>dema  of,  330  ;  paralysis  of,  800 ;  spasm  of, 
800;  ulceration  of,  331. 

Pliilailclphia  IIcis])ital,  reln]isinir  fever  at,  ISM, 
41;  tyiihoid  and  typhus  t'ever  at,  2;  typhus 
epiilemic  in  1HH3,  4(1;  Kfafi'nlics  of  cerebro- 
spinal fever,  95  ;  of  delirium  tremens  i:i,  1004. 

Philadelpliia   Inllrnuiry   for  Nervous  I)iHeu.ses, 


gtatiKtics  of  chorea,  929  ;  of  liemiple;ria  M\h 
diplejfia  in  iii(ant.s,  900;  of  epilepsy,  ',t48. 

Philadelphia,  tulicreulosis  in  city  wards,  190; 
yellow-fivcr  epi<lemic  in,  1793,  125. 

Plilcbitis  ot'poital  vein,  440. 

Phlebo-scU'rosis,  007. 

Phloroirlucin  te.st  for  free  IICl,  340. 

i'hospliiitis,  alkaline,  734;  curtliy,  734. 

Phosphutic  calculi,  705. 

Phospluituria,  734. 

Phosphorus  poisoninjf,  similarity  of  acute  yel- 
low atroi)hy  to,  427. 

Phrenic  nerve,  all'ections  of,  813, 

Phtliiriasis,  1048. 

I'litliisieal  frame,  Ilippocrates's  description  of, 
i;i2. 

Phthisis,  acute  pneumonic,  209. 

I'lilhisis,  chronic  uicerative,  214;  acute  pneu- 
monia in,  232;  arterio-selcrosis  in,  233;  basic 
form  of,  215  ;  IJright's  diseiuse  in,  230 ;  of  coal- 
miners,  1'J4,  555;  chronic  arthritis  in,  233; 
cough  in,  220;  endocarditis  in,  228;  diagno- 
sis of,  230;  distribution  of  lesions  in,  214; 
erysipelas  in,  232;  fatal  iia'morrhage  in,  234; 
fever  in,  222  ;  Ibrms  of  cavities  in,  210;  gits- 
trie  symptoms  of,  228 ;  haemoptysis  in,  222 ; 
modes  of  death  in,  234;  modes  of  onset  in, 
218;  iihysieal  si;rns  of,  225;  relation  of  fis- 
tula in  ano  to,  241;  sputum  in,  220;  sum- 
mary of  lesions  in,  215;  symptoms  of,  219; 
ty[)hoid  fever  in,  232;  vomiting  in,  229. 

Phthisis,  fibroid,  231 ;  florida,  212 ;  rcnum,  243  ; 
syphilitic,  175;  of  stone-cutters,  194,  553, 
unity  of,  190;  ventriculi,  352. 

Physioloi;ieal  allnmiinuria,  720. 

Pia  nuiter,  diseases  of,  822,  803. 

Picric-ucid  test  for  albumen,  728. 

Pigeon  -  breast,  in  rickets,  310;  in  mouth 
breathers,  337. 

Pigmentation  of  skin,  from  arsenic,  1011  ;  from 
phtliiriasis,  1048;  in  Ail  J  i. to //''n  di.sease,  70'.t, 
710;  in  clironic  pulmonary  tuberculosis, '230; 
in  melanosis,  710  ;  in  [)eritoiieal  tuberculosis, 
238. 

Pigmentation  of  viscera  in  pellagra,  1017. 

Pigs,  tuberculosis  in,  I8t. 

Pin- worms,  1020. 

Pitch,  in  cavities,  change  of,  227. 

Pitting  in  snuiU-pox,  51 ;  measures  to  prevent, 
58. 

Pituitary  l>ody  in  acromegalia,  992. 

Pityrinais  versicolor,  230. 

I'laques  h  surface  rdtieul^c,  0. 

Pla((ucs  jauncs,  87'.t. 

Plasmodium  nialariif,  143. 

Plastic  bronchitis,  502. 

Pleura,  diseases  of,  558. 

Pleura,  cchinococcUB  of,  1045;  tuberculosis  of 
235. 


INDEX. 


1071 


■ 


jiriveiil, 


IrcuKisU  "i 


Pleural  cfTusinn,  nuccelli'.-i  sij^n  in,  5fi2,  504; 
conipnission  ot"  lunir  in,  551);  diiiifnosis  of, 
5t!7  ;  ha'iiuirrliinric,  5ti(>;  in  soarlot  fever,  T'J; 
po.-iition  of  licurt  in,  500;  pseiklo-ciivonious 
sij^ns  in,  5ii2;  purulent,  5t)3;  serous  ettusion, 
constituents  of,  55'J  ;  -uiiden  ileiith  in,  5lJ3. 

J'leurul  nienil)ranes,  culelrtoation  of,  57"2. 

I'leuri.sy,  ueute,  558;  diaplmiginiitie,  5i)i) ;  cn- 
oysteJ,  5(17 ;  etioloi^y  "f,  SoS,  5(j;i;  fibrinous, 
558;  intfrlobiilar,  51)7 ;  pain  in  side  in,  5(50; 
plastic,  558 ;  pleural  frietion  in,  5i)'2 ;  jiulsat- 
in}?,  51)5,  077  ;  sero-flbrinous,  558 ;  treatment 
of,  509  ;  tubcriHilous,  'J;J5,  559,  50li. 

rieurisy,  ehroiiie,  571;  dry.  571;  primitive 
dry,  572 ;  vaso-motor  phenomena  in,  573 ; 
with  etfusion,  571. 

Pleurodynia,  'J8iJ. 

Pleuro-peritoiH'ul  tuberculosis,  235. 

Pleurosthotonos  in  tetanus,  104. 

Piiea  poloniea,  luls. 

Plunibism,  1007  ;  in  iiout,  288 ;  as  a  cause  of 
renal  cirrhosis,  750 ;  paralysis  in,  1009. 

I'ly  mouth,  epidemic  of  typhoid  fever  at,  4. 

Pneumojja-stne  auno,  950. 

Pneumoj^astrie  nerve,  alfeetions  of,  So5  ;  cardiac 
branches  of,  808;  ),'!istnc  and  asopbasfeal 
branches  of,  809 ;  laryngeal  branches  of,  800  ; 
pharynj^eal  branches  of,  800 ;  j)ulinonary 
brandies  of,  808. 

Pncuuioniu,  acute  croupous,  511;  abscess  in, 
527;  acute  delirium  in,  521;  bleeding  in, 
5;?0 ;  elinical  varieties  of,  524 ;  eol  itis,  croupous, 
in,  510;  oomplicatiiins  of,  522;  crisis  in,  517  ; 
delayed  resolution  in.  527  ;  dia;;nosis  of,  5'js  ; 
diajfnosis  from  acute  piuiimonic  'hiwia, 
211;  diplococcus  pneumoniK!,  511,  ,  iii- 
docarditis  in,  510;  ein^orifcmont  of  luii^  in, 
514;  epidemics  of,  512,  525;  etioloiry  of,  511  ; 
fever  of,  517;  tibroid  induration  in,  527; 
Kanirrcno  in,  527  ;  yray  iiep.itizatioii  in,  515; 
herpes  in,  521;  immunity  from,  513;  in  dia- 
betes, 525  ;  in  infants,  525 ;  in  inHuenza,  525 ; 
in  old  aije,  525  ;  nieninjjitis  in,  5ir, ;  morbid 
anatomy  of,  514;  mortality  of,  527  ;  i>ericar- 
ditis  in,  510;  physical  siirns  of,  519;  iiroi^- 
noais  in,  520  ;  pseudo-crisis  in,  517  ;  purulent 
infiltration  in,  515;  reeurronco  of,  524;  red 
hepatization  in,  514;  relapse  in,  524;  resolu- 
tion of,  515;  terminations  of,  520;  treatment 
of,  529. 

Pneumonia,  acute  syphilitic,  170;  apex  pneu- 
monia, 525;  as])iraticm  or  dc^irlutilion,  537; 
"  cerebral,"  522 ;  chronic  interstitial,  5.">2, 
534;  chronic  pleuro^renous,  573;  contusions, 
512;  double,  525;  fibrinous,  51 1  ;  hypostatic, 
605;  in  mahiria,  140;  interstitial,  of  the  root, 
in  syphilis,  175;  in  typhoid  fever,  24;  lar- 
val, 525;  lobar,  511;  massive,  525;  miitra- 
tory,  525 ;  pleuitJifenoua  interstitial,  533 ;  ty- 


phoid pneumonia,  525;  white,  of  the  fojtus, 
175. 
Pneumonitis,  511. 
Pneumonokoniosis,  534,  553. 
Pncumo-pericaixliuni,  591. 
Pneumothora.x,  574 ;   after  traeheotomy,  580 ; 
causes  of,  574  ;  chronic,  577  ;  Ilippoeiatic  sue- 
eussion  in,  570;   morbid  anatomy  of,  575;  in 
phthisis,   21 S;    from    mu.scular    effort,   575; 
Skoda^i  resonance  in,  575  ;  symptoms  of,  575; 
treatment  of,  577. 
Pneumotoxin,  513. 

Pneuino-typhus,  24. 

Poda^i-a,  287. 

Pododynia,  901. 

Poikiloeytosis,  092. 

Poisoninj;,  by  lcueoinaine.s,  1012;  by  meat, 
1013;  by  ptomaines,  1012;  by  so\ver-ga.s, 
2i!4. 

Poliomyelitis,  acute  and  subacute,  in  adults, 
835. 

Poliomyelitis  anterior,  acute,  831 ;  etiology  of, 
831;  morbid  anatomy  of,  832 ;  prognosis  of, 
833  ;  symptoms  of.  832. 

Poliomyelitis  anterior  chronica,  857. 

Polyneuritis,  acute  febrile,  777. 

Polysareia,  1019. 

Polyuria  (sec  Diauetks  Insii'idus),  30.5. 

Polyuria,  in  abdominal  tuinoi-s,  300;  in  hys- 
teria, 307. 

Pons,  lesions  of,  898 ;  tumors  of,  920. 

Popliteal  nerve,  external,  818;  internal,  818. 

!'iircneci)lialus,  907. 

Pork  in  relatimi  to  tiichinosis,  1028. 

Portal  vein,  429;  thrombosis  of,  429 ;  suppura- 
tion in,  411!. 

Post-epileptic  conditions,  952. 

Post  I  ■miplegie  chorea,  908,  epilopey,  908, 
'.'     ,  movements,  Itos. 

Post-mor'  HI  iiMivcmcnt-   ti  eholcni  bodies,  120. 

Po.st-pharyngeal  abscess,  "•■i2. 

Post-typhoid,  anoimia,  17;  elc  itiniis  ,)f  tem- 
perature, 13. 

f^itfn  disease,  851 . 

Poumoli,  uleeres  i.      535,  55.5. 

I'regnancy,  an<l  acute  yellow  atropliy, 420;  and 
chorea,  931  ;  and  phthisis,  247. 

Presystolic  murmur,  010. 

I'riajiism  in  leukiiMniii,  to-i. 

Prickly  heat  (sec  Li:         jia). 

Probefri'ihstiiek,  345. 

PiT)cession  caterpillar,  ert'ecU  of,  10.50. 

Professional  spitsms,  903. 

Proglottis  of  tamia,  1030. 

Progressive  muscular  atro|)hy,  8.57. 

Progressive  pernicious  anienjiu,  089;  blood  in, 
092;  diagnosis  of,  094;  etiology  of,  089;  mor- 
bid anatomy  of,  l!91  ;  pro;;nosis  of,  094  ;  symp- 
toms of,  091 ;  treatment  of,  OUU. 


^M 


I    ■: 


1072 


INDEX. 


I'lopeptonc,  728. 

I'roiiliyliixiM,  u},'ninst  cholera,  123;  ajrainst 
scurvy, ;Ui) ;  a;^aiint  tuberculosis,  'J47  ;  aLrniiist 
tii'tiia,  10:38;  uf^ainst  trichina,  1U;JI;  ugaiust 
yellow  fever,  128. 

I'rosopalifia,  'MM. 

rro.stalc,  tulierculosis  of,  21."). 

I'rotozoa,  diseases  caused  hy,  1022. 

Prune-juice  expectoration,  •557. 

I'ruritus  from  diuUetes,  300 ;  from  urieaiia,  730. 

I'seii  I'l-aiU'ina  p.ictoris,  (!r)7,  (i5S,  \)~i. 

IVeudo-apoplcctic  seizures  in  fatty  iieart.  Oil. 

Pscudo-bulbar  paralysis,  8il. 

I'soudo-cavernous  signs,  228,  51)2,  508. 

I'seu  lo-cycsis,  970. 

J'sL'U  lo-iliphtheiitic  processes,  lol. 

l'seudo-liypertro|ihio  muscular  paralysis,  000. 

Pseud(-leuka?iiiia,  701. 

Pseudo-parasites,  1050. 

Pseudo -ptosis,  701. 

I'seudo-raliies,  102. 

Pseudi)-rheumatio  affections,  270. 

Pscudo-scleroso  en  plaques,  014. 

Psorospormiiusid,  1022;  cutancoua,  1025;  in- 
ternal, 1022. 

Pt.>maino  poisoning,  1012. 

Ptomaines  in  septicicmia,  115. 

Ptosis,  forms  of,  701  ;  hysterical,  791 ;  in  ataxia, 
842;  p.seudo-,  701; 

Ptyalism,  327,  328. 

I'ulex,  irritans,  1010;  penetrans,  1040. 

Pulmonary  (sec  Liincis). 

I'ulmonary  apoplexy,  508. 

Pulmonary  artery,  .sclerosis  of,  067 ;  perforation 
of,  070. 

Pulmonary  luemorrhage,  f)00;  treatment  of,  509. 

I'ulmonary  orifice,  congenital  lesions  of,  001  ; 
valves,  lesions  of,  ()20. 

Pulsating  pleurisy,  505,  077. 

Pulsation,  dynamic,  of  aortii,  077. 

Puls(',  altcrmiti',  051 ;  under  influiince  of  digi- 
talis, ()25  ;  intermittent,  050;  irregular,  051; 
bigeminal,  O'll,  05i  ;  paradoxical,  050. 

Pulse,  capillary  (see  ('apii.i.aky ) ;  <'ijn'i(ffin\i, 
000 ;  water-luxnuaer,  600. 

Pulse,  slow,  in  tuberi'ulous  meningitis,  ^03;  in 
jaundice,  430  (see  liitAcnvcAiiDiA,  053). 

J'upil  (see  Iiiidoi'i.koia  i,  702. 

Pupil,  Ar(/>/n-/Mirrtso/i,7'.^± 

Pupillary  inaction,  heniiopic,  780. 

J'upils,  une(iual,  792  ;  in  general  paresis,  010;  in 
tahcs,  812. 

Puri>ura,  31 1>;  arthritic,  317  ;  cachectic,  310;  di- 
agnosis of,  310;  fulminan.s,  310;  infectious, 
310;  mechanical,  31";  neurotic,  317;  pelio- 
sis  rheumatiea  in,  317  ;  hicniorrhagica,  318; 
simplex,  317  ;  syrnptonuitic,  310;  toxic,  310; 
treatment  of,  320;  urticans,  317;  variolosa, 
62. 


Purpuric  asdema,  318. 

Pustule,  nuilignant,  l.')7. 

Pya-mia,  110;  arterial,  110,  590;  idiopathic 
110. 

Pyi'litis,  758;  diagnosis  of,  701;  intermittent 
fever  in,  70O  ;  morbid  anatomy  of,  750 ;  prog- 
nosis of,  702;  pyuria  in,  70O;  symptoms  of, 
7(iO ;  treatment  of,  702, 

Pyelonephritis,  758. 

Pyelothrombosis,  420. 

Pylephlebitis  lulhesiva,  429. 

Pylei)lilebitis,  in  dysentery,  137  ;  in  pyiumia, 
1 10  ;  su(ipurative,  420,  417. 

Pv  onephrosis,  758.  ,        , 

Pyo-pncumothorax,  574. 

Pyopneumothorax  subphrenicus,  309,  570 ;  in 
perforative  appendicitis,  408. 

Pyramidal  tract,  course  of  tibrcs  of,  891. 

Pyrosis,  35.3.  .  ; 

Pyuria,  720. 

Quarantine  against  yellow  fever,  128;  against 

cholera,  123. 
Quartan  ague,  151. 
Quebec,  cholera  at,  in  1832,  118. 
(Quinine  rash,  08,  74. 
Quintan  ague,  151. 

(Quinsy  (SCO  Tonsillitis,  Suppurative). 
Quotidian  ague,  150. 

Kabies,  150;  etiology  of,  150  ;  morbid  anatomy 
of,  101;  preventive  inoculation  in,  101; 
symptoms  of,  100;  treatment  of,  101. 

Rachitic  bones,  ,308. 

Kachitis  (SCO  Rickets),  307. 

Radial  paralyses,  81.5. 

Rag-picker's  di.sea.sc  (sec  Wool-sortek's  Dis- 
ease), 1.58. 

Railway  brain,  081. 

Railway  spijie,  081. 

Rainey's  tubes,  1022. 

Rashes,  from  drugs,  74,  310 ;  in  glanders,  260 ; 
in  measles,  78;  in  relapsing  fever,  44;  in 
rubella,  81 ;  in  scarlet  fever,  00  ;  in  small-i)ox, 
>">0,  51 ;  in  syphili.s,  108 ;  in  typhoid  fever,  15  ; 
in  typhus  fever,  41 ;  in  pyamiia,  117  ;  in 
vaccination,  63 ;  in  varicella,  60. 

Ray -fungus  (actinomyces),  201. 

Raynaud's  disease,  087  ;  epilepsy  in,  088;  hsBlu- 
oglobinuria  in,  088;  pathology  of,  089. 

Reaction  of  degeneration,  780,  700. 

Reorutlesconce  of  fever  in  typhoid  fever,  14. 

Rectal  crises  in  tabes,  8W. 

Rectum,  irritable,  073;  stricture  of,  178;  syph- 
ilis of,  178. 

Re(  nrrent  laryngeal  nerve,  paralysis  of,  806. 

Red  softening  of  brain,  870. 

Re.luiilicfttion  of  licart-sounds,  051. 

Ri  lux  crepitus,  520. 

Reflex  epilepsy,  950. 


INDEX. 


1073 


Reflexes  in  nseendinj?  paralysis,  83f) ;  in  cerc- 
briil  liii'inorrliiifjfi',  «7") ;  in  locomotor  iitiixia, 
84:i;  in  polio-myelitis  ueiitu,  .s;ia ;  in  Hpuftie 
paniplegiu,  8:i7  ;  in  hysterical  paraplegia,  SV3, 
W.>;  in  progres.sive  niUNcular  utrojiliy,  8o'J. 

Relapse  in  typhoid  fever,  2'^. 

Relapsing  fever,  Hi;  spirillum  of,  44. 

Remittent  fever,  151. 

Ren  mohilis,  717. 

Renal  calculus,  705. 

Renal,  colic,  7i)(; ;  sand,  7(io. 

Resolution  in  pneumonia,  iy2(i. 

Resonance,  amphoric,  227,  575  ;  tympanitic,  227, 
5(il,  575. 

Respiratory  system,  diseases  of,  474. 

Rest  treatment,  U77  ;  in  aneurism,  078. 

Retina,  lesions  of,  783. 

Retinal  liypcriestliesia,  785. 

Retinitis,  alhuminuric,  784;  in  anicmia,  784; 
in  malaria,  784;  leuku-mic,  784  ;  pigmentosa, 
784;  syphi'itic,  1<)8,  784. 

Retraction  of  head  in  meningitis,  203,  SGi!. 

Retroperitoneal  abscess,  408. 

Retroperitonieum,  hiemorrhage  into,  4H,  457. 

Retropulsion  in  paralysis  agituns,  [)-M. 

Revaeciuation,  01. 

Rhabdo-niyoma  of  kidney,  770. 

Rhabdonenia  intestiuale,  1030. 

Rhagades,  170. 

Rheumatic  fever,  270 ;  age  in,  270 ;  cerebral 
complications  of,  274  ;  diagnosis  of,  275  ;  en- 
docarditis in,  273;  etiology  of,  270;  fibrous 
nodules  in,  275 ;  germ  theory  of,  271 ;  hered- 
ity in,  271 ;  hyperpyrexia  in,  273  ;  metabolic 
theory  of,  271 ;  morbid  anatomy  of,  271 ; 
nervous  theory  of,  271  ;  pericarditis  in,  273; 
purpura  in,  274;  sex  in,  270 ;  symi)toms  of, 
272 ;  treatment  of,  270. 

Rheunuitie  gout  (see  AisrnuiTis  Dekoiimans). 

Rheumatic  nodules,  275. 

Rhejmatism,  clironie,  278;  etiology  of,  278; 
morbid  anatomy  of,  278 ;  prognosis  of,  278 ; 
symptoms  of,  278;  treatment  of,  278. 

Rheumatism,  muscular,  2S1. 

Rheunuitism,  subacute,  273. 

Rheumatoid  arthritis  (see  AiniiuiTis  Dkfou- 

MANS). 

Rhinitis  atropliica,  475;  hypertrophicn,  475; 
simjilcx,  475;  syphilitic,  170. 

Ribs,  resection  of,  in  empyema,  571. 

Riec-water  .stools,  122. 

Ricketrt,  307;  acute,  311,  815;  etiology  of,  307  ; 
fa'tal,  307  ;  morbid  anatomy  of,  JSOs  ;  progno- 
sis of,  311  ;  symi)toms  of,  301* ;  treatment  of, 
312. 

Rigidity,  early,  in  liemiiilcgia,  873. 

Rigidity,  late,  in  hemiplegia,  875. 

Rigors,  in  abscess  of  brain,  1)04;  in  abscess  of 
liver,  448;  in  ague,  147;  in  pyuumia,  117;  in 


pnetimonia,  517;  in  pyelitis,  700;  in  tuber- 
culosis, 2111. 

Risus  sardonicus,  lO.'i. 

Riverside  Hospital,  New  York,  typhus  epi- 
dendc,  1881,  43. 

Koek-fever,  200. 

h'oiiihi  n/n  symptom,  843. 

Root-nerve  .symptoms  in  compression  para- 
plegia, 851. 

Root-zone  of  C/iarcot,  alfeeticn  of,  in  tabes,  841. 

Rosary,  rickety,  3oii. 

Ro.seola  (see  ItosK  Rash  of  Tvi'IIoid),  15. 

"  Rose  cold,"  477. 

Rose  nush  in  typhoid  fever,  15. 

Rotation  in  epilepsy,  1)51. 

Rotatory  spasm  in  hysteria,  971. 

Ur.tticln,  81. 

'■  Rough-on-r.its,"  poisoning  by,  1011. 

Round- worms,  1U25. 

Rub  (sec  Fiuction;. 

Rubella,  81. 

Rubeola  notha,  81. 

Rumiiuition,  302. 

Kumiing  pulse  in  typhoid  fever,  17. 

Russian  fever,  88. 

Saeclniromyces  albicans,  .",25. 

Sacral  plexus,  lesions  of,  81". 

St.  Vitus's  dance,  1121). 

Saline  injections,  intravenous,  in  diabetic 
coma,  305;  mbeufaiwous,  in  cholera,  124. 

Salaam  cf)nvulsions,  945,  070. 

Saliva,  arrest  of,  328  ;  hypersecretion  of,  ."SiiS. 

Salivary  glands,  diseases  of,  32h';  intlanimation 
of,  328. 

Salivation  (see  Ptvai.is:;.-),  ,".27,  328;  in  siuall- 
jKix,  52;  in  bulbar  paralysis,  801. 

Salpingitis,  tuberculous,  231),  245. 

Saltatorie  spasm,  1)43. 

Sanitaria  for  tuberculosis,  252. 

Saprannia,  114. 

Saranac  Sanitarium,  251. 

Sarcitui  vcntrieuli,  305;  in  lung  cavities,  222. 

Sarcoma,  of  brain,  !il8;  of  kidney,  77li ;  of 
liver,  453;  of  lung,  550;  mediastinal,  578; 
melanotic,  453. 

Sarcoptes  hominis,  1047. 

Saturnine  neuritis,  771). 

Saturnism,  10117. 

Sausage  jioisoning,  1013. 

Scapulodynia,  2s2. 

Scarlatiiui  miliaris,  00. 

Scarlatina  sine  crujitiono,  71. 

Searlatimd  nephritis,  71. 

Scarlet  fever,  07  ;    anginosc  form,  71 ;  ataxic 
form,  71  ;    complications  and  sequehe,  71 
contagiousness  of,  07 ;  des(iuanuition  in,  70 
diagnosis  of,  7;'';  enij  tion  in,  00;  etiology  of 
07;  ha'niorrhagic  form,  71;   incubation  in, 


lit 


)| 


i 


1074 


INDEX. 


60;  invasion  in,  fiO ;  maliijnant,  71  ;  inorliid 
onutoiiiy  of,  08;  proirnosis  of,  7-t ;  puurperul, 
tiH;  »ur),'i('ul,  (iti ;  treatment  of,  7o. 

SchOnlciii's  (lisi'iuso,  317. 

Srliool-niiulc  clion  a,  !)I52. 

Huiatifa,  818. 

Sciatic  nerve,  817. 

Sc'irrlius  cancer  of  .sto:nacii,  377;  of  pancrciui, 
4(')1. 

Sclerema  in  eliolera  infantum,  "1)3. 

Sclerotlaetyle,  Wi. 

Sclcroilerma,  !iy3. 

S(!l(;roso  en  plaques,  !ll3. 

Sclerosis,  cerel)ro-.-<]>inal,  '.'11,  013;  <lo;.'enora- 
tivc.  Oil;  developmental,  Ol'i;  iiiHamnui- 
tory,  91 'J  ;  sypliilis  iw  a  cause  of,  UiO. 

Sclerosis,  lateral,  837. 

Sclerosis,  posterior  spinal  (sec  Locomotok 
Ataxia),  840;    in  clironic  ergotism,  lOltJ. 

Sclero-sis,  primary  eoinhined,  840. 

St^lerosis  in  tuUercles,  I'J."). 

Sclerosis,  renal,  740. 

Sclerostomum  duoJenule,  1031. 

Seolicc8  of  eeliinococcus,  1042. 

Scorbutus,  312. 

S(,.-ivener's  palsy,  003. 

Scrofula,  204;  alleged  protective  inoculation 
by,  201). 

Scrofulous  pneumonia,  107,  210, 

Scurvy,  312;  diajjnosis  of,  31.1;  eti'ilcwy  of, 
312;  in  children,  31">;  tliajrnosis  from  rick- 
ets, 31.");  morbid  anatomy  of,  313  ;  [iroirnosis 
of,  31.");  prophylaxis  of,  31.");  symi'toins  of, 
314;  treatment  of,  310. 

Soybala,  421. 

Seasonal  relations,  of  chorea,  0.30  ;  of  malaria, 
141  ;  of  |)ne\nnonia,  .')11  ;  of  rh(annati.--m,  270. 

Secondary  contracture  in  licniiplegia,  875. 

Secondary  deviation,  70.3. 

Secondary  fever  of  small-pox,  51. 

Self-limitation  in  tubercidosis,  240. 

Semilumir  space  of  Traiihc,  .102. 

Semilunar  valves,  aortic,  incompetency  of,  002. 

Senile  emphysema,  .')40. 

Sensation,  painful,  loss  of,  in  syringomyelia, 
8.")0. 

.Sensation,  retardation  of,  in  ataxia,  813. 

Sensory  centres  and  paths  in  brain  and  cord, 
80.'). 

Septiciuniia,  114;  progressive,  IIT). 

Scrratus  palsy,  815. 

Sewer-gas  and  tonsillitis,  332. 

Sewer-gas  ami  diphtheria,  00. 

Sewcr-gas  poisoning,  etfects  of.  204. 

Sexes,  proportion  of,  ai'Vctcd  with  acute  yel- 
low atrophy,  420 ;  in  chlorosis,  OHO;  in  cho- 
rea, 020;  in  exophthalmic  goitre,  712,  in 
general  paresis,  014;  in  hiemoi))iilia,  320. 

Sex,  iufluenco  of,  in  huart-diticiwe,  621. 


Sextan  iiguo,  151. 

Shaking  palsy,  020. 

Shell-llsh,  poisoning  by,  1014. 

Ship-fever,  30. 

Shock  as  a  cau.se  of  traumatic  neuroses,  081. 

Shock,  death  from,  in  acute  obstruction,  417. 

Sick  headache,  057. 

Siderosis,  553,  555. 

Signal  symptom  (in  cortical  lesions),  897. 

Sinus  thrombosis,  885 ;  in  chlorosis,  885 ;  and 
))ya'mia,  880  ;  secondary,  in  ear-disease,  885. 

Sixth  nerve,  paralysis  of,  703. 

Skin,  itching  of.  in  uriemia,  739. 

SkoUa'ii  resonance  in  pleural  eti'usion,  501 ;  in 
pneumonia,  510. 

Skull,  of  congenital  sypliili.s,  171  ;  of  hydro- 
cephalus, 023  ;  of  rickets,  310. 

Small  sciatic  nerve,  817. 

Smalt-pox,  40  ;  complications  of,  55  ;  contiuent 
form,  51  ;  contagiousness  of,  40  ;  diagnosis 
of,  50 ;  discrete  form,  51  ;  eruption  in,  51  ; 
etiology  of,  40  ;  liujinorrhagic,  52  ;  inocula- 
tion in,  40 ;  morbid  anatomy  of,  48  ;  progno- 
sis of,  50 ;  symptoms  of,  49 ;  treatment  of, 
58  ;  vaccination  in,  40. 

Smell,  atfections  of  sense  of  (see  Olkactobv 
IS'erve),  782. 

Snake-virus,  purpura  caused  by,  310, 

Snutlles,  170. 

Sollening  of  bruin,  878. 

Soil,  intluence  of,  in  cholera,  120;  in  tubercu- 
losis, 103  ;  in  typhoid  fever,  5. 

Solvent  treatment  of  renal  calculi,  709. 

Soor,  325.- 

Sordcs,  20. 

Sore  throat,  330, 

iS"o//a  brcail,  304. 

Spiusms,  in  ergotism,  1015 ;  in  hydrophobia, 
100  ;  in  hysteria,  909 ;  of  face,  800 ;  of  muscles, 
after  facial  paralysis,  790  ;  professional,  963  ; 
saltatoric,  943. 

Spasm,  lock,  in  -writer's  cramp,  004. 

Spasinodic  wryneck,  810. 

Spiustic  paraplegia,  830  ;  in  children,  838. 

Si)eeific  infectious  diseases,  1. 

Spectra,  fortification,  958. 

Speech  (see  Aphasia),  898. 

Speech,  in  adenoid  vegetations,  337  ;  in  bulbar 
parolysis,  801;  in  insular  sclerosis,  914;  in 
general  paralysis,  910;  in  liereditury  ataxia, 
849 ;  in  paralysis  agitans,  927. 

Speech,  scanning,  in  insular  sclerosis,  014. 

Spes  phthisica,  220. 

Siiina  bifida,  involvement  of  cauda  equina  in, 

855. 
Spinal  accessory  nerve,  paralysis  of,  809. 
Si)inal  apoplexy,  820. 
Spinal  concussion,  effects  of,  982. 
Spinal  cord,  discoaus  of,  820, 


INDEX. 


1076 


siia. 


9U. 

iquiua  in, 
b09. 


Spinal  cord,  nouto  affections  of,  828 ;  nntcinin 
(if,  H'J5 ;  t'limiiic  utl'cctioiiH  of,  Hfiii ;  ciiroiiic 
li'l)ti>iiiuniiif.'itis  of,  H2.'i ;  compression  of,  n'll  ; 
(•0111,'cstion  of,  S'^') ;  enit)oliMm  ami  tlironibo- 
His  of  voB-sels  of,  825;  endarteritis  of  vessels 
of,  82") ;  tlssin'cs  in,  827  ;  iiicmorrlm^tc  into, 
s-ii) ;  l('ptornciiiiiL(itis  of,  822  ;  localization  of 
functions  of,  Sh7  ;  jiadiynicnin^ritis  of,  s-jo ; 
McliTosis,  primary  comhincd,  of,  840 ;  sypiiilis 
of,  174  ;  tuberculosis  of,  2t3  ;  tumors  of,  855 ; 
unilateral  lesions  of,  853. 

Spinal  epilepsy,  HW. 

Spinal  irritation,  'J7!t. 

Spinal  nieiiibrancs,  hromorrliage  into,  824. 

Sjiinat  neurasthenia,  979. 

S])inal  paralysis,  atrophic,  S.^l. 

Spinc-eliair  of -A  J\'.  Mitflull,  h.").*?. 

Spino- muscular  segment  (of  motor  path), 
lesions  of,  893. 

Spirals,  C'iin<c/imanii\  .500.  503. 

Spirillum  of  rclapsin;f  fever,  44. 

Spirocluete  Obermeieri,  44. 

Splanchnoptosis,  7 1 9. 

Sjileen,  amyloid  dcjjcneration  of,  in  sypliilis, 
177;  in  tuberculosis,  218. 

Spleen,  in  :i  'iic,  145,  154;  in  anthrax,  158;  in 
cirrhosis  of  liver,  443;  in  //r)7;//v/iV  disease, 
705  ;  hydatid  of,  1043;  in  Icuka'uiia,  702;  in 
riel<et.s,  308,  31 1 ;  ill  acute  tiilierciilosis,  199; 
in  typhoid  fever,  8  ;  in  typhus,  40. 

Spleen,  tioatiiii.',  excision  of,  703. 

Spleen,  enlargement  r)f,  in  eongcnital  syphilis, 
170,  172  ;  in  malaria,  \U. 

Spleen,  exeision  of,  in  hypertrophy,  703;  in 
Icukieinia,  7o3. 

Spleen,  puncture  of,  31. 

Spleen,  rupture  of,  in  malaria,  144;  in  typhoid 
fever,  8,  23. 

SplenecttJiny,  statistics  of,  703, 

Splenic  fever,  15fi. 

Splenization  of  lung,  212.  ,538.    ■  *         ' '" 

Spondylitis  defornians,  28(5. 

Sporozoa,  10*22. 

Sputa,  albuminoid,  after  aspiration  of  chest, 
570;  alveolar  cells  in,  491,  504;  ainieba  coli 
in,  138;  in  cancer  of  lung,  557;  hieniatoidin 
crystals  in,  496 ;  in  anthracosis,  555 ;  in 
asthma,  499 ;  in  bronehiectiusis,  49i> ;  in 
acute  bi'oncliitis,  491  ;  in  ehronie  lironchitis, 
493;  in  putrid  brondiitis,  494;  in  gangrene 
of  lung,  551. 

Sputa,  in  phthisis,  220;  in  pneumonia,  519;  in 
acute  pulmonary  tuberculosis,  200;  prune- 
juice,  557  ;  uric-acid  crystals  in,  290. 

Staphylococci,  in  diiihtheria,  loi;  in  endocar- 
ditis, 590 ;  in  peritonitis,  4(i3 ;  in  pneumonia, 
515;  in  pytctnia,  llii;  in  septicfcinia,  114. 

Staphylococcus  pyogenes',  albus,  403. 

Staphylococcus  pyogenes  aurcua,  463. 

68 


Starch,  test  for,  in  gastric  contents,  347. 

Status  epileptieils,  951. 

Stearrhd'a,  4(11. 

Sti-llwaifn  sign,  713. 

Stcnocarilia,  055. 

Stenosis,  of  aortic  orifice,  0O8  ;  of  mitral  orifice, 
014  ;  of  pulmonary  orilice,  O'JO,  001  ;  of  trioUM- 
pid  oritiee,  019. 

Sti'i'coraceous  vomiting,  410. 

Stcrtor,  in  apoplexy,  873, 

Stit!  neck,  2«1. 

Stij.,  I  ita,  in  liysteria,  974;  in  purjiura,  317. 

Stiti  ,1  Ml  sid(!  in  pneumonia,  517,  500. 

Stolidity  of  fa(!C  in  LTcncral  paresis,  916. 

Stomach,  ubsorjitivo  power  of,  tests  for,  34S ; 
atlTphy  of,  352. 

Stomach,  cancer  of,  370  ;  absence  of  free  IICl 
in,  379 ;  diairnosis  from  gastric  ulcor  and 
chronic  ga.stritis,  382 ;  etiology  ot',  370  ;  huMii- 
orrhiige  in,  379;  morbid  anatomy  of,  370; 
vomiting  in,  379. 

Stomach,  diseases  of,  344. 

.Stomach,  dilatation  of,  304;  tetany  in,  305. 

Stomach,  examination  of  contents  of,  .; 45  ;  for- 
eign bodies  in,  384;  luemorrhage  from,  371, 
3.S5;  hair  tumors  in,  384;  methods  of  clini- 
cal examination,  344 ;  motor  powerof,  test  for, 
347  ;  neuroses  of,  359  ;  non-cancerous  tumors 
in,  3M4;  position  and  siz(^  of,  344;  size  of, 
method  of  determining,  300  ;  tuberculosis  of, 
240;  uleerof,3()8;  wiLshingoiit  of  ( lavage ),3.")7. 

Stomatitis,  323  ;  acute,  323 ;  ai)hthous,  323  ;  fet- 
id, 324;  follicular,  323;  gangrenous,  320; 
mercurial,  327 ;  parasitic,  325  ;  ulcerative, 
324;  vesicular,  323. 

Stone-cutter's  {ihthisis,  194,  553. 

Stools,  of  acute  yellow  atrojiliy,  427  ;  of  chol- 
era, 122;  of  dysentery,  i:'.l,  134,  131);  of  ty- 
phoid fever,  20;  in  liaMiiatcmesis,  387  ;  of  ob- 
structive jaundice,  424. 

St.  Thomas's  Hospital,  statistics  of  pneumonia 
at,  528. 

St.  Petersburg  Foundling  .\syluni,  statistics  of 
tubi'i'oulosis  at,  233. 

Strabismus,  793;  as  an  early  symptom  ot 
tabes,  S42, 

Strangulation  of  bowel,  413,  418. 

"  Strawberry"  toniruo  in  scarlet  fever,  09. 

Stricture  of  bile-duet,  437. 

Stricture  of  colon,  cancerous,  415. 

Stricture  of  intestine,  415 ;  atYcr  dy.sentcry, 
1.37,  415  ;  after  tuberculous  ulcer,  241. 

Stricture  of  cesophogus,  341. 

Stricture  of  pylorus,  304.  '  * 

Strei)tococci  in  diphtheria,  101  ;  in  empy- 
ema, 504 ;  in  endocarditis,  590 ;  i'l  pneu- 
monia, 515;  in  peritonitis,  403  ;  in  pyuiinitt, 
110  ;  in  scarlet  fever,  68 ;  in  septicuiiniu,  II4; 
iu  tonsillitis,  S33. 


« 


1076 


INDEX. 


Streptococcus  of  Fehlehen  in  cryBipelnfi,  111. 

Mtrcptoeoccus  pyoirt'iics,  4(!;i ;  in  orysipcliw,  111. 

Htroujfylu.i,  ariimtiw,  10.11 ;  duoderuilis,  1031. 

Stupes,  turpoutiiio,  inutliod  of  ai)plifutioti,  30. 

Stuttering'  in  nioutii-l)rt^atli(!rM,  .'5;J7. 

Mtyriiin  peanantM,  ai-se'nii'u!  luil)it  in,  1012. 

Bubcluvian  artiTV,  murmur  in,  and  throbbing 
of,  in  plitliisis,  :i:i7. 

Subsultus  tondinuin  in  typlioid  fever,  25. 

Succussion,  Iliippofnitic,  .')7(!. 

SucousHion  HjiliuHh  in  tliluted  stomach,  306. 

Sueklinps,  tubercuionis  in,  1H7. 

Sudumina  in  typlioid  fever,  1(>. 

Sudden  deatli,  in  aortic  insulHcicncy,  C07 ;  in 
coronary  artery  disease,  040 ;  in  jileural  ett'u- 
sion,  r>03;  in  typlioid  fever,  ,31. 

Sudoral  form  of  typhoid  fever,  10. 

Sugar  in  tiie  urine,  2i)8. 

Sulphocyanides  in  excess  in  saliva  in  rheuma- 
tism, 273. 

Sunstroke,  1017;  aftcr-ctt'ects  of,  1018;  treat- 
ment of,  101!). 

Suppurative  nephritis,  759. 

Surgical  kidney,  7i'>y. 

Suspension  in  compression  paraplegia,  853. 

Sweating,  in  acute  rheumatism,  272;  in  ague, 
150;  in  diabetes,  300;  in  phthisis,  225;  in 
pymmia,  117  ;  in  typhoid  fever,  10  ;  in  ulcera- 
tive endocarditis,  597;  profuse,  in  rickets, 
309  ;  unilateral,  in  cervical  caries,  852  ;  uni- 
lateral, in  aneurism,  070. 

Sweating  sickness,  208. 

Sydenham's  chorea,  929. 

Symmetrical  gangrene,  987. 

Sympatlictic  ganglia,  in  Addinon^s  discoae, 
709;  in  exophthalmic  goitre,  712. 

Sympathetic  nerve  flbres  (see  Vaso-motob). 

Syncopal  ague,  153. 

Syncope,  fatal,  in  diplitheria,  107 ;  in  cardiac 
disease,  007,  022,  044;  in  phthisis,  234;  in 
pleural  effusion,  503. 

Syncope,  local,  087. 

Synovial  rheumatism  (see  Gonobrikeal  Riiku- 
matism'),  279. 

Synovitis,  gormrrlKical,  280. 

Synovitis,  symmetrical,  in  congenital  syph- 
ilis, 171. 

Syphilides,  macular,  108  ;  papular,  108;  pustu- 
lar, 108  ;  squamous,  108;  the  late,  109. 

Syphilis,  105:  accidental  infection  in,  105; 
acquired,  107  ;  amyloid  degeneration  in, 
109;  congenitiil,  109;  diagnosis  of,  179;  eti- 
ology of,  105;  gumniata  in,  100;  hereditary 
transmission  of,  105;  modes  of*  infection  in, 
105;  morbid  anatomy  of,  106;  of  brain  ond 
cord,  172 ;  of  circulatory  system,  178  ;  of 
digestive  tract,  178;  of  liver,  170;  of  lung, 
174 ;  orchitis  in,  179;  primory  stage  of,  107  ; 
prophyla.\i8  of,  180;  renal,  179;  secondary 


stage  of,  lfi7;  symptoms  of,  109;  tertiary 
stage  of,  109;  treatment  of,  IMI ;  visceral,  172. 

Syphilis  hiemorrhagica  necmatorum,  170. 

Syphilis  hereditaria  tarda,  ls7. 

Sy]ihilis  and  locomotor  ataxia,  841. 

Syi)liilis  and  dementia  paralytica,  173,  917. 

Syphilitic  arteritis.  178. 

Syiihilitic  encephalopathy,  173. 

Syphilitic  fever,  107. 

Syphilitic  ])htliisis,  175. 

Syringo-niyelia,  849;  witli  hajmorrhogc,  826. 

Tabes,  diabetic,  301. 

Tabes  niesenteriea,  208. 

Talies  dorsalis  (see  Locomotou  Ataxia),  840; 
in  chronic  ergotism,  1010. 

Tabes  dorsalis  spasniodifjue,  830. 

Taches  bluu&tres,  15,  1049 ;  relation  to  pedieuli, 
15, 1049. 

Tache  cdrdbralc,  10,  203, 

Tacliycardia,  652. 

Tactile  fremitus,  in  emphysema.  .548 ;  in  pneu- 
monia, 519;  in  pleural  ettusion,  501  ;  in  pneu- 
mothorax, 575;  in  pulmonary  tuberculosis, 
220  ;  at  right  opex,  225. 

Ticnia  ecliinocoecus,  1041.  ... 

Tuinia  clliptica;  T.  cucumerina;  T.  flavopunc- 
tuta;  T.  nana;  T.  Madugascariensis,  1037. 

Toiiiia  saginata  or  mcdiocanelluta,  1037. 

Tienia  solium,  1030. 

Tape-worms,  1030 ;  treatment  of,  1038. 

Taste,  disturbances  of,  805  ;  tests  for  sense  of, 
805. 

Tocliomyza  fusca,  1050. 

Teeth,  aetinomyces  in,  263 ;  looseness  of,  in 
scurvy,  314;  erosion  of,  327;  Jliitchinsoii's, 
171,  327 ;  of  infantile  stomatitis,  327. 

Teicliopsia,  958. 

Telegraphes's  cmmp,  903. 

Temperature  sense,  loss  of,  in  syringo-myclia, 
850  ;  in  Morvati's  disease,  850. 

Temperature,  subnormal,  in  acute  alcoholisna, 
1001;  in  apoplexy,  873;  in  heat  exhoustion, 
1017;  in  malaria,  1.53;  in  pulmonary  tubercu- 
losis, 224;  in  tuberculous  meningitis,  199;  in 
unumia,  739. 

Temporal  lobe,  centre  for  hearing  in,  801 ; 
tumors  of,  920. 

Tender  points  in  neuralgia,  960;  in  hysteria, 
971. 

Tendon-reflexes  (see  Reflexes). 

Tertian  ague,  150. 

Testes,  tuberculosis  of,  245;  syphilis  of,  179  (see 
also  Orchitis).    • 

Tctnnin,  163. 

Tetanus,  162;  bacillus  of,  163;  diagnosis  of, 
164 ;  etiology  of,  162 ;  prognosis  of,  164 ;  symp- 
toms of,  163 ;  treatment  of,  164. 

Tetanus  hydrophobicu»,  104. 


i 


INDEX. 


1077 


Tetany,  !H!r);  ufUT  tliyroideotomy,  905;  il\un- 
iioNis  of,  iMiti ;  ('|iiiluini(^  or  rlieiinuitio,  \)M> ;  i!i 
diliitutiuii  of  tl)o  Htoimich,  8(!r),  'Jtlfi;  in  niyx- 
cudtiinii,  9()5 ;  rurity  of,  in  Aini-rifii,  SltiS ;  Myinj)- 
tonm  of,  UOti ;  truutineut  of,  UOO;  vuriutiuM  of, 
Wui. 

Tetrodon,  poisonin)^  by,  1015. 

Tlicrnpcutic.  test  in  xypliiiin,  180. 

Tliurinic  fovor,  1017  ;  continued,  1019. 

Tlicrinic  Hense,  lo«s  of,  in  Hyringo-niyelia,  850. 

Third  nerve,  diBeiwes  of,  790. 

Third  nerve,  reeurrin)^  piiralynirt  of,  791 ;  sign-s 
of  parnlyMis  of,  791. 

Tliird  ventricle,  tumors  in,  920. 

Thirnt  in  diabetes,  299. 

ThomReu\  diticase,  998. 

Thoracic  duct,  tuberculosis  of,  198. 

Thorax,  deformity  of,  in  niouth-brettthers,  337  ; 
in  rickett,  309. 

Thorax  in  enipliysenia,  548;  in  phthisis,  192, 
225. 

Thorn-headed  worms,  1036. 

Thread-worm,  102i!. 

Tlirondii  in  veins  in  typhoid  fever,  19. 

Thrombi  in  heart,  015;  in  diphtheria,  103;  in 
pneumonia,  516. 

Thrombi,  marantic,  885. 

Thrombosis  of  cerebral  arteries,  878 ;  of  cere- 
bral sinuses,  885 ;  of  cerebral  veins,  S85. 

Thrush,  325. 

Thymic  a.sthma,  486,  580. 

Thymus  gland,  in  acromegalia,  991 ;  enlarge- 
ment of,  580 ;  sudden  death  in,  580. 

Thyroid  gland,  diseases  of,  711. 

Thyroid  gland,  abeiTant  or  accessory  tumors 
of,  712;  abscnccof,  in  cretins,  714;  adenoma- 
ta of,  712;  cancer  of,  712;  in  exophthalmic 
goitre,  712;  in  goitre,  711;  in  myxtt'deina, 
714 ;  sarcoma  of,  580,  712 ;  tumors  of,  712. 

Tic  convulsif,  943. 

Tic  douloureux,  9C0.  .    :\- i 

Ticks,  1048.  i  ■  ,  i. 

Tinnitus  aurium,  802. 

Tintcuient  m^talliquo,  632.  ■    :  ■ 

Tobacco,  influence  of,  on  the  heart,  629, 634, 1549. 

Tongue,  atrophy  of,  812;  in  bulbar  parulysis, 
861 ;  spasm  of,  813;  tuberculosis  of,  240. 

Tongue,  tremor  of,  in  general  paresis,  916; 
ulcer  of  frcenum  in  whooping-cough,  85. 

Tonsillitis,  332 ;  acute,  332;  albuminuria  in, 
384;  endocarditis  in,  334;  in  the  newly  mar- 
ried, 333. 

Tonsillitis,  chronic,  335 ;  follicular,  .332 ;  lacu- 
nar, 332;  suppurative,  334;  and  rheumatism, 
332. 

Tonsils,  diseases  of,  332. 

Tonsils,  abscess  of,  334 ;  calculi  of,  338 ;  cheesy 
masses  in,  838;  enlarged,  336;  tuberculosis 
of,  240. 


Tophi,  291. 

Toronto  General  Hospital,  statistics  of  typhoid 
fever  at,  3. 

Toitieollis,  281,  810;  congenital,  810;  facial 
asymmetry  in,  810;  spas". iodic,  81u;  treat- 
ment of,  811. 

Toxan)umin  in  diphtheria,  loi. 

Toxiiies.  Idl'J;  in  st'iilica-iiiia,  115. 

Tracheal  tugging,  674. 

Trance  in  hy.ttcriu,  969. 

Traiihe^  semilunar  space,  562. 

Trauma  as  a  factor,  in  ileliriuin  tremens,  1003; 
in  neurasthenia,  9sl  ;  in  pneumonia,  512;  iu 
tuberculosis,  193. 

Trcmatodes,  diseiuics  caused  by,  1024. 

Trembles  in  cattle,  266. 

Tremor,  alcoholic,  929,  1002;  liereditary,  029; 
hysterical,  929,  971 ;  in  exoplithulmic  goitre, 
713;  in  paralysis  agitans,  927;  lead,  1010; 
senile,  929;  simple,  929;  toxic,  929;  voli- 
tional, in  insular  sclerosis,  913. 

Trichina  spiralis,  distribution  of,  1026 ;  statit- 
ti'va  of,  in  American  hogs,  1028;  in  Germanyj 
1028. 

Triehiniasls,  1026;  diagnosis  of,  1030;  statis- 
tics of,  in  America,  1029. 

Trichoceplialus  dispar,  1035. 

Trichter-brust,  22.5. 

Tricu-spid  valve,  insufficiency  of,  018. 

Tricuspid  orifice,  stenosis  of,  619. 

Trigeminus  (see  Fifth  Neuve). 

l'foinmer''s  test,  299. 

Tropicolin  test  for  free  acid,  346. 

Trophic  disorders,  987. 

Trousseaii's  plienomenon  in  tetany,  966. 

Tubal  pregnancy,  ruptured,  simulating  perito- 
nitis, 465. 

Tubercle  bacilli,  18,5,  220. 

Tubercle,  diffuse  infiltrated,  196,  216  ;  miliary, 
195;  chiuiges  in,  195;  structure  of,  195. 

Tubercles,  miliary,  in  chronic  phthisis,  215. 

Tubercula  dolorosa,  782. 

Tuberculin,  186. 

Tuberculosis,  ac\ite,  197;  general  or  typhoid 
form,  198  ;  meningeal  form,  201 ;  pulmonary 
form,  200. 

Tuberculosis, bacillus  of,  1 85, 220 ;  changes  pro- 
duced by  bacillus,  195 ;  chronic  miliary,  21.') ; 
conditions  influencing  infection,  192;  con- 
genital, 187  ;  dietetic  treatment  of,  252;  dis- 
tribution of  tlie  tubercles  in,  194;  duration 
of  pulmonary  form  of,  247  ;  etiology  of, 
184 ;  general  measures  in  treatment  of,  250 ; 
hereditary  transmission  of,  187;  individual 
prophylaxis  in,  248;  infection  by  meat,  191  ; 
infection  by  milk,  191 ;  infection  through 
the  air,  189;  inoculation  of,  188;  in  infants, 
233;  in  old  age,  233;  medicinal  treatment  of, 
253 ;  modes  of  death  in  pulmonary,  234 ;  modes 


t    t 


1078 


INDEX. 


of  iiifi'ction  in,  187;  nntural  or  Hpoiitaiutous 
cure  of,  '2-Ut-  of  aliiiu'iitury  I'unul,  ii;!:i ;  of 
arteries,  '241! ;  ot  bruin  iin<l  eord,  -M-i  ;  of  Fiil- 
lo|iiiin  tiilicH,  •J4.');  of  ;,'enito-iiriniiry  Nvsteni, 
24:i ;  of  kidneyn,  'Jt:! ;  of  liver.  •J4-J  ;  of  iyiin)li 
«liinils,  'Mi\  of  oviirie.s,  ii4') ;  of  perieanliuni, 
23r> ;  of  peritonu'iun,  237  ;  of  j)leiirii,  'J.'f.5 ;  of 
pro.Htiite,  245;  of  serous  nienil>rane.s,  2^r>; 
of  testes,  24.");  of  urefei-s  ami  lilaililer,  244; 
of  uterus,  24");  of  vesieuliu  seminales,  24."); 
pre^'iuiiiey,  influenee  of,  in,  'J47 ;  pro^nosiH 
of,  24fi ;  prophylaxis  in,  l'47  ;  i)ulinoiuiry, 
20H  ;  speoitlc  treatment  of,  2.")2  ;  treutinont  of, 
240,  2.")4. 

Tii/iiill'n  treatment  of  uncurisin,  078. 

Tumors  ol  brain,  !»18. 

Tuniu^l  unuimia,  l();i2. 

Tympanites,  in  intestinal  obstruction,  417  ;  in 
peritonitis,  AfA\  in  tuliereulous  |ieritonitis, 
2;i8 ;  in  typhoid  fever,  2.f  ;  its  a  euiise  of  sud- 
den heart-failure,  4o;} ;  in  the  constijiation 
of  infants,  422. 

Typhlitis,  405. 

Typhoid  fever,  1  ;  abortive  form,  28;  afebrile, 
1"),  21» ;  ambulatory  form,  l.*?,  2M  ;  ana'uiia  in, 
17  ;  untl  tuberculosis,  ."!!),  2.S2  ;  bacillus  of,  3  ; 
circulatory  .system  in,  It);  complications  of, 
27;  diajjnosis  of,  30;  diarrhd'tt  in,  20;  di- 
gestive system  in,  19;  A7(/'//('/iV  reaction  in, 
2ii;  etiolo^ry  of,  2;  ),'rave  form  of,  2s  ;  htem- 
orrha.ifo  in,  H;  historical  note  on,  1;  in  the 
ftifed,  29;  in  children,  29;  liver  in,  23;  nic- 
teorisni  in,  22  ;  mild  form,  2S  ;  modes  of  con- 
veyance of,  4  ;  morbid  amitomy  of, .') ;  nerv- 
ous system  in,  24;  osseous  system  in,  27; 
parotitis  in,  20;  perforation  of  bowel  in,  7, 
22 ;  post-typhoid  elevations  of  temperature 
in,  13;  prof^nosia  of,  31  ;  proi)bylaxis  of,  32; 
relapses  in,  29  ;  renal  system  in,  2.") ;  respira- 
tory system  in,  23  ;  skin  rashes  in,  l.'*;  spleen 
in,  23;  symptoms  of,  10;  treatment  of,  33; 
varieties  of.  27. 

Typho-malarial  fever,  so-called,  27,  LIS. 

Typhotoxin,  3. 

Typhus  fever,  30 ;  complications  and  sequcltc 
of,  42 ;  ccntai^iousness  ot",  40 ;  diagnosis  of, 
42;  etiolofry  of,  39 ;  morbid  anatomy  of,  40; 
period  of  incubation  of,  40;  prognosis  of,  42  ; 
tia^o  of  eruption  in,  41 ;  symptoms  of,  40 ; 
treatment  of,  4.3. 

Typhus  siderans,  42, 

Tyrosin,  427. 

Tyrotoxicon,  1014. 

Ulcer,  cnncerous,  of  intestine,  898;  gn.stric, 
8'')8  ;  of  duodenum,  .3(iH ;  of  bowel  in  dys- 
entery, 132,  13.">;  in  tyi>hoid  fever,  7. 

Ulcer  of  mouth,  324 ;  in  the  new-born,  .325  ;  in 
~    nursing  women,  325 ;  of  palate  in  infants,  325. 


llleor,  peptic,  3»;8  :  perforating,  of  foot,  844. 

Ulcerativi^  cinlocarditis,  SO.'i. 

Ulnar  neivc,  atl'ections  of,  Hli}. 

UlU'ons<Moniiiess  (see  CoM.v). 

UraMiiia,  cerebral  numifestations  of,  738,740; 
chronic,  740;  coma  in,  730;  convulsions  in, 
739;  diagnosis  from  apoplexy,  877;  dys|')- 
noea  in,  730;  headache  in,  739;  in  Uright's 
disease,  757;  local  palsies  in,  739  ;  (edema  of 
bniin  in,  870;  stomatitis  in,  740;  symptoms 
of,  738 ;  theory  of,  737. 

Urate  (lithatu)  of  soda  in  gout,  288, 

Urates  in  the  urine,  732. 

I^rutes  (lithates),  amorphous,  732. 

I'reter,  nnieous  cysts  of,  lo:i;!;  obstructed  liy 
calculi,  707  ;  psorospermiusis  of,  1023, 

I'rethritis,  gouty,  293. 

Uric  acid,  calculus,  705;  deposition  of,  732; 
mode  of  elimination,  731  ;  pla^'C  and  mode 
of  formation,  731;  in  gout,  288;  in  urine, 
732;  "showers,"  293;  solubility  of,  732, 

Urie-aeid  diathesis  (see  LiTll.liMlA),  733. 

Uric-acid  hcailache,  292. 

Uric-acid  theory  of  gout,  288, 

Urinary  calculi,  70.5. 

Urine,  anonudies  of  tlic  secretion  of,  722. 

Urine,  density  of,  in  acute  Bright's  disease, 
742;  in  chronic  Bright's  disease,  752;  in 
diabetes,  298 ;  in  diabetes  insipidus,  300. 

Urine,  liuimoglobin  in,  723;  in  acute  yellow 
atrophy  of  liver,  427  ;  in  grave  anminia,  094  ; 
in  cholera,  122;  in  diabetes  insipidus,  300 ; 
in  diabetes  -.nellitus,  208  ;  in  diphtheria,  100  ; 
in  erysipelas,  113;  in  gout,  290,  202;  in 
jaundice,  424;  in  melanotic  sarcoma,  736  ;  in 
]>neumonia,  521 ;  in  acute  pulmonary  tuber- 
culosis, 230;  in  typlioid  fever,  20;  oxalates 
in,  733;  pus  in,  720. 

Urine,  qurtntity  of,  in  chronic  Bright's  disease, 
752;  in  diabetes  insipidus,  .300;  in  diabetes 
mellitus,  208 ;  in  intestinal  obstruction,  417. 

Urine,  retention  of,  in  typlioid  fever,  25. 

Urine,  suppression  of,  in  cholera,  122;  in'acuto 
nephritis,  742 ;  in  scarlet  fever,  72 ;  in  r  ;utc 
intestinal  obstruction,  417 ;  obstructive  sup- 
pression, 707. 

Urine,  tenU /or  albumen  in,  727;  biliary  pig- 
ment in,  424 ;  blood  in,  723. 

Urobilin,  increase  of,  in  pernicious  antcinia,  694. 

Uro-gcnital  tulnirculosis,  243. 

Urticaria,  after  tapping  of  hydatid  cysts,  1044: 
cpidemica,  1050;  gi, ant  form  (see  Neithotic 
OJokma),  390 ;  with  purpura,  317  ;  in  small- 
pox, 60;  in  typlioid  fever,  10. 

Uterus,  tuberculosis  of,  245. 

Uvula,  a'Jcma  of,  330;  infarction  of,  318,  830. 

Vaccination,  46;  mark,  60;  operation  of,  64, 
ra^cs,  63  ;  ulcers,  62 ;  value  of,  64. 


INDEX. 


io7y 


in 


.ysts,  1044: 
Nkuhotio 
in  sniuU- 


;ion  of,  01, 
4. 


Viu'oino  lymph,  cIki'u'o  nf,  (iO ;  I'min  tlii'  ciilf, 

tit;  hiuiiiiiii/.('(l,  li:). 
Viuoiniii,  'I"  ;  kfcrnnili/.iMl,  til. 
Viiiciiio-syiiliiliK,  112;  (liii;;nnsiH  tVoiii  vui'cinii- 

t'uiii  iilccru,  (>;;. 
Viijiuliiind't  tl'iMMtldratiou,  Tl'i. 
Viiu'iiiitiH,  t^onorrliiL'ul,  nl'tlii'  ni'\v-lM)rn,  'JTtl. 
V'ulvuliir  ilisi'iisi)  III'  luiirt,  ilnj;  |ii();rn(isi.s  in, 

Oiil  ;  trciitiiii'iit  (if,  iij;(. 
Viirii't'llii,  <>.');  lii("iiiiirrliiij.'i<',  ilil. 
Var'ucs,  (rr»n)liu'/('iil,  hi  I'irrlioMi.s  of  liver,  •')4<i. 
Varidiii,  4ii ;  hiuiiiDiTliiiitiou,  'jl',  54  ;  vera,  4',i. 

Valinla  siliir  orillitiolic,  'i[. 

Varioloid,  .'ii. 

VasK-iiiotor  ili-ordcrs,  ',>x'. 

Vuso-iiioior  ili.stiirbaui'us,  in  anicnilu,  fiS7  ;  in 
curios,  852  ;  in  eliroriio  pluuriny,  i)":} ;  in  ex- 
oplitlialmic  ifciitris  711;  in  iiuiuicrania,  lt')H  ; 
ill  Miyclitis.  ^•.",l ;  in  iU'Unili.'iii,  '."10. 

Veins,  cfrcln-al.  tluoiuliiisis  in,  sx.');  (iiiustiilio 
cdll.ipsi:  of,  .'i',!!!;  pulsation  ill.  -J-^H,  l»;Ji(,  yso. 

Vi'ua  eava,  inliTior,  twi.st  in,  ."iiio. 

Vt'Ua  cava,  superior,  pi'ri'oration  i)f  liy  aneu- 
rism, liV:.',  Cisj. 

Veneswtion  (see  l{[.oo|)i.KTTIN<i). 

Venous  pulse,  •J-2->,  '.>:W,  !tsi(. 

Ventrielen  of  brain,  dilatation  ot'  ( liydro.'ephn- 
lus),  '.>\H  ;  puiietiire  of,  ',t-j4. 

Veiitrieuiar  lueiiiorrliajje,  B7'i. 

Verruea  neerojfeniea,  Isy. 

Vertebne,  earies  of,  «.')!. 

Vertcljral  artery,  obstruction  of,  8S0. 

Verli}.'o,  auditory,  so.!;  cerebellar,  !>i1  ;  in 
l>rain  tumor,  '.(111;  irastric,  y.")i  ;  labyrinthine, 
so:!;  paral\  /.\u-x,  si'4. 

Vesicular  seiiiinales,  tuberculosis  of,  2l'\. 

Vicarious,  cpistaxis,  47'.';  lucmoptysis,  .')0;. 

Vitilijioidea.  4:i4. 

Vocal  freniitu.s,  .Mil,  Ml ;  resonance,  .')L'0,  '><;■_'. 

Voice  (.see  Si'KKcil ). 

Voice.  alt(Tation  of.  in  moutli-t)reathers,  337. 

Volitional  tremor,  'J13. 

Volvulus,  41.''),  411). 

Vomica,  siirii.s  of,  in  phthisis.  '21  li. 

Vomit,  black,  127  ;  cotfcc-jjround,  370. 

Vomitill\',  iu  Addisoit^n  disease,  710;  in 
yy/'iV/Z/^V  diseiwc.  754;  from  cerebral  iibsecsst, 
flo-t;  from  cerebral  tumor,  !U!);  in  chronic 
obstruction  of  intestines,  417;  in  ehronie 
ulcerative  phthisis,  22'.i;  trall-st<nie  colic, 
432;  in  jjastric  cancer,  37'.';  in  pistric  ulcer, 
371;  i"  acuto  obstruction  of  intestines,  410  : 
in  tuberculous  nioninjritis,  '202  ;  in  mii?raino, 
St58;  in  peritonitis,  4fi3;  in  sniall-po.\,  40; 
nervous,  .'■'il  ;  irimary  iieriodie,  302;  sterco- 
ruceous,  416;  uneinic,  740. 


Wnlh  riitii  dcifcncration,  803. 

Wall-paper,  iioisoniii;,'  by  arsenic  in,  loll. 

War  of  rebellion,  statistics  of  ilysentery  in,  bin. 

War  of  rebellinn,  maligimnl  measles  in,  70. 

Wart-pox,  52. 

Warts,  post-iiiorleni,  1h(i. 

Wnshiii;;  out  stoinaeli,  357,  3i)ii. 

Water-liamriier  pulse,  i'.imi. 

Water,    infection     by,   in   dipbtheria,   00;    in 

cliolera,  1 10;  in  typhoid  livcr,  4. 
"  Water  on  the  bruin,"  20l. 
KViVV  di.sease,  2t)5, 
Wirlliiiffit  disease  (see  I'lltPlltA  I,  .'lis. 

HV/'h/c/(\  lieiiiiopic  ]piii.illary  iniiciioii,  7s9, 

Wet-])ai'k,  75.  I 

Wliip-worm,  lo35. 

White  tlu.v  of  India,  30."). 

White  softeniniT  of  brain,  879. 

White  tiirombi  in  luiirt,  til."). 

Whoo])inir-coU);h,  84;  <<)iiiplications  and  sc- 
(piela'  of,  sii ;  diagnosis  of,  Sii ;  etioloL'y  of, 
84;  morbid  anatomy  of,  84;  jiro^nosis  of, 
8ii ;  symptoms  of,  85  ;  treatment  of,  s7. 
MV//(/<7V  diseiLse  (see  KrioK.Mic  H.k.moom»- 
niNiHiA  OF  THE  Nkw-iiohn),  171,7'.i4. 

"  Wind  "  in  the  ])r<)eess  of  truinintf,  i)35. 

"  Winded  scapulie,"  2:i5. 

Wliitriili'K  siu'ii,  227. 

l\'oi//iz,  iiKiliiili,  (/(',  5tX3. 

Wool-sr)rter's  disease,  158. 

Word-blindness,  8!iO. 

Word-deafness,  800. 

Wormian  Ijones  in  hydrocephalus,  923.        ' 

^\ Onus  (sec  I'.vitAsrrKs). 

Wrist-drop,  81t) ;  in  leiKl-poisoniiiLr,  loOO. 

Writer's  cramp,  903. 

Wryneck,  8U). 

Wurzbui'!,'  Sur>.'iciil  Clinic,  statistics  of  tuber- 
culosis at,  104. 

Xanthelasma,  424. 
Xanthine,  7ilO. 
Xantho|)sia.  lo2fi. 
Xerostomia,  32S. 

Yellow  fever,  1'25;  diufrnosis  of,  128;  etiolopy 
of,  1'25;  morbid  anatomy  of,  120  ;  proj<nosis 
of,  128;  prophyla.xis  of,  128;  .synijitonis  of, 
l'.>7  ;  treatment  of,  1'20. 

Yellow  sotlcnini.''  of  brain,  879. 

Yellow  vision,  102t>. 

Yea's  dietary  in  obesity,  1020. 

Zona,  901. 

Zynio;^en,  tests  for,  in  gastric  juice,  347. 


THE  END. 


- 


A  TEXT-BOOK  OF 

ANIMAL   PHYSIOLOGY, 

With  iNTKonucroRY  Chaitkbs  on  Gknkkal   I'iolooy,  and 
A  Full  Tueatment  of  KEruoDucnoN, 

For  Students  of  Human  and  Comparative  Medicine. 

By  WESLEY  MILLS,  M.  A.,  M.  1)., 

I'norEBSOR  OP   FUYHIOLOOT  in    MCOILL   UNIVVR8ITT  AMD  TUE   VBTKIilNAHY  COLLRUR,   MONTIiEAL. 


8vo.    With  606  niuatratloui.    Cloth,  96.00 ;  sheep,  $6.00. 

"...  The  luithor  hiis  set  himaelf  a  task,  ns  announced  in  the  pri'fiu'e,  of  trying  to 
moke  the  Btiulcnt  uii  observer  and  reasoner,  rather  than  merely  to  tax  liis  memory;  to 
auquauit  him  with  the  general  truths  in  the  broad  domain  of  bioh)<;y,  rather  tliun  to  over- 
whelm him  witli  useless  detail  and  burdensome  statistics.  None  who  carefully  peruse 
his  work  can  fail  to  recognize  that  the  subject  has  been  successfully  presented  in  accord- 
once  with  this  plan.  .  .  .  Tlie  general  merit  of  the  work  easily  places  it  on  a  par  with 
any  text-book  yet  written  for  beginners  in  this  branch ;  and  the  clear  deductions  of  the 
difference  in  function  and  general  structure  between  man  and  lower  animals  can  not  fail 
to  give  broader  ideas  of  the  whole  science." — Joseph  Eichuero,  M.  D.,  Pro/mor  of 
Phymology  in  Miami  Medical  College,  Cincinnati,  Ohio. 

"...  I  am  pleased  to  accord  this  work  my  hearty  indorsement,  siuiply  from  the 
fact  that  it  presents  the  suliject  in  a  new  way.  and,  strange  to  say,  in  n  manner  that  wc 
wonder  had  not  been  thought  of  before,  viz.,  the  comparotive  anin)al  Mhysiology  together 
with  biology  and  embryology,  together  with  evolution,  all  in  a  work  quite  suitable  for  a 
medical  student.  Hitherto  we  have  been  compelled  to  go  to  noUiral  history  for  these 
matters.  ...  It  surely  deserves  a  place  in  our  literature." — J.  O.  .Stili.kon,  M.  D.,  Pro- 
fessor of  Phi/niolofffi  in  the  Ventral  College  of  Physicians  and  Surgeons  of  JndianapoUs,  Iiid. 

*'I  am  delighted  with  Dr.  Mills's  book,  the  plan  of  which  is  excellent,  and  the  details 
well  worked  out.  It  will  give  students  in  human  physiology  a  new  insi}.'ht  into  the  r/la- 
tions  of  the  subject." — Williau  Osler,  M.  D.,  I*rofcssor  of  Jhysiology  in  Johns  Hopkins 
University. 

"...  It  fills  a  gap  in  the  works  on  physiology  hitherto  vacant,  and  I  commend  it 
cordially  as  an  excellent  work." — Roheht  Rkyhurn,  M.  D.,  Professor  of  Physiology  in  the 
Medical  Department  of  Howard  University,  Washington,  D.  C. 

"As  a  text-book  for  students  this  work  will  undoubtedly  take  a  high  place,  not  alto, 
gether  because  it  is  a  succinct  and  clear  record  of  the  latest  knowledge  in  animal  physi- 
ology, but  also  on  accotmt  of  its  being  founded  on  the  true  principles  of  teaching. 
Especial  care  is  taken  to  point  out  what  is  really  known ;  to  sei)arato  the  known  from 
the  unknown ;  to  show  what  directions  our  investigations  must  take  in  order  that  our 
knowledge  may  increase.  The  work  is  well  printed  and  profusely  illustrated,  and  reflects 
great  credit  on  the  publishers." — Montreal  Medical  Journal. 


I     i 


New  York :   D.  APPLETON  &  CO.,  1,  8,  &  5  Bond  Street. 


Il 


THK 

SCIENCE  AND  ART  OF 

MIDAVIFERY. 

JJv   WILLIAM  THOMPSON  Ll'SK,  M.  A.,  M.  D., 

Professor  of  Obstt'trics  mid  Diseases  of  \V(  tiwii  iinil  Cliililrciijii  the  Helleviic 

Hospital  Medical  Collcf^e;  Obsic'ric  Siirffeon  to  the  Maternity 

and  Kiiier^'t'iKV  Hospitals  ;  and  (iyiui'coK)gist 

to  the  Hellevue  lio-pilal. 


FOURTH    EDITION.     REVISED  AND   REWRITTEN. 
With  '210  Ii.i.i  sti!ation.s. 

Svo.    Cloth,  $6.00 ;  sheep,  .$6.00. 


"It  was  the  pleasure  of  the  nndci-i;;:iU'd  to  write  a  review  of  tliis  most 
exeellcnt  and  masterly  work  on   dlislelrics,  when  it   appeared  in  its  first 


(Million. 


J'he  present  is  the  fonrlli 


ditioi 


1  eiilarp( 


I  and 


*1.     Jt  iij 


a  model  of  reeciil  medical  literaliii'c  in  olistetrics,  and  can  not  hid  jjivc 
jrreat  credit  to  the  author  anil  to  .Viin'iican  medicine,  .Model  it  is  of  clear, 
forcilile.  and  lieaiitifnl  I'lnjilish.  of  ^(ood  arranp'meiit  of  suhjcct-matler.  and 
of  thoriiii>;liness  of  modern  olistetric  eNposition.  The  chancres  whi(  J;  have 
taken  place  in  liic  theory  and  practice  of  olistetrics  since  tiie  issii(>  of  ;!io 
last  edition  have  mad(!  it  necessiiry  for  the  anil. or  to  present,  to  the  pro- 
fession what  is  e>seiiiially  a  new  hook.  Most  eiieerfidly  will  we  recommend 
to  the  sliidenls  of  mediciiii' a  study  of  husk,  it  ranks  well  w it h  !'lavfair, 
and  is  second  to  no  i)ook  in  our  language." — C'ii.mm  k^  !>.  l'.\i,.MrH,  in  tlin 
0/tii!  Mi'<lic<ll  ■/udri'dJ. 


The  1. 


now  beyond  eritici-im,  for  it  has  bet  ^  accepted  by  th"  nn- 


orriiig  judgment  of  tlie  itii'mI   body  id'  physicians.     We  congratulate  Dr. 
Liisk  upon  this  reward  for  the  immense  labor  he  has  bestowed  .ipoii  it." — 


iVcM)  )'()r/i  Mriiiciil  Jo 


il. 


It  contains  one  of  the  best   expositions  of  th,'  obstetric  .science  and 

ire  acMMiainted.     'i'liroughoiit  the  'vork 


practice  of  the  dav  with  wliiel 


the  author  shows  an  intiiiiale  ac(|uaiiitaiice  with  the  literature  of  obsU't- 
rics.  and  gives  evidence  of  large  practical  experience,  great  di^'rimination, 
anil  .sound  judgment.  We  heartily  recommend  the  book  as  a  full  and  clear 
exposition  of  obstetric  .science,  riid  .  afi^  guide  to  student  and  practitioner.'' 
—  London  Ij  inert. 


It 


IS  but  a  slioi't  time  since  we  lii'i  oeoiision  to  review  this  wor 


rk.  of 


which  we  were  enabled  to  sp -ak  in  tiie  h.'/lie.-t  terms  of  praise.  The  rajiiil 
advaiici  of  many  departnients  of  obstetrics  has  meantime  called  for  n  few 
additions.  These  having  been  made,  it  can  b-  confidently  .said  that  lir.-k's 
l^Iidwifery  holds  a  liigii  place  among  .American  authors,  and  deserves  to 
be  extensively  ei,  ojoyed  for  reference,  and  recommended  to  students  as 
a  reliable  and  uniisiially  readal)le  text-book." — Caniida  Midical  and 
Snrfliciil  Joiinni/. 


New  York:   D.  APPLETON  &  CO..  1,  il.  &  5  Hoxn  Stkeet. 


n^ 


TEXT-BOOK  OF  HUMAN 
PHYSIOLOGY, 

For  the  Use  of  Students  and  Practitioners  of  Medicine. 


By  AUSTIN    FLINT,  M.  D.,  LL.  D., 

Prole!<sor  of  riiysioloRy  and  Pliysiolo^fical  Anutomy  in  the  Bellcvuii  Ilospitiil  Medical  Col- 
lege, New  York;  Fellow  of  the  ^ow  York  State  Medinil  As.sociutioii,  eto. 


FOURTfi    EDITION.     ENTIRELY   REWRITTEN. 


Large  8vo.     872  pages,  with  Two  Lithographic  Plates  and 
316   Engravings  on    Wood. 


Cloth,  $6.00;   sheep,  $7.00. 


■  I 


"  During  thn  short  time  that  has  elapsed  since  the  publication  of  the  third  edition  of 
this  work  the  advance  in  pliysioloj^ical  knowledjro  has  been  ho  trriat  that  the  author  found 
it  impossible  to  make  the  necessary  corrections,  and  bring  the  text  up  to  the  prcfcut 
without  entirely  rewriiing  the  work.  Thus,  while  it  is  a  descendent  from  former 
editions,  the  work  is  new  in  all  its  features.  The  form  and  lypofrnipliy  have  been 
changed.  Many  old  figures  have  been  expimged,  and  numerous  new  ones  have  been  in- 
ti'oduced.  Most  of  the  figures  that  have  been  retained  are  of  cuts  tin  t  have  l)een 
ro-engraved.  Historical  references  contained  in  former  editions  have  bed  greatly  cur- 
tailed; tmprolitable  discussion  of  disputed  (piestions  and  theories  have  been  avoided  ; 
physiological  chemistry  has  been  onutted  as  far  as  piacfical)le.  The  new  book  is  there- 
fore  trimmed  of  all  incidental  subjects  and  topics,  and  the  text  contined  to  the  statement 
of  established  facts." — Physician  and  iSnn/(oii. 

"  This  is  the  fourth  edition  of  Flint's  poptdar  text-book  on  physiology,  entirely  re- 
written,  and  so  great  have  been  the  advances  in  oin-  knowledge  of  this  branch  of  medical 
science  that  little  remains  of  the  original  text;  even  the  defects,  or  rather  deficiencies, 
of  the  edition  of  1880  have  rendered  it  imperative,  in  the  light  of  recent  progress,  that 
a  new  edition  be  issued.  The  sanu'  general  arrangement  is  preserved,  and  with  reason. 
The  beauty  of  Flint's  Physiology  consists  in  the  exaetm>ss  with  which  the  author  has 
carried  ut  his  intentions  as  expressed  in  the  [jrefaee :  '  I  shall  be  more  than  satisfied  if 
I  hav<  been  able  to  give  concise  and  connected  statements  of  wellestabiished  facts,  in 
such  for.n  that  they  can  not  b(!  inisimder-<too(l.  Peculiar  views  and  theoi-ies,  whether  of 
the  author  or  of  others,  have  no  proper  place  in  a  text-book  which  shoidd  represent  facts 
generally  recognized  and  acce])te(l,  and  not  the  ideas  of  any  one  individual.'  For  a  text- 
book containing  the  results  .f  the  most  recent  investigations  in  minute  anatomy  .ind 
physiolo;'v — one  that  studiously  avoids  profitless  discussions  of  unsettled  and  dis|)Uted 
tpiestions  — one  that  is  as  exact  a'  .1  rcliafde  as  the  pre.-jcnt  state  of  knowledge  will  per- 
mit, Flint's  treatise  can  not  be  c.i^-cllcd." — htnifus  Cilu  Miilicd  /m/ex. 


Now  York  :  D.  APPLKTON  &  CO.,  1,  '.i,  &  5  Bond  Street. 


A  TREATISE  ON 

THE  DISEASES  OF  THE 

NERVOUS   SYSTEM. 

Ly  WILLIAM  A.  HAMMOND,  M.D., 

Surgeon-General  U.  S.  Army  (retired  list). 

With  the  Collaboration  of  GRAEME  M.  HAMMOND,  M.  D., 

Professor  of  Diseases  of  the  Mind  and  Ncrvou.s  System  in  the  Now  York 
Post-Graduate  Medical  School  and  Hospital,  etc. 

With  118  Illustrations. 
NINTH    EDITION,  WITH    CORRECTIONS   AND   ADDITIONS. 


8vo.    932  pages.    Cloth,  $5.00;  sheep,  $6.00. 


"  Dr.  Hammond's  treatise  on  the  diseases  of  the  nervous  system  is  a  work  which 
has  been  long  familiar  to  the  profession,  and  has  attained  a  great  reputation  among 
the  standard  books  for  reference.  In  the  i)reparation  of  the  present  edition  the 
author  has  been  aided  by  his  son.  A  vast  amount  of  clinical  material  is  made  use 
of,  and  the  results  of  experimental  investigation  recorded.  The  book  is  written  in 
a  dear  and  pleasing  style,  and  obscure  conditions  arc  dealt  with  in  a  maimer  which 
will  prove  of  great  assistance  in  the  study  of  this  most  interesting  class  of  diseases." 
— Canadian  Practitioner. 

"Dr.  Hammond  published  tlie  first  edition  of  his  •'Treatise  on  Diseases  of  the 
Nervous  System'  in  1871.  It  has  thorefoie  been  before  the  profession  for  twenty 
years,  and  during  these  years  it  has  continued  to  grow  in  public  favor,  this  being 
the  ninth  edition  that  has  been  issued.  Appreciation  of  this  work  has  not  only 
been  shown  in  this  country,  but  abroad,  as  it  has  been  translated  into  the  French, 
the  Italian,  and  the  Spanish  languages.  The  present  edition  has  been  thoroughly 
revised,  and  several  new  chuptisrs  added.  This  is  a  book  of  such  great  value,  and  is 
referred  to  so  frequently  by  the  medical  press  and  other  medical  works,  that  no 
library  is  complete  without  it." — Alabama  Medical  and  Surgical  Age. 

"  There  are  few  books,  even  upon  those  subjects  which  are  constantly  in  (he 
ordinary  physician's  mind,  which  succeed  as  has  that  of  Dr.  Hammond;  and  when 
we  recollect  that  when  the  first  edition  of  this  work  appeared,  neurology  in  America 
was  in  its  very  infancy,  the  rapid  exhaustion  of  its  editions  is  the  more  remarkable. 
In  the  ninth  edition  the  writer's  son  has  done  much  toward  keeping  the  work  abreast 
of  the  times,  and.  with  more  confidence  than  ever,  it  can  now  bo  regarded  as  one  of 
the  best  and  most  satisfactory  works  on  nervous  diseases,  either  for  the  practitioner 
or  for  the  advanced  student.  Tiie  l)ook  is  beautifietl  and  its  usefulness  increased  by 
a  larger  number  of  illustrations  than  heretofore — among  the  best  from  a  medical 
point  of  view  iH'ing  those  representing  syringo-myelia,  which  have  been  taken  from 
the  studies  of  Van  Giesen." — Medical  Neics. 


New  York:   D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Steket. 


A    TEXT-BOOK    ON    THE 

DISEASES    OF   "WOMEN. 

By  ALEXANDER  J.   C.  SKENE,  M.  D., 

I'rofossor  of  (iynuTology  In  tho  Long  Itnlatul  Colli'Si;  lloBpifal,  Brooklyn,  N.  Y.;  formorly  I'roft'hKir 
of  (JyuiL'cology  in  the  New  York  Post-graduate  Medical  School  and  lloBpitul,  etc, 

SEVOXI)  EDITIOX. 

With  Two  Hundred  and  Fifty-four  Illustrations,  of  which  one  hundred  and 
■ixty-five  are  origrlnal  and  nine  Ohromo-litbographa. 

Sold  by  subscription  only. 


This  treatise  is  the  outcome  and  represents  the  experience  of  a 
long  and  active  professional  life,  the  greater  part  of  which  has  been 
spent  in  the  treatment  of  the  diseases  of  women.  It  is  especially 
adapted  to  meet  the  wants  of  the  general  practitioner  in  recognizing 
this  class  of  diseases  as  he  meets  them  in  every-day  practice  and  in 
treating  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in 
their  natural  order,  and  thus  more  easily  comprehended  and  remem- 
bered by  the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in 
his  practice,  and  it  has  been  his  endeavor  to  so  describe  the  operative 
procedures  ado[)ted  by  him  even  to  their  minutest  details,  as  to  make 
his  treatise  a  practical  guide  to  the  gynajcologist. 

Although  all  the  subjects  which  are  discussed  in  the  various  text- 
books on  gynajcology  have  been  treated  by  the  author,  it  has  been  a 
prominent  feature  in  his  plan  to  consider  also  those  which  are  but 
incidentally,  or  not  at  all,  mentioned  in  the  text-books  hitherto  pub- 
lished, and  yet  which  are  constantly  presenting  themselves  to  the  prac- 
titioner for  diagnosis  and  treatment. 

The  illustrations  are  mostly  entirely  new,  and  have  been  specially 
made  for  this  w"ork.  The  drawings  are  from  nature,  or  from  wax 
and  clay  models  from  nature,  and  have  been  reproduced  by  processes 
best  adapted  to  represent  in  the  most  truthful  and  permanent  forms 
the  exact  appearances  of  the  diseased  organs,  methods  of  operation, 
or  instruments  which  they  are  designed  to  illustrate. 

Wherever  it  has  been  possible  to  make  clearer  the  author's  methods 
of  treatment  by  histories  of  cases  which  have  actually  occurred  in  his 
])ractice,  this  has  been  done.  A  simple,  typical  case,  such  as  is  ordi- 
narily met  with,  is  first  described,  and  then  diflicult  and  obscure  cases, 
with  the  various  complications  which  occur.  The  history  of  such  cases 
and  the  ?nethods  of  examination  and  treatment  are  so  minutely  detailed 
as  to  8e»*ve  for  guides  in  similar  cases. 


New  York :   D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


THE 


NEW  YORK  MEDICAL  JOURNAL, 

Edited  by  FRANK  P.  FOSTER,  M.  D. 


It  is  tho  LEADISG  JOURS^AL  of  America,  and  contnins  more  reading- 
matter  tlmn  any  other  journal  of  its  class. 

It  is  the  exponent  of  tho  most  advanced  scientific  medical  thought. 

Its  contributors  are  among  the  most  iearned  medical  men  of  this  country. 

Its  "Original  Articles"  are  the  results  of  scientific  observation  and  research, 
and  are  of  infinite  practical  value  to  the  general  practitioner. 

The  "  lieports  on  tho  Progress  of  Medicine,"  which  are  pnblislied  from 
time  to  time,  contain  the  most  recent  discoveries  in  the  various  departments  of 
medicine,  and  are  written  by  practitioners  especially  qualified  for  the  purpose. 

Tho  Society  I'rocoidings,  of  which  each  number  contains  one  or  more,  are 
reports  of  tho  practical  experience  of  prominent  physicians  who  thus  give  to 
the  profession  the  results  of  certain  modes  of  treatment  in  given  cases. 

Tho  Editorial  Columns  are  controlled  only  by  tlio  desiixs  to  promote  the 
welfare,  honor,  and  advancement  of  the  science  of  medicine,  as  viewed  from 
a  standpoint  looking  to  the  best  interests  of  the  profession. 

Nothing  is  admitted  to  its  columns  that  has  not  some  bearing  on  medicine, 
or  is  not  possessed  of  some  practical  value. 

It  is  publislied  solely  in  the  interests  of  medicine,  and  for  the  upliolding  of 
the  elevated  position  occupied  by  the  profession  of  America, 


The  volumes  begin  with  January  and  July  of  each  year.    Sub- 
scriptions must  be  arranged  to  expire  vritb  the  volume. 


SUBSCBIPTION  PBIOB,  $6.00  PER  ANNUM. 


D.  APPLETON   &  CO.,   Publisher.*?. 

N«w  York,  Boaton,  Chlea^,  ▲tlaota,  San  Franolaoo* 


JpriJ,   1S93. 


MEDICAL 


ANn 


HYGIENIC    WOEKS 

rcnusHED  BY 
D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street,  New  York. 


AULDE  (JOHN).  The  Pocket  Phnnnacy,  with  Thcrapoiitir  Iixlex.  A  rcxiime 
of  the  C'liuicii]  ApplieatioiiH  of  Iveniedies  adapted  to  tlie  J'<>eket-<'ase,  tor 
tlie  Treatment  of  Emergencies  and  Acute  Diseases.     ]2tmi.     C'lotli,  ^2.00. 

BARKER  (FORDY("E).  On  Sea-Sickness,  A  I'opular  Treatise  tor  Travelers 
and  the  General  Reader.     Small  J'2nio.     Clotli,  To  cents. 

BARKER  (FORDYCE).  On  Puerperal  Disease.  Clinical  Lectnrcs  delivered  at 
Bellevue  Hospital.  A  Course  of  Eectures  valuable  alike  to  the  Student  and 
the  Practitioner.    Third  edition.     8vo.     Cloth,  ^o.OO;  sheep,  $(1.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  Materia  Medica  and  Therapeutic. 
Sevrntb  rdition.  Revised,  enlarfjed,  and  adapted  to  "  The  New  Pharnuicopd'ia.'" 
8vo.     Cloth,  $5.0(1;  sheep,  $(5.00. 

BARTHOLOW  (P^OBEIiTS).  A  Treatise  on  the  Practice  of  Medicine,  for  the 
Use  of  Students  and  Practitioners.  Sixth  edition,  revised  and  enlarged.  8vo. 
Cloth,  $0.00 ;  sheep,  $ti.00. 

BARTHOLOW  (ROBERTS).  On  the  Antagonism  between  Medicines  and  be- 
tween Remedies  and  Diseases.  Being  the  Cartw right  J.ectures  for  tiie  Year 
1880.     8vo.     Cloth,  $1.25. 

BASTIAN  (IJ.  CHARLTON).  Paralyses:  Cerebral,  Bulbar,  and  Spinal.  A 
Manual  of  {diagnosis  for  Students  and  Practitioners.  With  l:j(>  Illustra- 
tions.   Small  8vo,  (iTl  pages.     Cloth.  $4.50. 

BASTIAN  (II.  CHAKLTOX).  Paralyis  from  Brain  Disease  in  its  Coinmcn 
Forms.     With  Illustrations.     l-Jino,  .'140  jiages.     Cloth,  $  I. To. 

BILLIN(iS  (  F.  S.).  The  Relation  of  Animal  Diseases  to  tlio  Public  Ilcidth,  and 
their  Preventit)n.     8v<).     Cloth,  %\AW. 

BILLROTH  (THKODOR).  (Jeneral  Surgical  Pathology  and  Therapeutics.  A 
Text-Book  tor  Student>  and  Physicians.  Translate.l  from  the  tenth  (iirnian 
edition,  by  special  permission  of  i!ie  author,  by  Charles  K.  Ilackley,  M.  D. 
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8 

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WERHER  (S.  (}.).  A  Treatise  on  Nervous  Diseases:  Their  Symptoms  and 
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■WEEKS-SHAW  (CLARA  S.).  A  Text-Book  of  Nursing.  For  the  Use  of 
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